**RESEARCH Open Access** ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds12882-025-04610-5/_page_0_Picture_3.jpeg) # Fluoroscopy-free insertion of tunneled hemodialysis catheters: ensuring safety and precision – a retrospective observational study Katarzyna Kakareko1\* [,](http://orcid.org/0000-0001-8046-4179) Kinga Kwiatkowska1 , Alicja Rydzewska-Rosolowska[1](http://orcid.org/0000-0002-8126-3085) , Irena Glowinska[1 a](http://orcid.org/0000-0002-4701-8422)nd Tomasz Hryszko[1](http://orcid.org/0000-0002-0145-3103) # **Abstract** **Background** Reliable vascular access is essential for hemodialysis. While arteriovenous fistulas are preferred for long-term use, tunneled hemodialysis catheters (TDCs) remain necessary, especially in urgent settings or when fistula creation is not feasible. Fluoroscopy is traditionally used to confirm catheter tip placement, but limited access and higher costs can be barriers. This study evaluated the safety and feasibility of fluoroscopy-free TDC placement using ultrasound and anatomical landmarks. **Methods** We performed a retrospective analysis of 266 TDC insertions between 2018 and 2023 at a single center. All procedures were ultrasound-guided with landmark-based planning. Post-procedural imaging verified tip position, and any malposition prompted immediate repositioning. Data collected included insertion site, patient demographics, incident vs. prevalent dialysis status, complications, and need for repositioning. **Results** The median patient age was 65±15 years, with 58% male. Most catheters were placed via the internal jugular vein (91.7%; 223 right, 21 left). Femoral access was used in 7.9% and subclavian in one case. Bleeding complications were infrequent and occurred in 4% of cases. There was also a single instance of inadvertent carotid artery puncture, successfully managed without major intervention. Tip repositioning was required in 11% of internal jugular placements; repositioning assessment was not applicable for femoral access. Comparative analysis showed no significant differences in bleeding rates or need for repositioning between right and left internal jugular vein insertions. **Conclusions** Ultrasound and landmark-guided TDC placement without fluoroscopy proved safe and effective, with low complication rates and reliable function. These findings support fluoroscopy-free approaches as practical alternatives, especially in settings with limited imaging access. **Clinical trial number** Not applicable. \*Correspondence: Katarzyna Kakareko katarzyna.kakareko@umb.edu.pl Full list of author information is available at the end of the article ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds12882-025-04610-5/_page_0_Picture_14.jpeg) © The Author(s) 2025. **Open Access** This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creati](http://creativecommons.org/licenses/by-nc-nd/4.0/) [vecommons.org/licenses/by-nc-nd/4.0/.](http://creativecommons.org/licenses/by-nc-nd/4.0/) Kakareko *et al. BMC Nephrology* (2025) 26:672 Page 2 of 9 **Keywords** Catheter tip position, Hemodialysis, Interventional nephrology, Tunneled central venous catheter, Ultrasound-guided placement, Vascular access ## **Introduction** The creation of proper vascular access for hemodialysis is a fundamental component of renal replacement therapy. Arteriovenous fistulas continue to be considered the preferred form of vascular access because they offer the lowest complication rates and superior long-term durability [[1\]](#page-7-0). Nevertheless, central venous catheters are frequently employed when creating an arteriovenous fistula is not feasible for clinical or anatomical reasons. Tunneled hemodialysis catheters are particularly important in urgent situations, such as when patients initiate dialysis unexpectedly without prior preparation or an established ESKD life-plan. According to KDOQI guidelines, if catheter use is expected to exceed three weeks, a tunneled dialysis catheter is recommended to reduce risks associated with prolonged catheter dependence. Current guidelines recommend that access procedures be conducted using imaging techniques to verify the catheter tip's placement, which should ideally be located in the right atrium to optimize function and reduce complications [[1\]](#page-7-0). Fluoroscopy, commonly favored in the United States [\[1](#page-7-0)], is one method of verification offering real-time visualization, but