Use of Permcath (Quinton) catheter in uraemic patients in whom the creation of conventional vascular access for haemodialysis is difficult

During the last 4 years, the Permcath Quinton double-lumen silicone catheter was inserted into the internal jugular vein of 57 uraemic patients with difficulty for creating conventional vascular access for haemodialysis. In 4 patients, with definitive contraindication of conventional vascular access, this catheter still permits haemodialysis after a duration of 8-25 months. In 25 further patients with terminal uraemia, but poor vein system, it allowed the maturation of an arteriovenous fistula after 2-14 months of use. In 17 patients already on chronic haemodialysis, but who lost abruptly their vascular access (15 grafts and 2 arteriovenous fistulae), it allowed a new arteriovenous fistula to mature in 16 cases after a mean duration of 7.3 +/- months. In 5 patients with short life expectancy because of neoplasia, it allowed to dialyse them until their death which occurred after 6.5 +/- 2.2 months. In 6 patients with acute renal failure and haemostasis problems, it allowed to perform not only dialysis, but also plasmapheresis in 3 and parenteral nutrition in 3 other cases. The complications were the following: sepsis (n = 3); episodes of hypocoagulability due to inadvertent injection of heparin stored in the lumen (n = 2), thrombosis of the lumen (n = 3), and insufficient flow (n = 6). In no case these complications prevented continuation of haemodialysis. The catheter had to be removed in 2 cases because of septis and in 1 case because of insufficient flow. In 3 cases the catheter had to be replaced because of thrombosis and in 1 case because of laceration. These complication rates are, however, fewer than those reported in the literature for arteriovenous shunts or rigid subclavian and femoral catheters. The Permcath catheter seems, therefore to be the method of choice for immediated vascular access in patients in whom the creation of conventional vascular access is difficult.     

A retrospective study of palindrome symmetrical-tip catheters for chronic hemodialysis access in China

Abstract

Hemodialysis catheters remain necessary for long-term vascular access in patients for whom arteriovenous access may be problematic or impossible. Developments in catheter design have improved long-term catheter functionality, and reduced the rate of infection and complications associated with their use. This retrospective study of 284 cases of chronic catheterization in 271 patients treated between 2009 and 2011 using Tal Palindrome? symmetrical-tip (N?=?118) or Quinton? Permcath? step-tip (N?=?166) hemodialysis catheters evaluates the efficacy and the safety of symmetrical-tip dialysis catheters for chronic hemodialysis, compared with a step-tip catheter. Measurements of catheter performance included mean catheter dwell time, incidence of low blood flow, and rates of infection and catheter-related blood stream infection (CRBSI). The symmetrical-tip catheter had a significantly longer mean dwell time compared with the step-tip catheter; 329.4?±?38.1 versus 273.1?±?25.4?d (p?<?0.05). In addition, the rate of occurrence of low blood flow per 1000 catheter days was lower for the symmetrical-tip compared with the step-tip catheter; 1.13 versus 6.86 (p?<?0.01). The symmetrical-tip catheter was also associated with a lower incidence of complications; the rates of infection (0.28 vs. 0.78; p?<?0.01) and CRBSI (0.15 vs. 0.44; p?<?0.01) were lower compared with those for step-tip catheters, and catheter removal occurred less often for the symmetrical-tip catheter (8% vs. 16%; p?<?0.05). The symmetrical-tip hemodialysis catheter was associated with a longer mean dwell time, lower incidence of low blood flow, and lower infection rate compared with the step-tip catheter.     

Vascular access surgery: a 2-year study and comparison with the Permcath.

The results of a 2-year prospective study of primary and secondary vascular access surgery for haemodialysis have been compared with a retrospective study of central venous access via a flexible silicone catheter (Permcath). Cumulative patency for 61 primary fistulae in 57 patients was 64.8% at 1 year and 57.7% at 2 years. The patency of 55 secondary procedures in 43 patients was 48.1% at 1 and 2 years. Cumulative survival of 64 Permcaths inserted into 51 patients was 74% at 1 year and 43% at 2 years. Surgical complications included explorations for bleeding (2), haematomas (4), swollen arms (4), and inadequately dilated veins (4). Permcath complications included explorations for bleeding (3) and a temporary recurrent laryngeal nerve palsy (1). Exit site infection and septicaemia rates were 4.95 and 3.36 per 1000 catheter days respectively, but 20.6% of septicaemic episodes occurred in a patient who refused catheter removal. For haemodialysis, the Permcath is comparable with secondary vascular access. The Permcath may have a primary access role in patients with limited life expectancy.     

