IMAGING IN DIALYSIS PATIENTS
Imaging and Peritoneal Dialysis Catheters
Stephen Ash,* Adrian Sequeira,† and Rajeev Narayan‡
*Indiana University Health Arnett, Lafayette, Indiana, †LSU Health Shreveport School of Medicine,
Shreveport, Louisiana, and ‡San Antonio Kidney Disease Access Center, San Antonio, Texas
ABSTRACT
The placement of a peritoneal dialysis (PD) catheter by
interventionalists demands not only procedural skill but
also an ability to decipher real-time ultrasonographic and
fluoroscopic images. In this article, we discuss how imag-
ing assists in PD placement and recognition of complica-
tions. To aid this endeavor, we have provided images and
Tunneled peritoneal dialysis catheters are the
most successful long-term transcutaneous access
devices ever used in medical practice. While flow
and infection problems complicate central venous
catheters for hemodialysis in weeks to months, peri-
toneal dialysis (PD) catheters can provide successful
dialysis access for years with few problems in dialy-
sate flow or infection. The various components of
the catheter must be placed in specific locations
within quite different tissues and spaces, such as the
lower part of the peritoneal cavity, the rectus mus-
cle tissue, and subcutaneous space. During place-
ment of a PD catheter, entry must be obtained into
a cavity that is normally almost completely empty,
the peritoneum. Recognition of the various tissues
encountered during PD catheter placement is greatly
aided by the images of fluoroscopy or perito-
neoscopy, even though careful physical examina-
tion, surgical techniques, and sensitivity to tactile
sensations are still needed.
General Principles of PD Catheter Placement
There is general agreement on the proper location
of the components of chronic peritoneal catheters
(Fig. 1):
• The intraperitoneal portion should be between
the parietal and visceral peritoneum, and the
Address correspondence to: Dr. Adrian Sequeira, MD,
FACP, FASN, FASDIN, LSU Health Shreveport School of
Medicine, 1501 Kings Highway, Shreveport, LA 71103,
e-mail: aseque@lsuhsc.edu.
Conflict of interest: None.
Seminars in Dialysis—Vol 30, No 4 (July–August) 2017
pp. 338–346
DOI: 10.1111/sdi.12607
© 2017 Wiley Periodicals, Inc.
338
video clips that should assist interventionalists. Compared
with the fluoroscopic technique, peritoneoscopic PD
catheter placement provides direct visual imaging to also
aid placement of the initial trocar and the peritoneal
catheter.
tip or coil of the catheter should lie next to the
parietal peritoneum in the lower abdomen
• The deep cuff should be within the rectus mus-
cle, near the medial or lateral border of the rec-
tus sheath and
• The subcutaneous cuff should be approximately
2 cm from the skin exit site
In placement of peritoneal catheters, it is best to
choose a deep cuff location that is free of major
blood vessels (Fig. 2). The superficial epigastric
arteries course from the femoral artery and ligament
toward the umbilicus, anterior to the rectus sheath.
The inferior epigastric artery generally lie in the
posterior portion the rectus muscle, and roughly in
the middle of the rectus sheath, but there is consid-
erable variation in its course. Considering the posi-
tion of these arteries, the safest locations for placing
the deep cuff are in the rectus muscle near the med-
ial or lateral border. The parietal peritoneum
attachment to the posterior rectus sheath is another
consideration, since this attachment is what allows
a penetrating needle or trocar to puncture the peri-
toneum rather than merely stretching it. The peri-
toneal attachment is stronger in the mid or upper
abdomen than in the lower abdomen. Below the
arcuate line, which is somewhere between the
umbilicus and the pubis, the posterior rectus sheath
disappears and the parietal peritoneal attachment is
weak; the attachment is strongest near the umbili-
cus. Regardless of the location of the umbilicus, the
entry to the peritoneum by a needle or trocar and
subsequent location of the deep cuff should be at a
level above the anterior superior iliac spine. When
the entry to the peritoneum is above the umbilicus,
it should be done with caution on the medial border
of the right rectus, to avoid the falciform ligament,
which attaches to the parietal peritoneum and runs
from the umbilicus toward the liver.
 IMAGING AND PERITONEAL DIALYSIS CATHETERS
Fig. 1. Proper relationship of peritoneal cuffs to abdominal musculature, parietal and visceral peritoneum, and skin exit site for