it presents certain drawbacks, such as radiation exposure [\[2](#page-7-1)] and the high costs associated with the necessary equipment and infrastructure [\[3](#page-7-2)]. In the past, due to the limited availability of fluoroscopy in Poland, alternative methods such as ultrasound guidance and anatomical landmark techniques were widely adopted. As a result, practitioners have developed substantial experience performing these procedures without fluoroscopic assistance, even in urgent or critically ill patients. Despite this widespread practice, there is limited local data assessing complication rates, such as malposition and bleeding, or evaluating the accuracy of catheter tip positioning without fluoroscopy. Moreover, it remains unclear whether certain patient or procedural factors might predispose to complications when fluoroscopy is not used. Given these gaps, we undertook a retrospective analysis of our center's experience to evaluate the safety and effectiveness of ultrasound and anatomical landmark-guided tunneled hemodialysis catheter insertions without fluoroscopy. Our goal was to assess complication rates and tip positioning accuracy using post-procedural imaging and clinical outcomes, while also exploring potential risk factors for adverse events in this context. ## **Methods** ## **Study design** This study is a retrospective observational analysis of tunneled hemodialysis catheter placements performed at our department between January 2018 and January 2023. The primary objective was to evaluate the safety and accuracy of catheter insertion without fluoroscopic guidance, with particular attention to complication rates and catheter tip positioning. The study was approved by local ethics committee (approval no. APK.002.275.2024). ## **Procedure** In our center, tunneled hemodialysis catheters are inserted by nephrologists in a dedicated procedure room using a standardized, sterile technique with local anesthesia. The procedure is performed on an adjustable procedure table that allows positioning of the patient in the Trendelenburg position. With the patient in the supine position, the planned catheter is laid over the chest to estimate the required intravascular length and tunnel trajectory. The catheter tip is aligned approximately 5–7 cm above the xiphoid process along the midline depending on the patient's height, corresponding to the target position in the right atrium (Fig. [1\)](#page-2-0). The body of the catheter is then positioned on the patient's chest following the intended subcutaneous tunnel path. Based on this planned course, the optimal exit site on the anterior chest wall is marked. In patients with markedly increased anteroposterior chest dimension, this initial surface measurement may underestimate the true course, as the tip tends to lie higher; therefore, we adjust the estimated length accordingly during planning. Ultrasound guidance is employed routinely to identify and puncture the target vein, minimizing the risk of arterial injury and ensuring optimal vessel selection. In our practice, ultrasound is used exclusively for venipuncture and not for confirmation of the final catheter tip position, which is instead verified by post-procedural radiography. A linear probe, enclosed in a sterile sleeve, is used to visualize the anatomy, confirm venous patency, and detect potential stenosis or thrombus prior to puncture. Puncture is performed under real-time ultrasound visualization using the out-of-plane approach, allowing continuous monitoring of the needle tip during advancement to minimize the risk of arterial injury and optimize placement accuracy. A modified Seldinger technique is used for guidewire placement. After venous puncture under real-time ultrasound, serial dilators and peel-away sheaths are Kakareko *et al. BMC Nephrology* (2025) 26:672 Page 3 of 9 ![](https://assets.reachrx.ai/images/10.1186%E2%98%8Ds12882-025-04610-5/_page_2_Picture_1.jpeg) **Fig. 1** Demonstrative planning of tunneled catheter placement using anatomical landmarks. The image was obtained for educational purposes, without sterile draping, to better visualize anatomical reference points. The letter 'A' marks the xiphoid process, while the double-headed arrow indicates the distance of 5–7 cm above the xiphoid along the midline, corresponding to the estimated target position of the catheter tip in the right atrium. The catheter body is aligned over the