Five years experience with the Quinton Permcath for vascular access

Over a five-year period 64 Quinton Permcaths were inserted into 51 dialysis patients (age range 17-72 years, mean 52.1 SD 12.83). The duration of catheter use ranged from 5 to 1479 days, mean 315.7 SD 337. The actuarial catheter survival rate at 1 year was 74%, at 2 years 43%, at 3 years 25% and at 4 years 12%. The indications for use were: exhausted peripheral access; CAPD contraindicated; abrupt failure or lack of an arteriovenous fistula; acute renal failure; limited life expectancy; patient insistence; conventional access contraindicated. Only minor complications occurred during insertion: haemorrhage requiring exploration in three patients and a temporary left recurrent laryngeal nerve palsy in one patient. The exit site infection and septicaemia rates were 4.95 and 3.36 per 1000 catheter days respectively. Eighteen catheters failed due to infection (range of use 72-1479 days, mean 559 SD 388). Inadequate initial blood flow (less than 150 ml/min) occurred in 10% of dialyses but only six catheters failed due to intractable flow difficulties (range of use 5-49 days, mean 22 SD 17.5). Catheter sepsis was implicated in the death of two patients. One subclavan/innominate vein thrombosis occurred. The Quinton Permcath represents a significant advance providing immediate, durable, and relatively safe access in a variety of difficult circumstances.     

Do AshSplit haemodialysis catheters provide better flow rates in the long term?

BACKGROUND: Recently, interventional radiologists have adopted an increasingly prominent role in the placement and management of hemodialysis catheters, as well as in the research and development of new and better catheters. The purpose of this study was to evaluate the viability and hemodialysis efficiency of the AshSplit catheter and the Permcath catheter. METHODS: 204 consecutive patients requiring radiological insertion of hemodialysis catheters were followed, retrospectively, over a 42-month period. Both hemodialysis catheters were placed using a combination of ultrasonic and fluoroscopic guidance and tunneled appropriately. Information collected included catheter insertion sites, insertion complications, catheter duration, and final outcome. RESULTS: Over the study period of two years, 269 catheters were placed into 204 patients with end stage renal failure. Patients received either an AshSplit (101 patients, 127 catheters) or a Permcath (103 patients, 142 catheters). Vascular access route of choice was the right internal jugular vein (67% AshSplit, 71% Permcath). Insertion complications occurred in 18 patients overall (6.6%), with only 1 requiring further intervention (hemopneumothorax). Flow rates averaged 259 mls/min for AshSplits and 248 mls/min for Permcaths (p < 0.001). Follow-up of catheter viability for 42 months yielded a mean AshSplit catheter duration of 246 days (range 6-932) and 239 days (range 1-1,278) for Permcath (p = 0.46). Reasons for catheter failure and elective catheter removal were similar in both groups; however, Permcaths required significantly more thrombolysis than AshSplits, p < 0.001. CONCLUSION: The AshSplit provides significantly better flow rates and less thrombolysis compared to the Permcath, with similar catheter dwell times.     

Factors affecting long-term survival of tunnelled haemodialysis catheters--a prospective audit of 812 tunnelled catheters.