straight Tenckhoff catheter.
• The thickness of the rectus muscle; a 1 cm
• The location of the inferior epigastric artery
Fig. 2. Major blood vessels and landmarks of the anterior
abdominal wall. Open squares represent the preferred points for
location of the deep cuff of a chronic peritoneal catheter within
the medial or lateral border of the rectus muscle after careful
ultrasound evaluation of the rectus muscle and peritoneal sur-
faces. Solid squares indicate the external landmarks used during
blind insertion of a needle or cannula at the start of blind cathe-
ter placement.
• The absence of bulky or firm adhesions
Patient Evaluation Prior to PD Catheter
Surgery
In determining the best entry point for a needle
or trocar into the peritoneum, and the location of
the deep cuff of the PD catheter, ultrasound is
immensely valuable. Ultrasound evaluation
improves the ease and success of the placement pro-
cedure and occasionally prevents bleeding and
immediate failure of the procedure or catheter.
Using a medium frequency (10–12 MHz) vascular
probe such as used in placing internal jugular cathe-
ters, accurate information can be gained on:
• The exact location of the medial and lateral
border of the rectus muscle, noted by thinning
of the rectus sheath at these locations
339
thickness is ideal for reception of the entire
deep cuff
within the rectus muscle. With 2D echo, the
vessel appears as a round, echo-free space
which expands with heartbeats and does not
compress under pressure from the probe. With
color power Doppler (CPD), it is recognized by
red or blue, pulsatile color. The artery is easiest
to find by first locating it in the lower part of
the rectus and tracking it upward. It usually
lies near the middle of the rectus muscle and
against the posterior rectus sheath, but has
considerable variation. Smaller arteries and
veins also can be identified by CPD. If the infe-
rior epigastric artery is not found by either
method of ultrasound, then it is small and unli-
kely to cause any bleeding problems during
placement of the catheter. Using ultrasound
and a marker, one can “surface mark” the infe-
rior epigastric artery onto the abdomen. This
will provide a visual guide to the course of the
vessel.
between the visceral and parietal peritoneal sur-
faces. The normal visceral peritoneum moves
freely against the parietal peritoneum. When
the patient inhales deeply, all of the visceral
surfaces and structures that are imaged move
caudally out of the field of view and return on
exhalation; this is known as visceral slide (1).
Also, the normal parietal peritoneum has a
clear double line image on ultrasound, created
by the posterior rectus sheath and the parietal
peritoneum (separated by a thin layer of fat). If
a single line is seen, or no line is seen clearly,
there is a chance that this is an area of adhe-
sions. Though this method is not perfect, it at
least demonstrates the presence of thick adhe-
sions (as often seen underneath surgical scars).
It also demonstrates whether adhesions are
340 Ash et al.
more likely on one side of the abdomen or the
other.
• The thickness of the subcutaneous fat layer
between the rectus muscle and the skin and a
comparison of the fat layer thickness at differ-
ent levels. In patients with panniculus, the fat
is much thicker in the lower abdomen than in
the mid abdomen. In general, the length of
the skin incision over the deep cuff location
should be the same as the depth of the fat
layer.
To properly perform the ultrasound examination,
the patient must lie flat in the supine position, as
they will on the procedure table. Figure 3 is an Fig. 4. Noncontrast CT of patient with subcutaneous plexus of
example of an ultrasound of the lateral border of veins developing after superior vena cava occlusion, and shown
penetrating the rectus muscle sheath (white arrows).
the rectus muscle in a normal patient, and the Sup-
porting Information files also include a video ultra-
sound (Video S1).
During the ultrasound examination, there are
sometimes surprises, such as subcutaneous veins,
which enlarge with superior vena cava (SVC) occlu-
sion, connect through the rectus, and create a
plexus in the pre-peritoneal space of the abdominal
wall. A subcutaneous plexus of veins is shown in
Fig. 4, a noncontrast CT of the anterior abdominal
wall in a patient with asymptomatic (and previously
undetected) SVC occlusion. This is similarly seen in
portal hypertension (Video S2).