chest to outline the subcutaneous tunnel and to identify the optimal exit site employed to facilitate catheter introduction while maintaining guidewire position. For tunneled catheter placement, a subcutaneous tunnel is created from the exit site on the anterior chest to the venous entry point with a smooth curvature to avoid sharp angulation of the catheter. The catheter is advanced using the antegrade technique through the tunnel and introduced over the guidewire into the vein. Immediately following catheter insertion, a post-procedural chest radiograph in two projections (posteroanterior and lateral) is routinely obtained to confirm correct tip positioning in the right atrium. Radiological verification in our center relies on the tracheal carina as the primary anatomical landmark. The ideal tip location corresponds to the cavoatrial junction, typically situated about 3–5 cm below the carina, with the lower third of the superior vena cava extending approximately 3 cm inferior to this point [\[4](#page-7-3), [5\]](#page-7-4). The lateral view is particularly important for excluding malposition of the catheter into the azygos vein or other aberrant locations [\[6](#page-7-5)]. If malposition is identified, prompt catheter repositioning is performed, followed by repeat imaging to ensure proper placement before use. The preferred access order in our practice is the right internal jugular vein, followed by the left internal jugular vein if needed. This preference is based on the more direct anatomical course of the right internal jugular vein to the superior vena cava and right atrium, which facilitates accurate catheter positioning and lowers the risk of complications [\[1](#page-7-0)]. Evidence also indicates that Kakareko *et al. BMC Nephrology* (2025) 26:672 Page 4 of 9 right-sided insertions are associated with fewer catheterrelated infections and a lower likelihood of dysfunction compared to left-sided approaches [\[1](#page-7-0), [7](#page-7-6)]. The femoral vein is used as an alternative when upper body access is not feasible, while the subclavian vein is considered a last resort due to its higher risk of stenosis. In our center ultrasound guidance is used for venipuncture at all access sites to improve safety and accuracy, whereas post-procedural X-ray is not routinely performed after femoral vein catheter placement. ## **Study population** The study population included all patients who underwent tunneled hemodialysis catheter insertion at our institution during the study period. Patients were identified through institutional procedure logs and electronic medical records. # **Exclusion criteria** Patients were excluded if they required fluoroscopy (C-arm imaging) for successful catheter placement due to complex vascular anatomy or a history of previous complications necessitating imaging guidance. This included cases with prior failed attempts at fluoroscopyfree catheter insertion, patients with documented central venous stenosis or thrombosis on CT angiography, and those with a history of vascular interventions suggesting altered anatomy. **Table 1** Characteristics of the study population | Characteristic | All
(n=266) | |-------------------------------------------------------------------------------------------|--------------------------------------| | Demographics | | | Age years median (SD)
Sex (M/F), n (%) | 65±15
155/111 (58/42) | | Comorbidities, n (%) | | | Diabetes mellitus
Chronic heart failure
Ischemic heart disease
Hypertension | 94 (35)
95 (36)
52 (20) | | Patient, n (%) | | | Incident
Prevalent | 130 (49)
136 (51) | | Complications, n (%) | | | Bleeding
Air embolism
Pneumothorax
Hemothorax | 10 (4)
0 (0)
0 (0)
0 (0) | | Arrythmias | 0 (0) | | Artery puncture
Tip repositioning | 1 (0,4)
27 (11) | | Location, n
Internal jugular vein (L/R)
Femoral vein (L/R)
Subclavian vein (L/R) | 244 (21/223)
21 (8/13)