BACKGROUND: In 2001, in the US, 23% of haemodialysis patients were dialysing through tunnelled venous catheters (TVCs), and in the UK (2006) there were 28% of prevalent patients using catheters. It is unlikely that numbers will significantly decrease. We present the results of a prospective audit of the survival of 812 TVCs placed in 492 patients at our institution over a 6-year period (comprising 212 048 patient catheter days or 7068 patient catheter months of follow-up). Four different designs of catheter were studied: Split-Cath III (Medcomp), HemoSplit (Bard), Tesio twin catheter (Medcomp) and Permcath (Quinton). METHODS: We used Kaplan-Meier survival analysis with log-rank test, to compare the effect of different parameters on catheter survival.The relative importance of significant parameters was determined by Cox regression analysis. RESULTS: We have shown a significant catheter survival advantage of first catheters over second and subsequent insertions, of right internal jugular site over left internal jugular and thereafter over femoral site, and of non-diabetic over diabetic patients. Patient age, sex and operator (physician in ward-based procedure room under ultrasound control or surgeon in operating theatre under fluoroscopic assistance) did not significantly affect survival. The Permcath design demonstrated inferior survival in all but first catheter insertions in catheter-na?ve patients. The HemoSplit and Tesio twin catheter designs demonstrated best survival overall. By Cox proportional hazard modelling the design and the position of the TVC seemed to be the most significant independent survival factors. CONCLUSIONS: Clinicians need accurate data regarding catheter survival, mode of insertion and design, to inform practice.     

Use of permanent dual lumen catheters for long-term haemodialysis.

Permanent dual lumen catheters (PDLC) provide alternative vascular access in patients considered unsuitable for arteriovenous fistula, arteriovenous graft or peritoneal dialysis. Experience with their use for long-term haemodialysis is presented. Between January 1990 and April 1994, 101 catheters were inserted into 63 patients (median age 62 years). A PDLC was the primary vascular access type in 5 patients. Of the first catheters, 70% were inserted percutaneously into the subclavian vein. The median duration of catheter use was 168 days (range 5-1582 days). The overall cumulative observed catheter survival rate was 94% at 6 months, 89% at 1 year and 75% at 4 years following insertion. The major complications were blockage and catheter related infection occurring in 28% and 15% of catheters, respectively. Death and blockage were the commonest reasons for catheter removal. PDLC play a vital role in the provision of access for long-term dialysis and should be considered the access type of choice in patients with limited life expectancy.     

Use of the Tesio catheter for hemodialysis in patients with end-stage renal failure: a 2-year prospective study

BACKGROUND: The Tesio catheter system has been proposed to be a reliable source of vascular access for the dialysis patient with low rates of infection and other complications. Whether such catheters provide reliable short- and long-term access remains undetermined. METHODS: This study prospectively examined all Tesio lines inserted over a 2-year period in patients with end-stage failure with careful recording of all catheter complications and reasons for catheter loss. RESULTS: 100 catheters were inserted in 82 patients giving a total experience of 13,749 catheter days; 74 catheters were inserted into the jugular veins, the remainder into the femoral veins; 82 insertions were covered with antibiotics. At the end of the study, 29 catheters remained in situ. Of the remaining 71 catheters, 27 catheters were removed because of fashioning of definitive access. Nine catheters were lost due to infection and 10 were lost due to non-function; 19 patients died with a functioning catheter. Episodes ofnon-function were the major complications, although catheter patency was restored in 90% of cases utilizing urokinase and warfarin. Overall 80% of femoral and 16% of jugular catheters required anticoagulation. CONCLUSIONS: Tesio catheters inserted into the jugular or femoral veins can provide excellent access whilst awaiting definitive dialysis access. They are well-tolerated with a low complication rate compared to standard temporary central venous catheters. Non-function remains a significant problem, especially in femoral catheters, which should be anticoagulated following insertion. Because of our results we suggest that these catheters be used as part of the co-ordinated approach to the management of vascular access in end-stage renal failure patients without definitive access.     

Five years' experience with Hickman catheters as temporary access for haemodialysis

Two different types of Hickman catheters were used as central venous access for haemodialysis. The device was implanted in 58 patients with chronic renal failure, already undergoing haemodialysis, because of thrombosis or infection of the previous vascular access, in order to permit immediate treatment and in nine patients with acute renal failure, as a 'first choice' method suitable either for dialysis or for parenteral infusions and nutrition. The catheter was inserted, under local anaesthesia, through the external jugular vein up to the right atrium; the haemodialysis treatment was carried out by single-needle technique 3-4 times weekly and all the catheters were filled daily with heparinised saline and Miconazole solution. The mean duration was 76 +/- 93 days with an overall of 2253 treatments. The flow rate ranged between 150 and 290 ml/min, with acceptable recirculation rate and biochemistry similar to that of standard dialysis. The complication rate was 20%, including thromboses and infections; no operative mortality nor major complications were observed. Based on these data, we believe that the Hickman catheter represents the ideal method of temporary access for haemodialysis.     

Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: an ultrasonographic survey in uraemic patients

Background: Creation of a reliable haemoaccess is a critical problem for practicing nephrologists once haemodialysis has been considered. A double-lumen internal jugular-vein catheter is favoured in most cases requiring temporary haemoaccess. However, numerous complications, even lethal ones, may occur with the cannulating procedure. Using ultrasound, we attempted to describe the occult anatomical variations of vessels which may be responsible for complications. Methods: A 'SiteRite' ultrasonographic device was used to inspect the anatomical structure of the internal jugular veins (IJV) in 104 consecutive uraemic patients undergoing creation of internal jugular vein temporary angioaccess. Images of the vessels and demographic data of patients were recorded and analysed. Results: Anatomical variations of the right and left IJVs were found in 19 (18.3%) and 17 (16.4%) uraemic patients respectively. Unilateral IJV variations were discovered in nine patients (8.7%). A total of 27 patients (26.0%) had IJV anatomical variations that might contribute to difficulty in external landmark-guided IJV cannulation. Conclusions: The external anatomical landmarks for cannulating the IJV are not reliable in about one-quarter of uraemic patients. An ultrasound survey on the IJV anatomy is recommended for selecting proper puncture site and reducing risks of insertion complications for IJV dialysis catheters. Key words: jugular vein; anatomy; uraemia; haemodialysis catheter; vascular access; ultrasonography      

Vascular access: choice and complications in European paediatric haemodialysis units

Background  

European and U.S. guidelines emphasise that permanent vascular access in the form of arteriovenous fistulae (AVF) or grafts (AVG) are preferable to central venous catheters (CVC) in paediatric patients on long-term haemodialysis. We report vascular access choice and complication rates in 13 European paediatric nephrology units.     

Ultrasound-guided cannulation versus the landmark-guided technique for acute haemodialysis access

Background. The correct placement of large-bore venous catheters plays an important role in the management of haemodialysis patients. Whilst the procedure for landmark-based placement of these catheters is well known, the technique is not without significant morbidity and mortality. Complications include arterial puncture, haematoma, and pneumothorax. The procedure may be further complicated in these patients by venous thrombosis and abnormal vein position from multiple previous attempts at venous access. Methods. Data on the use of ultrasound guidance versus anatomical landmarks for the placement of internal jugular vein (n=69) and femoral vein (n=30) dialysis access was retrospectively analysed over a 13-month period. Data collected included age, sex, duration on dialysis, number of vein cannulation sets required, number of attempts for successful cannulation, salvage of failed cannulation using landmark-based technique by ultrasound guidance, and the complication rate. Results. Internal jugular vein cannulation using ultrasound was ultimately successful in 96.67% compared to 82% in the landmark group. The vein was entered on the first attempt in 83.3% of patients with ultrasound compared to 35.9% of the landmark group (P<0.0001). Seven patients in whom the landmark technique was unsuccessful had access placed under ultrasound guidance. There were fewer carotid artery punctures in the ultrasound group (7.7 versus 0%, P=n.s.). In the femoral vein group, the vein was entered on the first attempt in 85.7% of patients with ultrasound compared to 56.25% of the landmark group. (P=n.s.). Conclusions. The use of ultrasound guidance is associated with fewer complications and is more likely to lead to cannulation of the vein at the first attempt in haemodialysis patients.     

Survival and complications of cuffed catheters in children on chronic hemodialysis

 Central venous catheters are being increasingly used as hemodialysis vascular access. We evaluated catheter survival, outcome predictors, and complications in a total of 36 catheters used in 13 children and young adults undergoing chronic maintenance hemodialysis through catheter for a duration of 10.4±5.6 months. Reasons for catheter failure were: thrombosis 12 of 36 (33%), infection 6 of 36 (17%), and extrusion 2 of 36 (5.4%). Catheters were lost to infection and thrombosis at 1.1 and 2.2 episodes per 1,000 catheter days, respectively. Symptomatic infections, Gram-negative and polymicrobial sepsis increased the risk of catheter failure. Most of the thrombotic episodes occurred in patients with inherent thrombotic tendency. The survival of the 36 catheters was 62% at 1 year. The survival of 13 randomly chosen catheters, 1 from each patient, was 85% at 1 year. The time from insertion to first complication correlated significantly with the outcome (P<0.03). We conclude that central venous catheters are still associated with a high rate of failure and may be a regular access choice only in a selected patient population with no inherent thrombotic tendency and no other option available for long-term hemodialysis. Received: 21 July 1997 / Revised: 20 July 1998 / Accepted: 22 July 1998     

Assessing the utility of ultrasound-guided vascular access placement with longer catheters in critically ill pediatric patients

Background

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long-dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.

