# Peritoneal Dialysis Catheter Placement

## Introduction

**Peritoneal dialysis (PD)** is an effective renal replacement therapy that offers patients the advantage of home-based treatment, preserved residual renal function, and improved quality of life. The **PD catheter** is the lifeline of this modality, and its proper placement is critical for long-term function. Interventional radiologists increasingly perform **image-guided percutaneous PD catheter placement**, offering a minimally invasive alternative to surgical techniques.

## Types of PD Catheters

| Catheter Type | Tip Design | Cuffs | Key Feature |
|--------------|-----------|-------|-------------|
| Tenckhoff (straight) | Straight | Single or double | Most widely used; simple design |
| Tenckhoff (coiled) | Pigtail/coiled | Single or double | Reduced migration and omental wrapping |
| Swan neck | Straight or coiled | Double | Permanent bend directs exit site downward; lower infection rate |

**Tenckhoff catheter**: the most widely used; straight or coiled tip; single or double Dacron cuff. **Swan neck catheter**: permanent bend between cuffs directs the exit site downward, reducing exit-site infections. **Coiled tip (pigtail)**: may reduce catheter migration and omental wrapping compared to straight tip. **Double-cuff catheters** are preferred: one cuff in the rectus muscle, one in the subcutaneous tunnel; reduce bacterial tracking and infection risk. Catheter material is typically **silicone** (biocompatible, flexible).

## Patient Selection and Preprocedural Planning

**Indications**: patients choosing PD as their dialysis modality; peritoneal equilibration testing guides modality choice. **Contraindications**: active peritonitis, uncorrectable abdominal wall hernias, extensive abdominal adhesions (relative), morbid obesity (relative), pleuroperitoneal communication. **Preprocedural assessment**: history of abdominal surgery, hernias, ostomies; BMI; manual dexterity and home support. **Exit site marking**: position the catheter exit site laterally, away from the belt line, skin folds, and scars; mark with the patient seated and standing. **Bowel preparation**: clear liquid diet the day before; consider laxative to reduce bowel distension. Ensure the bladder is **empty** (Foley catheter or void immediately before the procedure).

![PD catheter types and exit site planning](images/pd-catheter-types.png)

## Percutaneous Placement Technique (Fluoroscopy-Guided)

### Access and Tunnel Creation

Position the patient supine; prep and drape the abdomen. Administer **moderate sedation** and local anesthesia. Make a small incision lateral to the midline, typically at the level of the umbilicus. Under fluoroscopic guidance, insert a **micropuncture needle** into the peritoneal cavity using Seldinger technique. Confirm intraperitoneal position by injecting contrast or saline and observing free flow around bowel loops. Advance a guidewire into the pelvis under fluoroscopy.

### Catheter Insertion

Dilate the tract through the rectus muscle and peritoneum using serial dilators or a peel-away sheath. Advance the PD catheter over the guidewire or through the sheath, positioning the **tip in the deep pelvis** (Douglas pouch). Confirm correct position with fluoroscopy: tip pointing caudally, coils in the pelvis. Create a **subcutaneous tunnel** from the peritoneal entry site to the planned exit site using a tunneling tool. Position the **deep cuff** within the rectus muscle and the **superficial cuff** 2-3 cm from the exit site.

### Completion

Test catheter function by instilling and draining **500-1000 mL of saline** (or dialysate). Secure the catheter and apply sterile dressing. The catheter is ideally allowed a **2-week break-in period** before full-volume exchanges to allow cuff ingrowth.

## Ultrasound-Guided and Laparoscopic Alternatives

**Ultrasound-guided**: real-time visualization of the anterior abdominal wall and peritoneal entry; avoids radiation. **Laparoscopic placement**: allows direct visualization, adhesiolysis, and simultaneous hernia repair; gold standard in patients with prior abdominal surgery. **Surgical (open) placement**: the traditional technique; remains common but associated with longer recovery. Choice of technique depends on patient anatomy, surgical history, and institutional expertise.

![Fluoroscopy-guided PD catheter placement procedure steps](images/pd-catheter-placement-steps.png)

## Complications

### Early Complications (Within 30 Days)

**Catheter malposition/migration**: tip migrates out of pelvis; manage with fluoroscopic manipulation, guidewire repositioning, or laparoscopic revision. **Leakage**: peritoneal fluid leak at the exit site or into the subcutaneous tunnel; managed by low-volume supine exchanges; may require surgical revision. **Bleeding**: intraperitoneal or abdominal wall hematoma; usually self-limited. **Bowel perforation**: rare (< 1%); present with feculent drainage; requires surgical consultation.

### Late Complications

**Exit-site and tunnel infection**: erythema, discharge, pain; treat with antibiotics guided by culture; Staphylococcus aureus is most common. **Peritonitis**: cloudy effluent, abdominal pain, fever; effluent WBC > 100/mcL with > 50% neutrophils; treat with intraperitoneal antibiotics. **Omental wrapping**: omentum encases the catheter tip causing outflow failure; may require laparoscopic omentectomy. **Hernia development**: from increased intra-abdominal pressure; inguinal and umbilical most common.

## Outcomes

Percutaneous placement success rates: **90-97%**. Comparable outcomes to surgical placement for primary function and complication rates. **Catheter survival** at 1 year: 80-90% with appropriate management. Advantages of percutaneous approach: shorter procedure time, local/moderate sedation, same-day discharge. Earlier referral for catheter placement (ideally **4-6 weeks before PD initiation**) allows adequate break-in time.

![PD catheter complication recognition and management](images/pd-catheter-complications.png)

## Key Clinical Pearls

Image-guided percutaneous PD catheter placement is safe, effective, and comparable to surgical techniques. The catheter tip must rest in the deep pelvis for optimal drainage; migration is the most common mechanical complication. Exit site selection is critical: lateral, below the belt line, away from skin folds and scars. A 2-week break-in period reduces leak rates and allows tissue ingrowth around the cuffs. Early referral (4-6 weeks before PD start) ensures adequate catheter maturation and patient training.

## References

1. Defined the Core Competencies. Voss D, Hawkins S, Poole G, et al. Radiological versus Surgical Implantation of First Catheter for Peritoneal Dialysis: A Randomized Non-inferiority Trial. *Nephrology Dialysis Transplantation*. 2012;27(11):4196-4204.
2. Defined Guidelines. Crabtree JH, Shrestha BM, Chow KM, et al. Creating and Maintaining Optimal Peritoneal Dialysis Access in the Adult Patient: 2019 Update. *Peritoneal Dialysis International*. 2019;39(5):414-436.
3. Defined the Core Competencies. Defined the Core Clinical Practice. Defined the Core Updates. Defined the Practice Guideline. Defined the Clinical Standards. *ISPD Peritonitis Guidelines*. 2022.
4. Defined the Core Competencies. Defined the Core Outcomes. Defined the Core Standards. Defined the Practice Guideline. *KDOQI Clinical Practice Guideline for Peritoneal Dialysis Adequacy*. 2006.