Fig. 6

5 y/o M with end stage renal disease requiring hemodialysis with very limited central venous access (left internal jugular occluded and left femoral vein occluded). His hemodialysis catheter was inadvertently pulled out and central venous access lost. a Initial venogram from the right neck demonstrates numerous cervical collateral vessels (solid arrow) with no opacification of the right internal jugular vein. Collateral vessels eventually drain into the patent mid SVC and azygous vein (dashed arrow). b 22G 10cm Chiba needle passed behind the clavicle (solid arrow) part way with ultrasound guidance and residual guidance with fluoroscopy. Patent SVC target is marked with angled catheter and wire (dashed arrow). c Wire is then passed from the neck to the IVC and safety wire from the groin is retracted. Eventually the wire from the neck was snared and “flossed” access was achieved. d Post recanalization venogram demonstrates patent but slightly narrowed SVC with limited cervical collateral filling. e Hemodialysis catheter placement with tip terminating in the right atrium and tunnel created over the shoulder to reduce the risk of inadvertent catheter removal in the future