Aim

The study sought to compare longevity, catheter-associated complications, and the need for additional vascular interventions when using ultrasound-guided longer peripheral intravenous catheters comparing to a traditional approach using standard-sized peripheral intravenous catheters in pediatric critically ill patients with difficult vascular access.

Methods

This single-center retrospective cohort study included children 0–18 years of age with difficult vascular access admitted to the pediatric intensive care unit between 01/01/2018–06/01/2021.

Results

One hundred and eighty seven placements were included in the study, with 99 ultrasound-guided long intravenous catheters placed and 88 traditionally placed standard-sized intravenous catheters. In the univariate analysis, patients in the traditional approach were at a higher risk of intravenous failure compared to those in the ultrasound-guided approach (HR = 2.20, 95% CI [1.45–3.34], p = .001), with median intravenous survival times of 108 and 219 h, respectively. Adjusting for age, patients in the traditional approach remained at higher risk of intravenous failure (HR = 1.99, 95% CI: [1.28–3.08], p = .002). Adjusting for hospital length of stay, patients in the ultrasound-guided approach were less likely to have additional peripheral intravenous access placed during hospitalization (OR = 0.39, 95% CI [0.18–0.85] p = .017).

Conclusion

In critically ill pediatric patients with difficult vascular access, ultrasound-guided long peripheral intravenous catheters provide an alternative to traditional approach standard-sized intravenous catheters with improved longevity, lower failure rates, and reduced need for additional vascular interventions.     

Dialock--an alternative to Permcath and access graft

PURPOSE: An adequate vascular access is the precondition for a well-functioning hemodialysis. Due to the increasing age and the rising co-morbidity of hemodialysis patients the number of those with grafts or central venous catheters (CVC) is steadily growing. The Dialock vascular access system provides a subcutaneously implantable device for hemodialysis that combines the advantages of central venous access with percutaneous puncture. PATIENTS AND METHODS: Over a period of 30 months 26 Dialock vascular access systems were implanted at our department. 17 patients were male, 9 patients female. In 11 patients the implantation of this system was indicated for internal medicine reasons. In 15 long-term hemodialysis patients implantation was carried out as ultimate solution because of persisting vascular access problems. In a comparable control group of 22 hemodialysis patients 47 vascular accesses were registered within the same period. In parallel, another 110 patients with grafts implanted at our department at that time but not put to hemodialysis at our clinic were analysed. RESULTS: In a comparable number of access days the graft and the central venous catheter showed a considerably higher infection rate (Exit site + blood stream infection) per 1,000 hemodialysis access days than the vascular access device. The rate of malfunctions with or without subsequent lysis was higher using the CVC than when applying Dialock or graft. Angiographies with percutaneous transluminal angioplasty (PTA), or thrombectomies, respectively were significantly more often required with the graft than changes of catheter when using the vascular access system. More than half of the 110 patients observed at the same time, who had a graft implanted at our department without subsequent hemodialysis at our clinic had to undergo another surgical or radiologic intervention. CONCLUSION: The Dialock access system represents in our experience a safe and with careful application less complicated vascular access device for the complex hemodialysis patient. With comparatively low infection and complication rates the Dialock vascular access system serves as a good alternative to the permanent CVC (Permcath) as well as to the graft.     