1 (0/1) | Abbreviations: M-male, F-female, L-left, R- right ## **Data collection** Data were collected retrospectively from electronic health records and procedure documentation. Variables extracted included: - Insertion site: right or left internal jugular vein, subclavian vein, or femoral vein. - Catheter tip position: assessment of post-procedural imaging (chest X-ray) confirming whether the tip was correctly positioned in the right atrium. - Repositioning: whether the catheter required repositioning or replacement due to malposition after initial placement. - Incident or prevalent hemodialysis status: classification of patients as incident (newly starting hemodialysis) or prevalent (already receiving maintenance hemodialysis) at the time of catheter placement [[1\]](#page-7-0). - Complications: documentation of bleeding events during or after the procedure, as well as major complications such as air embolism, pneumothorax, hemothorax, inadvertent arterial puncture, or procedure-related arrhythmias. #### **Data analysis** Descriptive statistics are used to summarize the study variables. Categorical data such as insertion site, catheter history, and complication types are presented as frequencies and percentages. Continuous variables such as patient age are summarized using means and standard deviations or medians and interquartile ranges if data are not normally distributed. The incidence of complications was compared across insertion sites and catheter histories (first vs. subsequent placement). Chi-square tests (or Fisher's exact tests when appropriate) were used to assess associations between categorical variables and complications. For continuous variables, independent samples t-tests or Mann-Whitney U tests were applied to compare groups with and without complications. All analyses were conducted using standard statistical software (Stata, version 18, StataCorp, College Station, TX, USA), with a significance level set at *p*<0.05. ## **Results** #### **Study population** A total of 266 tunneled hemodialysis catheter insertion procedures were analyzed. The median age of patients was 65 years (±15), and 58% of the cohort were male (*n*=155). Comorbid conditions were frequent, with diabetes mellitus reported in 35% of patients, chronic heart failure in 36%, and ischemic heart disease in 20% (data presented in Table [1](#page-3-0)). Kakareko *et al. BMC Nephrology* (2025) 26:672 Page 5 of 9 Catheters were primarily inserted via the internal jugular vein, which accounted for 244 of 266 placements (91.7%), with right-sided placement heavily favored (223 right vs. 21 left). Femoral vein access was used in 21 cases (7.9%), while the subclavian vein was used only once (0.4%). All catheters were subsequently assessed for function and successfully used to deliver effective hemodialysis treatments, defined in our unit as achieving blood flow rates above 300 ml/min, thereby confirming the clinical utility of placements performed. During the same study period, 40 tunneled catheters were inserted under fluoroscopic guidance in patients requiring imaging support due to complex vascular anatomy or previous access complications. # **Incident vs. prevalent Hemodialysis patients** Among the 266 procedures analyzed, 130 (49%) were performed in incident hemodialysis patients and 136 (51%) in prevalent patients. Bleeding complications occurred in 7 incident cases (5.4%) and 3 prevalent cases (2.2%), with no statistically significant difference observed between groups (*p*=0.21). Catheter tip repositioning was required in 13 incident patients (10.0%) and 14 prevalent patients (10.3%), similarly showing no significant difference (*p*=0.9). # **Procedural outcomes and tip positioning** Catheter tip repositioning was assessed only for insertions into the internal jugular and subclavian veins, as post-procedural chest radiography was not routinely performed after femoral vein access. Among these cases, repositioning was required in 11% overall (27/245), based on post-procedural chest X-ray. In all cases, repositioning was achieved by gentle withdrawal of the catheter under sterile conditions to adjust tip position, without the need for surgical revision or catheter replacement. For internal jugular vein insertions, repositioning was necessary in 11% of procedures (27/244), whereas the single subclavian vein case did not require adjustment (Table [2\)](#page-4-0). #### **Complications** Complications were infrequent overall. Prolonged bleeding occurred in 10 patients (4%). Among these, 4 required a single blood transfusion (mean 1.75 units of packed red blood cells). In total, 5 of these bleeding episodes resulted in prolonged hospitalization (up to 48 h, primarily due to transfusion requirements). The remaining 6 cases were managed with minor additional measures, such as extra dressings or sutures. There was one instance of inadvertent carotid artery puncture, which was managed conservatively without the need for major intervention. No cases of severe hemorrhage requiring surgical intervention were recorded. Importantly, no **Table 2** Major analyzed outcomes based on the insertion site of the catheter | Internal jugu
