Laser sheath for tunneled dialysis catheters extraction

The number of patients with acute renal failure and end-stage renal disease undergoing hemodialysis (HD) has increased during the past years, and the management of vascular access is pivotal. Among tunneled dialysis catheters (TDC), Tesio twin-catheter system (Medcomp, Harleysville, PA, USA) provides good long-term survival with acceptably high blood flow and low complication rates [1, 2]. Unfortunately, catheter infection is still a serious and common complication related to temporary HD vascular access. When catheter infection and/or dysfunction occur, extraction is mandatory [3]. Although the development of a fibro-epithelial sheath is a common occurrence, TDC extraction is usually easily performed by traction or cut down technique [3, 4]. However, when the catheters are tethered or attached to central veins and/or to right atrium, these techniques could lead to their rupture and retention and could increase the risk of vascular or atrial wall avulsion. Laser extraction technique is usually adopted for pacing leads, but it can also be helpful in TDC extraction to avoid the previous mentioned complications. A circumferential Excimer laser beam applied at the tip of a specialized telescopic sheath is passed over the lead. The energy source comes from a xenon chloride laser with an output wave length of 308 nm. It is a cool cutting laser (50 C) with a very limited absorption depth; twothirds of the energy are absorbed within 0.06 mm from the tip of the sheath by proteins and lipids instead of water. These technical characteristics allow the ablation of the fibro-epithelial sheath surrounding TDC without damaging the endothelial wall and the catheter itself [5]. According to these assumptions, our laboratory has decided to adopt this technique to extract tethered TDCs. A woman of 57 years, affected by endstage renal disease, was admitted to our Department for a Tesio twin-catheter system-associated bacteraemia. A transesophageal echocardiographic evaluation showed a thrombus occluding the apex of the right atrial appendage. A valvular involvement was excluded. After 2 months of oral anticoagulation therapy, she underwent TDC extraction performed using an Excimer Laser system emitting energy at the tip of a flexible, fiber-optic 12F-sheath (Spectranetics Inc., Colorado Springs, CO, USA). The procedure was performed under assistant sedation with i.v. midazolam. First, the TDC was isolated. Then, an A. Curnis L. Bontempi M. Cerini F. Vassanelli A. Lipari N. Ashofair C. Pagnoni L. Dei Cas Division of Cardiology, EP Lab, Post Graduate School of Cardiology, Spedali Civili, University of Brescia, Brescia, Italy