Placing an appropriate tunneled dialysis catheter in an appropriate patient including the nonconventional sites.

Hemodialysis remains the most frequently chosen kidney replacement modality across the world. A well-functioning dialysis vascular access is critical to providing successful dialysis therapy. Despite its drawbacks, central venous catheter is commonly used as a vascular access to initiate hemodialysis therapy in acute and chronic settings. The growing recognition of providing patient centric care and per recommendations from the recently published Kidney Disease Outcome Quality Initiative (KDOQI) Vascular Access Guidelines, selecting the appropriate patient population for a central venous catheter placement involves implementing the End Stage Kidney Disease (ESKD) Life-Plan strategy. The current review examines the circumstances and challenges that increasingly lead to the hemodialysis catheter being the default and the only available choice for patients. The current review outlines the clinical scenarios for selecting an appropriate patient for hemodialysis catheter use for short-term or long-term needs. The review further discusses clinical pointers to assist with the decision-making process on estimation on prospective catheter length selection, particularly in the intensive care unit setting without the aid of conventional fluoroscopic guidance. A hierarchy of conventional and non-conventional access sites is proposed based on KDOQI guidance and multi-disciplinary author experience. Non-conventional sites are reviewed, including complications and technical guidance, for trans-lumbar IVC, trans-hepatic, trans-renal, and other exotic sites.