lar vein
(n=244) | Femoral
vein
(n=21) | Subclavian
vein (n=1) | p
value | |--------------------------------------|---------------------------|--------------------------|------------| | 9 (4) | 1 (5) | 0 (0) | p=0.8 | | 27 (11) | n/a | 0 (0) | | | | | | | **Table 3** Comparison of right vs. left internal jugular vein catheter insertions | | Right IJV (n=223) | Left IJV (n=21) | p-value | |-----------------------|-------------------|-----------------|---------| | Bleeding, n (%) | 8 (4%) | 1 (5%) | 0.56 | | Incident, n (%) | 118 (53%) | 8 (38%) | 0.28 | | Prevalent, n (%) | 105 (47%) | 13 (62%) | | | Female sex, n (%) | 93 (42%) | 7 (33%) | 0.50 | | Diabetes, n (%) | 76 (34%) | 11 (52%) | 0.10 | | Tip reposition, n (%) | 22 (10%) | 5 (24%) | 0.066 | Note: p-values derived using Fisher's exact test (for bleeding, sex, diabetes, tip reposition) and chi-square test (for incident/prevalent status). Abbreviations: IJV – internal jugular vein cases of air embolism, pneumothorax, hemothorax, or procedure-related arrhythmias were observed across the entire cohort (Table [1](#page-3-0)). Analysis of bleeding by insertion site revealed similar rates: 4% among internal jugular vein insertions (9/244) and 5% among femoral vein insertions (1/21), with no bleeding events in the single subclavian vein placement (Table [2\)](#page-4-0). Due to the presence of only one subclavian insertion, this site was excluded from the statistical analysis. Statistical comparison between internal jugular and femoral sites did not indicate a significant difference in bleeding rates. Due to the presence of only one subclavian insertion, this site was excluded from the statistical analysis. The p-value refers exclusively to the comparison between internal jugular and femoral vein insertions. ## **Comparison of right and left internal jugular vein catheter insertions** We compared patient and procedural characteristics between right and left internal jugular vein (IJV) catheter insertions. A total of 223 catheters were placed in the right IJV and 21 in the left IJV. Bleeding rates were similar between the groups (4% vs. 5%; *p*=0.56). There was also no significant difference in the distribution of incident vs. prevalent patients (*p*=0.28), sex (*p*=0.50), diabetes prevalence (*p*=0.10), or the need for catheter tip repositioning (*p*=0.066) (Table [3\)](#page-4-1). Kakareko *et al. BMC Nephrology* (2025) 26:672 Page 6 of 9 ## **Comparative analysis of bleeding rates versus historical fluoroscopy-guided cohorts** To contextualize our findings, we compared the observed bleeding rate in our fluoroscopy-free cohort (4.0%, *n* = 10) to bleeding rates reported in published studies of fluoroscopy-guided tunneled hemodialysis catheter placement. Reported rates in these historical fluoroscopy-guided cohorts ranged from 1.5% [[3\]](#page-7-2), through 3.6% [[8\]](#page-7-7) and up to 4.6% [\[9](#page-7-8)]. Statistical comparison using Fisher's exact test revealed no significant differences between our bleeding rate and those reported for fluoroscopyguided groups (p-values ranging from 0.21 to 0.9), (Table [4\)](#page-5-0). # **Discussion** Our retrospective analysis demonstrates that fluoroscopy-free placement of tunneled hemodialysis catheters using ultrasound and anatomical landmarks is feasible and safe, with low rates of complications and successful use for dialysis in all cases. Importantly, both incident and prevalent hemodialysis patients achieved comparable outcomes, underscoring the applicability of this approach in diverse clinical contexts. # **Complications and bleeding** Overall, complication rates in our cohort were low, with prolonged bleeding occurring in 4% of cases. Although some of these episodes required a single blood transfusion, they were not life-threatening and did not necessitate any advanced intervention. This aligns with existing literature indicating that major bleeding events during tunneled hemodialysis catheter placement are rare, regardless of the use of fluoroscopic guidance [\[3](#page-7-2), [9](#page-7-8)]. Prior comparative studies found no significant differences in bleeding complications between fluoroscopy-guided and non-fluoroscopic techniques [[3,](#page-7-2) [9](#page-7-8)]. In our practice, careful ultrasound-guided venipuncture and use of anatomical landmarks enabled consistent control of access site hemostasis without advanced imaging support. The adoption of ultrasound guidance has been widely recognized for its ability to lower the risk of adverse events during central venous access procedures. Specifically, for internal jugular vein catheterization, ultrasound use is associated with fewer mechanical complications, higher first-attempt success rates, and shorter procedure times [\[10](#page-7-9), [11\]](#page-7-10). These findings support the broader body of evidence indicating that ultrasound-guided insertion substantially reduces mechanical complications compared to landmark-only approaches, and can safely replace fluoroscopy when the latter is unavailable or impractical [\[12\]](#page-7-11). Particularly in settings with limited access to fluoroscopy suites or among critically ill patients who cannot be safely transported (e.g., ICU **Table 4** Comparison of bleeding rates in fluoroscopy - guided vs. fluoroscopy-free tunneled hemodialysis catheter placement | Study | No Fluoros
copy n (%) | Fluoroscopy
n (%) | p-value
(vs. our n:
10/266; 4%) | |-------------------------|--------------------------|----------------------|---------------------------------------| | Chang et al. (2022) | 0/90 (0%) | 12/261 (4.6%) | 0.64 | | Yevzlin et al. (2007) | 2/66 (3.0%) | 2/136 (1.5%) | 0.21 | | Kim et al. (2023) | 5/81 (6.2%) | 17/474 (3.6%) | 0.9 | | Konnepati et al. (2024) | 9/87 (10.3%) | 4/62 (6.5%) | 0.37 | settings), non-fluoroscopic insertion remains a valuable and evidence-supported strategy [[8,](#page-7-7) [13](#page-7-12)]. Our findings align closely with those of a recent randomized controlled trial from India, which demonstrated that ultrasound-guided tunneled dialysis catheter insertions without fluoroscopic assistance were equally effective and safe compared to fluoroscopy-guided procedures. That study reported no significant differences in mechanical or thrombotic complications between the two groups, while noting a shorter procedure time for non-fluoroscopic insertions [\[14](#page-7-13)]. # **Catheter tip repositioning** Catheter tip malposition is a potential concern when fluoroscopic visualization is not available. In our study, repositioning was required in approximately 11% of cases, determined by routine post-procedural imaging. Notably, this rate is similar to those reported in cohorts using modified traditional (blind) techniques as well as fluoroscopy-assisted insertions [\[3](#page-7-2), [9\]](#page-7-8). Our findings are consistent with prior studies suggesting that the majority of catheter placements without fluoroscopy achieve satisfactory tip position on the first attempt, with acceptable rates of minor repositioning [[15\]](#page-7-14). Importantly, all catheters in our cohort ultimately achieved functional positioning sufficient to deliver effective hemodialysis. This result demonstrates that systematic post-procedural assessment and readiness to perform repositioning when necessary are key to ensuring quality outcomes without fluoroscopy [[15\]](#page-7-14). In addition to post-procedural imaging, other nonfluoroscopic techniques have been described for realtime tip localization. The intracavitary ECG method utilizes the catheter itself as an electrode, with the morphology of the P-wave progressively changing as the tip approaches the cavo-atrial junction, thereby allowing the operator to identify the optimal position [[16](#page-7-15), [17\]](#page-7-16). Alternatively, the agitated saline bubble–enhanced ultrasound method involves flushing saline mixed with microbubbles through the catheter while simultaneously imaging the right atrium with echocardiography; the immediate appearance of bubbles indicates correct tip location [[18\]](#page-8-0). The choice of these adjunctive methods varies among institutions, depending largely on operator Kakareko *et al. BMC Nephrology* (2025) 26:672 Page 7 of 9 experience, local preferences, and the availability of specific equipment. Further reduction in the need for tip repositioning may be achievable by incorporating real-time ultrasound confirmation of catheter position, as suggested in recent studies [[15\]](#page-7-14). #### **Left internal jugular vein access without fluoroscopy** Although right internal jugular vein access is the preferred