• Local anesthesia in adults and general anesthesia in pediatrics.
• The patient under fasting condition is placed prone on angiography table.
• Skin preparation and a sterile draping of the operating field.
• Puncture site is chosen 1.5 cm above right iliac crest 10 cm lateral to the posterior median line.
• Puncture into inferior vena cava is made using 21 gauge 15 cm long needle, inserted at 45 degree angle from the horizontal and advanced medially and superiorly under us then fluoroscopic guidance.
• Entry into the IVC is made below the level of the renal veins, immediately anterior to the 3rd lumber vertebra.
• Intravascular position of the needle is confirmed by free aspiration of blood and injection of contrast media under fluoroscopy.
• A guide wire is introduced through the needle and advanced well into the IVC.
• The needle is replaced with a dilator. A catheter of appropriate length is tunneled subcutaneously from the right flank and advanced to the IVC

• The patient lies in supine position.
• The procedure is done under local anesthesia.
• Under ultrasound guidance; access by a 21 gauge angiocatheter (15cm) to right or middle hepatic vein through intercostal or subcostal approach.
• Entrance of the hepatic veins is confirmed by injection of diluted contrast media (iopromide) under fluoroscopy.
• A 0.018-inch guidewire is advanced through the needle and into the right atrium.

Intravascular catheter length is measured and selected in standard fashion.

• The initial access needle is exchanged over the guidewire for a coaxial transitional sheath, which permits replacement of the 0.018-inch guidewire with a 0.035-inch guidewire.
• The tunneled catheter is inserted over the wire through a peel-away sheath

For selected ESRD patients who have exhausted all conventional access routes , translumbar and transhepatic insertion of long term hemodialysis catheters provide additional sites for access

patency (primary defined as the number of catheter days from initial placement until removal & secondary defined as the number of catheter days after device replacement using the same access site) , mean cumulative duration of catheter in situ defined as the cumulative catheter days divided by the number of patients