Successful use of single-lumen, urokinase immobilized femoral catheters as a temporary access for haemodialysis

Method: Placement of a femoral vein catheter as temporary vascular access for haemodialysis was conducted and the indications, catheter patency rate, and incidence of catheter-related infections were examined. A urokinase immobilized femoral vein catheter (UIFC) is a soft polyurethane single-lumen catheter 2.7 mm in diameter and 22 cm in length which needs no heparin infusion (Japan Shawood Co., Ltd., Tokyo; Unitica Co., Ltd., Hyogo, Japan). A soft silicon rubber was attached to the tip of the catheter in order to avoid excessive bleeding during insertion. Aseptic adhesive wound dressing was employed at the exit-site which was cleansed with popidone-iodine and renewed at each dialysis session. Results: Eighty-one UIFCs were used for haemodialysis in 64 patients (acute renal failure: 11; vascular access trouble: 53; initiation of chronic dialysis: 17). The average age of the patients was 58±13 years, ranging from 26 to 80 years. The mean duration of catheter indwelling was 22.4±13.1 days. An adequate blood flow of 180-200 ml/min was obtained through UIFC and returned to another peripheral vein punctured at each dialysis session. Unexplained fever occurred in four cases while the UIFC was in place (4.9%) but culture of either blood or the catheter tip was negative for bacteria. The catheter was removed immediately and fever subsided in all cases. The overall catheter survival rate was 84% at 34 days calculated using the Kaplan-Meier method. Catheter insertion was easy to perform and no serious complications such as pulmonary embolism or septicaemia occurred. Conclusion: Our modified type of UIFC is very useful as a temporary access for haemodialysis with a very low incidence of catheter-related infections and no need for heparinization. Excellent catheter patency was maintained with the plug system and careful dressing techniques without unnecessary bleeding during catheter care. Key words: femoral vein catheterization; haemodialysis; temporary vascular access; catheter survival rate      

A technique for the placement of a long-term hyperalimentation catheter in the head and neck oncology patient

The relative safety of silicone rubber catheters allows use of the deep brachial vein for long-term central venous access when other vascular access sites are unavailable or undesirable. After local infiltration, a small incision is made across the medial edge of the brachial biceps and the vein is isolated from the artery and median nerve. An introducer is used to aid in insertion of the catheter. Catheter position is checked with a postoperative radiograph of the chest. Sixty of our patients have had catheters in place from 14 to 200 days, with few complications. There was one catheter-related death from acute bacterial endocarditis and one case of clinical thrombosis. The surgical approach to the deep brachial vein provides a simple and safe method of long-term central venous access in the head and neck oncology patient, whereas regional therapy and treatment planning often preclude use of other more conventional access sites.     

Central venous access for haemodialysis using the Hickman catheter

One hundred and seven Hickman catheters for haemodialysis were inserted in 90 end-stage chronic renal failure patients, and were used for 1-448 days (median 45 days). Sixty-nine per cent of the patients were treated without any problem for 1-165 days (median 34 days). Clinically evident complications occurred in 44 catheters inserted in 28 patients, and included outflow obstruction (16.8% of the catheters) and thrombosis (13.1% of the catheters). However, many episodes of clotting or insufficient flow could be corrected by simple manoeuvres. Other less frequent complications were recorded: sepsis, mainly in patients with increased risk factors (4.1% of the catheters), laceration of the catheter (3.7%) and occasional cases of jugular-vein phlebitis, transient palsy of a vocal cord, haematoma of the wound, and bleeding of the cutaneous orifice. No clinical sign of subclavian or innominate-vein thrombosis was observed. Nevertheless, a prospective study conducted in 50 asymptomatic patients demonstrated a 12% rate of anomalies of the venous system, although two-thirds of these alterations were mild and had no consequence. When the present series is compared to the results obtained with currently available percutaneous haemodialysis catheters, it is concluded that the Hickman catheter is a safe, comfortable and efficient vascular access device.     

Success and failure with the Demers catheter in dialysis

Between January 1995 and January 1999 54 Demers atrial catheters were implanted in 48 uraemic patients. Indications for implantation were: urgent need for haemodialysis with missing vascular access (39), fistula occlusion (7), low shunt flow (3) and problems with a previously implanted catheter (5). We observed 7 catheter infections, 5 catheter occlusions, 1 intraoperative air embolism, 3 haematomas and 1 dacron socket dislocation. The average period of use of an atrial catheter was 170 days, the longest period almost 2 years. The majority of catheters were explanted without any dysfunction. The long time of availability makes Demers atrial catheters an alternative to fistula for multimorbid patients on dialysis with poor long-term survival.