approach due to its straighter course to the superior vena cava and right atrium, left-sided access is sometimes unavoidable. In our cohort, 21 catheters (8%) were placed in the left internal jugular vein without fluoroscopy. Outcomes, including bleeding rates, incident vs. prevalent status distribution, diabetes prevalence, and need for tip repositioning, were statistically comparable to right-sided placements. Despite these findings, left internal jugular placement without fluoroscopy remains controversial in some settings. Certain guidelines and experts have advised caution or even avoidance due to the increased risk of tip malposition and vessel stenosis [[1\]](#page-7-0). For instance, Yevzlin et al. noted that the lack of direct visualization can complicate left-sided placement because of anatomical challenges and potential for suboptimal catheter tip location [[3\]](#page-7-2). Similarly, other authors highlight that fluoroscopic guidance is particularly beneficial for left-sided insertions to minimize malposition risk [\[9](#page-7-8)]. Nonetheless, our experience and that of others [\[8](#page-7-7), [15](#page-7-14)] indicate that with experienced operators, ultrasound guidance and anatomical landmarks can achieve safe and effective left internal jugular access even without fluoroscopy. Institutions choosing this approach should ensure operator training, systematic post-procedural imaging, and readiness to perform prompt repositioning as needed to mitigate potential risks. Operator experience plays a crucial role in minimizing complications, with data suggesting that performing 50 or more catheter insertions reduces the likelihood of mechanical issues by about half compared to less experienced physicians [[19](#page-8-1), [20](#page-8-2)]. However, there are no universally established guidelines defining the exact number of tunneled catheter procedures required to achieve expert competency. In our center, trainees progress at an early stage from assisting to performing procedures under direct supervision and real-time guidance. Once proficiency is demonstrated, they are encouraged to perform most procedures independently, consolidating skills and building confidence while maintaining safety. #### **Role of different specialties in tunneled catheter placement** Tunneled hemodialysis catheter insertion is a procedure that varies significantly among centers in terms of the specialists performing it. While it is often considered a nephrology-driven intervention, both surgeons and interventional radiologists traditionally play important roles in vascular access management [[21,](#page-8-3) [22](#page-8-4)]. Historical studies have compared outcomes between catheters placed by surgeons and those inserted by radiologists, reporting similar immediate complication and success rates across both groups [[21,](#page-8-3) [22](#page-8-4)]. This suggests that, in terms of technical success and early complications, procedural expertise rather than specialty designation is likely the key determinant of outcome. However, as highlighted in subsequent work, fragmented care, where nephrologists rely on other departments for access creation, can contribute to treatment delays and increased use of temporary non-tunneled catheters. A Korean study demonstrated that when nephrologists performed tunneled hemodialysis catheter placement themselves, time from decision to dialysis was significantly shortened compared to radiology-led insertion (median 275 vs. 415 min, *p* < 0.001), with comparable safety and success rates (94.5% vs. 95.3%) [[8\]](#page-7-7). While long-term catheter survival was not fully addressed in that analysis, these findings underscore the benefit of aligning procedural responsibility with specialists directly involved in longitudinal dialysis care. Such integration supports continuity, timely decision-making, and potentially improved patient outcomes. # **Resource and cost considerations** Beyond clinical safety, the choice of technique has important implications for resource utilization. Fluoroscopyguided insertion in an interventional radiology suite requires specialized infrastructure, additional personnel, and increased logistical coordination, all of which contribute to higher costs. In contrast, ultrasound-guided bedside procedures in the dialysis unit are significantly less resource-intensive while maintaining comparable safety and efficacy. Cost