Fluoroscopic Peritoneal Dialysis Catheter

Placement

Following entry into the peritoneum, the correct

position of the needle is easily confirmed by instil-
lation of radiocontrast medium as shown in Fig. 5
(Video S3). When contrast is injected, a spider-like
image immediately develops as the dye expands
into small spaces between the irregular visceral
Fig. 5. Radiologic images on injecting dye through a needle
into the peritoneum. Arrow shows tip of the Veress needle.

folds and the smooth parietal peritoneum. Ultra-

Fig. 3. Ultrasound of abdominal wall near the lateral border of
the rectus. [Color figure can be viewed at wileyonlinelibrary.com]
sound is also helpful in controlling the passage of
the needle through the rectus sheath, adding visual
tracking to the feeling of a “pop” as the posterior
rectus sheath and peritoneum are penetrated
(Video S4).
Insertion of a long guide wire into the abdomen
and advancing it until it forms a curve in the lower
abdomen brings the wire against the parietal peri-
toneal surface as shown in Fig. 6. If the wire forms
a large curve and crosses the midline, it is a good
sign that the wire is against the parietal peritoneum
and is not in a bowel lumen or a recess formed
under bowel loops or adhesions. A 5 Fr side-port
sheath can be advanced over the wire and used to
inject dye during retraction (Fig. 7 and Video S5).
If there is a through and through perforation of the
bowel loop (as can occur by entering an area of
 IMAGING AND PERITONEAL DIALYSIS CATHETERS
Fig. 6. Course of guidewire after insertion and curving into the
anterior peritoneal space.
adhesions), then the outline of the visceral lumen
will occur as the sheath is retracted.
The value of the initial peritoneogram is that it
confirms that the tip of the entering needle or trocar
has entered the peritoneal space. It is important
to recognize the images that represent needle
penetration into other organs or spaces outside the
peritoneum. If the injection is pre-peritoneal, a flat-
sided image of the dye evolves, and the dye does not
diffuse quickly over time. This image usually has
sharp borders in the shape of a dagger (Video S6). If
the needle penetrates the visceral fat, the injected con-
trast forms a round shape that also does not change
quickly. Figure 8 is an image that developed after
injection of a needle into colon (Video S7). Figure 9
is an image after injection of contrast into the small
bowel (through a completely placed peritoneal cathe-
ter). Figure 10 is an image from injection of contrast
through a Veress needle, into the bladder (Video S8).
341
If an 18-gauge or smaller needle penetrates the
bowel and this is detected by injection of a small
volume of contrast, there is usually not much dam-
age to the bowel wall. The procedure can be
stopped and the patient admitted for observation
and intravenous antibiotics. Surgical repair is not
necessary but needs to be considered on a case-by-
case basis (2).
After confirmation of the proper location of the
needle and the guidewire, a dilator and then dilator
with split sheath are advanced over the guidewire.
The catheter is then advanced through the split
sheath so as to follow the same course as the guide-
wire. As the catheter is advanced through the split
sheath, the deep cuff reaches the anterior surface of
the rectus muscle. When the deep cuff is properly
placed, the top edge can be felt but not seen, below
the external rectus sheath (Video S9). A suture may
be applied around the deep cuff if needed. The
catheter is then tunneled laterally and downward to
an exit site.
After the catheter is placed, contrast should be
injected through it to assure free flow into the peri-
toneum. The contrast will quickly move into sur-
rounding peritoneal spaces and become more dilute
if saline has been injected to the abdomen, as shown
in Video S10. Sometimes, the catheter will be lying
in position near a large flat structure, such as a
bowel loop, the bladder, or a cul-de-sac; in this
case, the contrast will outline the flat surface and
initially fill a limited space (Video S11). This might
appear like the catheter is within a pocket. How-
ever, the fluoroscopy should be used to image about
15 seconds after injection of contrast. If the contrast
progresses away from this limited space to enter the
larger peritoneal space, then the catheter is appro-
priately placed. Outflow of clear fluid from the
catheter and change in air-fluid level in the catheter
with inspiration also indicates free communication
to the peritoneum.

Fig. 7. Pull back peritoneogram images using a 5Fr sheath. Note the sheath is over the glidewire and the wire makes a smooth turn
across the pelvic cavity. Contrast is injected through the sheath as it is pulled back over the wire. Arrow marks the tip of the 5Fr sheath.
(A–D) Contrast between bowel loops. If the bowel were perforated, then features suggestive of valvulae conniventes (small bowel) or
haustral folds (large bowel) would be seen. [Color figure can be viewed at wileyonlinelibrary.com]
342
Fig. 8. Image of dye distribution after injection into the colon.
The radio opaque material is stool within the bowel. When the
needle was removed, fetid odor was noted along with stool at the
tip of the needle. Reprinted from Abreo K, Sequeira A. Bowel
Perforation During Peritoneal Dialysis Catheter Placement, with
permission from Elsevier. [Color figure can be viewed at wileyon-
linelibrary.com]
Fig. 9. Images obtained by dye injection into a peritoneal dial-
ysis catheter in the small bowel (Courtesy Dr. Rasmussen).
Repositioning and Replacing Peritoneal
Dialysis Catheters
Although persisting infection is the main reason
for PD catheter failure and removal, outflow failure
is the second most common reason. When a cathe-
ter has outflow failure and has migrated to a new
position in the abdomen, omental attachment is the
most likely cause (Fig. 11). Omental attachment
Ash et al.
Fig. 10. Bladder perforation with a Veress needle. Arrow
points to the tip of the needle within the bladder (Courtesy Dr.
Rasmussen).
occurs principally to the side holes of the catheter.
It does not restrict fluid inflow to the peritoneum.
Injection of contrast into the catheter usually shows
what appears to be adequate flow into the sur-
rounding peritoneum (Fig. 12, Video S12). Occa-
sionally, however, the catheter is in a truly
restricted pocket of peritoneal space from which
freeing the catheter is difficult or impossible by any
radiologic procedure (further discussed below).
The most popular method of repositioning PD
catheters is by fluoroscopy, using a long guide wire
to bring the catheter into the anterior peritoneal
space. When a long, flexible guidewire is advanced
into the coiled or straight Tenckhoff catheter, the
guidewire eventually forms a loop that can only fit
in the anterior peritoneal space. For coiled Tenck-
hoff catheters, it is necessary to assure that the tip
of the guidewire follows the entire 540-degree spiral
of the coil and does not exit through a side-hole
(Fig. 13). For “arcuate” catheters, some straighten-
ing of the catheter is needed in order to get a stiff
guidewire to move into the body of the catheter.
When the guidewire is advanced far enough to form
a large coil, the catheter tip is usually freed from
omental attachments and brought into the anterior
peritoneal space. When the guidewire is removed,
the catheter will usually remain in this position
though it may not coil to a natural position
(Fig. 14). The catheter will often be freed from
omental attachment by this reposition technique
(but not always). Injection of contrast into the
catheter after placement will demonstrate free egress
of the contrast with extension from the catheter
quickly (Video S13).
 IMAGING AND PERITONEAL DIALYSIS CATHETERS
Fig. 11. Coiled Tenckhoff catheter migrated out of the pelvis.
Fig. 12. Peritoneogram through a peritoneal dialysis catheter
with omental entrapment. Dense collection of contrast around
the catheter with mild dispersion into the surrounding
peritoneum.
On the first injection of contrast through a
catheter with outflow failure and migration, the
contrast sometimes delineates a completely isolated
space, as confirmed by injecting the contrast and
then inspecting the image at least 15 seconds later.
Usually a sheet of omentum that “plasters” the
catheter against the parietal peritoneum causes
this. In one patient, outflow failure occurred about
1 year after catheter placement and the perito-
neogram indicated a restricted space just above the
bladder (Fig. 15A). In this patient, the catheter
was freed from adhesions with laparoscopy and
large amounts of omentum were seen, but there
was no omentectomy. About a year later, the
patient had outflow failure associated with left
343
Fig. 13. Wire manipulation of coiled Tenckhoff catheter with
outflow failure, taking care to manipulate the wire through the
entire 540 degrees of the catheter.
upper quadrant pain on fluid infusion. The perito-
neogram indicated that the catheter had migrated
to the left upper quadrant and was again encapsu-
lated in a flat space (Fig. 15B). It was decided not
to try to manipulate the catheter with guidewire. A
new catheter was placed by peritoneoscopy on the
right side of the abdomen. The old catheter was
removed. One year later, the patient had right
upper quadrant pain and outflow failure. Perito-
neogram again indicated a restricted space, with
the catheter trapped against the liver (Fig. 15C). It
was decided to discontinue PD and the patient was
transferred to hemodialysis.
Another option for dealing with a catheter suffer-
ing outflow failure is to replace the catheter with a
new catheter using the same site for the deep cuff
and peritoneal entry. This is done by placing a
guidewire into the old catheter, removing the old
catheter over the guidewire, placing a dilator/split-
sheath over the guidewire, and then inserting the
new catheter through the split sheath (Fig. 16). This
method has a high probability of working. It avoids
placing the catheter into exactly the same track as
Fig. 14. Migrated Straight Tenckhoff catheter (A) repositioned
successfully using a guidewire (B).
344 Ash et al.