analyses confirm that performing tunneled catheter insertions without fluoroscopy can be nearly twice as cost-effective as fluoroscopy-based approaches [\[3](#page-7-2)]. Even when accounting for rare instances of malposition requiring secondary fluoroscopic correction, the overall savings remain substantial. While fluoroscopy ensures near-perfect real-time confirmation of catheter tip position, our findings and prior literature indicate that the need for repositioning is infrequent. This raises the question of whether routine fluoroscopic use is justified in all cases. Although chest X-ray is not radiation-free, its effective dose is relatively low (approximately 0.02 mSv per examination). By contrast, fluoroscopy is associated with substantially higher exposure, as even short procedures may deliver doses several-fold greater depending on duration and technique [[23,](#page-8-5) [24](#page-8-6)]. A selective approach, reserving fluoroscopy for anatomically complex or high-risk scenarios, appears Kakareko *et al. BMC Nephrology* (2025) 26:672 Page 8 of 9 practical and resource-conscious. Empowering trained nephrologists to perform ultrasound-guided tunneled hemodialysis catheter placement without fluoroscopy aligns with these principles, offering an effective and patient-centered model of care that optimizes both safety and efficiency. Our study has several limitations. First, its retrospective single-center design may introduce selection bias and limit the generalizability of findings to other institutions with different patient populations or operator experience levels. The lack of a contemporaneous control group undergoing fluoroscopy-guided placement prevents direct comparison of outcomes between techniques within the same setting. Although post-procedural imaging was routinely used to assess catheter tip position, the accuracy of tip placement evaluation may vary due to differences in imaging interpretation and documentation. Finally, while complication rates were low, the study may have been underpowered to detect rare but clinically significant adverse events. # **Conclusions** Our study shows that ultrasound- and landmark-guided placement of tunneled hemodialysis catheters without fluoroscopy is safe and effective in experienced hands in cases without anticipated anatomical difficulties (e.g., prior failed catheterization attempts, known central venous stenosis or thrombosis, or history of vascular interventions suggesting altered anatomy). Low complication rates and reliable catheter function in our study population support this approach as a practical alternative where fluoroscopy is unavailable. These findings highlight the value of training in non-fluoroscopic techniques to expand safe vascular access options in clinical practice, particularly in resource-limited or high-volume dialysis centers where timely access is critical. #### **Acknowledgements** Not applicable. #### **Author contributions** KK1 was responsible for statistical analysis and drafting of the manuscript, KK2 collected the data, IG was involved in analysis and interpretation of data, ARR and TH revised the statistics and the manuscript. All authors read and approved the final manuscript. #### **Funding** Not applicable. #### **Data availability** The dataset supporting the conclusions of this article is included within the article. # **Declarations** #### **Ethics approval and consent to participate** This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The study was approved by Medical University of Bialystok ethics committee (approval no. APK.002.275.2024). Due to the retrospective nature of the analysis, individual patient consent was not required. #### **Consent for publication** Not applicable. #### **Competing interests** The authors declare no competing interests. #### **Author details** 2nd Department of Nephrology, Hypertension and Internal Medicine with Dialysis Unit, Medical University of Bialystok, Sklodowskiej-Curie 24A, Bialystok 15-276, Poland Received: 28 July 2025 / Accepted: 4 November 2025 #### **References** - 1. Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–164. - 2. Kinsella SM, Coyle JP, Long EB, McWilliams SR, Maher MM, Clarkson MR, et al. Maintenance Hemodialysis patients have high cumulative radiation exposure. Kidney Int. 2010;78(8):789–93. - 3. Yevzlin AS, Song GU, Sanchez RJ, Becker YT. 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