Fig. 15. (A) Peritoneogram through peritoneal dialysis catheter that had outflow failure 1 year after placement. Catheter was reposi-
tioned laparoscopically, no omentectomy was performed. (B) Approximately 1 year later, again having outflow failure. Arrow shows tip
of the catheter above the pelvic inlet. Reposition by guidewire was not attempted. New catheter was placed on the right side by perito-
neoscopy with coil in the lower abdomen. (C) Same patient about 1 year later, with outflow failure again. Tip shows catheter in the
right subcostal area. Catheter was removed and patient was transferred to hemodialysis.

the previous catheter because the sheath can be
directed in a different direction once the guidewire
is removed. The deep cuff bonds to surrounding
fibrous tissue in about the same time as a cuff
would in a new position.
A final option for dealing with outflow failure is
to plan to place a new catheter and then remove the
old one. The new catheter should preferably be
placed on the opposite side of the abdomen through
the medial or lateral border of the rectus sheath. If
the placement of the catheter is performed by peri-
toneoscopy, then there is an extra advantage that
the old catheter can be visualized during the proce-
dure. After creating a pneumoperitoneum and view-
ing through the scope, the peritoneal entry site of
the catheter is first located. Inspection confirms that
the cuff of the failed catheter is extraperitoneal, and
whether there are adhesions to the site of entry
(Fig. 17). The body of the catheter is then inspected
to determine whether the tip of the catheter is lying
within the anterior peritoneal space. Catheters with
outflow failure and migration usually appear to dive
into the mass of omentum and bowels and the tip is
not visible (Fig. 18A). The tip of the Y-Tec scope
can be advanced under the catheter body and the
scope rotated to put traction on the catheter. If the
catheter is immovable, then it almost certainly has
omental attachment. In some failed catheters, there
is a thin layer of omentum over the body of the
catheter (Fig. 18B). In others, the catheter is “plas-
tered” against the parietal peritoneum by a thin
layer of omentum (Fig. 18C). The new catheter is
placed through the spiral guide around the needle-
scope cannula, and the failed catheter is then
removed. Often a variety of adhesions are seen
within the peritoneum, sometimes even in patients
without prior surgery (Fig. 19). Occasionally, the
peritoneoscopic evaluation of a failed PD catheter
indicates no omental attachment and proper posi-
tion of the catheter in the anterior peritoneal space.
In this case, the outflow failure is entirely “func-
tional” such as due to constipation or merely exces-
sive omental fat. In these cases, there is no reason
to place a new catheter.

Fig. 16. Fluoroscopic images of dysfunctional peritoneal dialysis catheter before, during, and after salvage.
 IMAGING AND PERITONEAL DIALYSIS CATHETERS
Fig. 17. Views of the parietal peritoneum and deep cuff of a
peritoneal dialysis catheter taken through the Y-TecTM peritoneo-
scope during placement of a new peritoneal dialysis catheter. (A)
Appearance of the normal deep cuff (arrow). (B) Thin omental
adhesion to the site of the deep cuff (arrow). [Color figure can be
viewed at wileyonlinelibrary.com]
Ultrasound Examination of Existing PD
Catheters
There are reliable physical signs of most problems
relating to PD catheters, especially those in the sub-
cutaneous tunnel and cuffs. However, as in other
345
areas of medicine, ultrasound imaging offers consid-
erably more detailed information.
Figure 20 includes a number of ultrasonic images
of various portions of normal and abnormal PD
catheters. The normal appearance of the cross-sec-
tion of a PD catheter within the subcutaneous tun-
nel has two circular lines, indicating each inner and
outer surface (Fig. 20A). The appearance of the PD
catheter subcutaneous tunnel when there is fluid
around the catheter is of an irregular anechoic
space. The catheter surfaces are no longer visible
within the fluid (Fig. 20B).
The normal appearance of the superficial cuff of
a PD catheter is similar to a rib bone shadow.
Due to the density of normal fibrous ingrowth to
the cuff, ultrasound waves do not penetrate the
cuff. The result is shadowing or a loss of imaging
on the opposite side of the cuff, and there is no
visibility of the cuff material (Fig. 20C). When
there is fluid around a cuff, the cuff outline is
accentuated because the fluid around the cuff pro-
vides a different density from the cuff. This creates
the “Signet Ring” sign (Fig. 20D). The ultrasonic
image of a normal subcutaneous tunnel and

Fig. 18. (A) Appearance of catheters with outflow failure and migration through the Y-Tec scope. The most common finding is that
the catheter dives down into the omentum, and it is immovable by mild pressure of the tip of the scope. (B) Sometimes the catheter is
covered by a thin layer of omentum, making the side-holes invisible. (C) Sometimes the catheter is held against the parietal peritoneum
by a thin layer of omentum (right). [Color figure can be viewed at wileyonlinelibrary.com]

Fig. 19. (A) Normal parietal peritoneum (below) and visceral peritoneum as seen through the Needlescope. (B) Broad midline adhe-
sion from prior midline incision of an uncomplicated surgery. (C) Broad omental adhesion to anterior parietal peritoneum after fungal
peritonitis. (D) Wispy adhesions sometimes seen in patients without prior abdominal surgery. [Color figure can be viewed at wileyonline-
library.com]
346 Ash et al.

Fig. 20. Ultrasound appearance of various components of peritoneal dialysis catheters. (A) Normal appearance of catheter in the sub-
cutaneous tunnel, when the plane of ultrasound is perpendicular to the catheter. Note lack of shadowing, and four curved lines indicat-
ing inner and outer surfaces of the silicone catheter. (B) Appearance of subcutaneous tunnel with fluid around the catheter. Note that
the catheter surfaces are no longer visible within the fluid. (C) Normal appearance of the superficial cuff of a PD catheter. Note shadow-
ing of the cuff and tissues below and no visibility of the cuff material. (D) Appearance of a cuff with fluid around it, with visibility of
cuff material creating the “Signet Ring” sign. (E) Normal subcutaneous tunnel and catheter in longitudinal view. (F) A subcutaneous
tunnel and catheter which seem to disappear at one point. Catheter is kinked turns downward towards the rectus at this point. (G) Deep
cuff within rectus muscle. Note shadowing below the cuff. [Color figure can be viewed at wileyonlinelibrary.com]

catheter, seen in longitudinal view, presents four
linear lines (Fig. 20E). If there is a kink in a
catheter, the longitudinal view of the catheter has
a portion that seems to disappear (Fig. 20F). The
normal picture of the deep cuff within rectus mus-
cle is also a dark area with posterior shadowing
(Fig. 20G). The deep cuff is not as clearly seen as
the superficial cuff, since it is much deeper. If there
is fluid around the cuff, there is an irregular black
shape around the site of the cuff. As with fluid
around the catheter in the tunnel or the superficial
cuff, this indicates pericatheter fluid leak or infec-
tion.
Ultrasonic imaging is also helpful in the evalua-
tion of abdominal hernias, whether spontaneous or
caused by prior surgery or forming around the cuff
(as caused by prior cuff loosening and outward
migration). Using ultrasound, the physician can
determine the size of the hernia, whether there are
bowel loops included, and the size and shape of the
opening to the peritoneum. Repeat evaluations and
printed images help to indicate whether the hernia
is enlarging. All of these factors relate to the
decision about whether the hernia must be repaired
for the patient to remain on PD.
With imaging techniques such as fluoroscopy,
ultrasound and peritoneoscopy, PD catheter place-
ment can be performed safely and effectively by
interventional techniques. This avoids the need for
general anesthesia and surgical suites, makes the
procedure more timely, and expands the option of
PD to many more patients.
References
1. Sigel B, Golub RM, Loiacono LA, Parsons RE, Kodama I, Machi J,
et al.: Technique of ultrasonic detection and mapping of abdominal
wall adhesions. Surg Endosc 5:161–165, 1991
2. Abreo K, Sequeira A: Bowel perforation during peritoneal dialysis
catheter placement. Am J Kidney Dis 68:312–315, 2016
Supporting Information
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