Analysis of early failure of tunneled hemodialysis catheters

OBJECTIVE: Tunneled hemodialysis catheters are often placed by the interventional radiology service using sonographic guidance and fluoroscopy for safe and optimal placement. The aim of this study was to determine the causes of early failure (相似文献   

Exchange of poorly functioning tunneled permanent hemodialysis catheters.

OBJECTIVE: The usefulness of exchanging poorly functioning tunneled permanent hemodialysis catheters in patients with end-stage renal disease was evaluated. MATERIALS AND METHODS: We retrospectively reviewed case histories of 51 consecutive patients who underwent 88 catheter exchanges because of poor flow rates. All hemodialysis catheters were initially placed by the radiology service using image guidance. Catheter exchanges were performed through the existing subcutaneous tract over two stiff hydrophilic guidewires and without additional interventions such as fibrin sheath stripping or venoplasty. Life table analysis was performed to evaluate catheter patency rates after initial placement (primary patency) and after multiple exchanges (secondary patency). RESULTS: The technical success rate for hemodialysis catheter exchange was 100%. Primary catheter patency was 42% at 60 days and 16% at 120 days. Secondary patency was 92% at 60 days and 82% at 120 days. The cumulative infection rate was 1.1 per 1000 catheter days. No complications from the procedure occurred. CONCLUSION: Catheter exchange is an effective means of prolonging catheter patency in patients with end-stage renal disease and limited central venous access.     

Radiologically placed tunneled internal jugular catheters in the management of chronic hemodialysis and long-term infusion therapies in the pediatric population

PURPOSE: To evaluate the long-term outcomes of radiologically inserted dual-lumen hemodialysis and infusion catheters in pediatric patients. MATERIALS AND METHODS: The authors retrospectively reviewed the outcomes of 114 tunneled internal jugular catheters in 71 consecutive pediatric patients between March 2003 and May 2006. Forty hemodialysis catheters were placed in 23 patients (11 girls, 12 boys), and 74 infusion catheters were placed in 48 patients (14 girls, 34 boys). The mean patient age was 11.2 years (range, 1-16 years) in the hemodialysis group and 7.86 years (range, 4 months to 16 years) in the infusion group. RESULTS: The technical success rate was 100%. The mean duration of catheter use was 84 days (range, 5-730 days) in the hemodialysis group and 58 days (range, 3-206 days) in the infusion group. Nine hemodialysis (22%) and 29 infusion (39%) catheters were electively removed. The most common reasons for catheter removal were malfunction (22%) in the hemodialysis group and completion of therapy (39%) in the infusion group. Revisions were performed at a rate of 0.6 and 0.4 per 100 catheters days in the hemodialysis and infusion groups, respectively. Total infection rates were 0.15 and 0.38 episodes per 100 catheter days in hemodialysis and infusion catheters, respectively. Mean primary device service intervals were 86 and 60 days for hemodialysis and infusion catheters, respectively, with total access site service intervals of 140 and 71 days. CONCLUSION: Radiologically placed tunneled internal jugular catheters appear to be safe and effective, with very low complication rates for both hemodialysis and long-term infusion therapies. Higher infection rates were seen in patients with cancer.     

Use of the brachiocephalic vein for placement of tunneled hemodialysis catheters

OBJECTIVE: The purpose of this study was to evaluate the use of the brachiocephalic vein as an alternative access site for the insertion of tunneled hemodialysis catheters in patients with occluded jugular veins. CONCLUSION: Placement of brachiocephalic catheters for central venous access is safe and provides an alternative access in patients with internal and external jugular vein occlusion.     

Endoluminal dilation technique to remove "stuck" tunneled hemodialysis catheters

Most tunneled catheters can be easily removed after the retention cuff is dissected. Occasionally, these catheters can become resistant to removal even after application of potentially hazardous forceful traction. In addition, an infected catheter may cause life-threatening septicemia. Several methods have been described for their extraction, some of which may be available only in tertiary-care facilities. The present report describes the successful extraction of five such "stuck" catheters by using a recently described technique of endoluminal dilation. The technique appears safe and straightforward and can be performed in any interventional suite while allowing preservation of venous access.     

Impact of tip culture on the management of infected tunneled hemodialysis catheters

PURPOSE: It is common practice to perform culture of the tip of a catheter when a previously indwelling vascular catheter is removed for presumed infection. This study was conducted to determine the effect of hemodialysis catheter tip cultures (CTCs) on patient management. MATERIALS AND METHODS: Patients whose tunneled hemodialysis catheter (TDC) was removed for infection and who had a CTC between July 2001 and June 2006 were identified. The study sample included 242 patients with 330 catheters (109 men, 133 women). Patients' mean age was 58 years (range, 22-94 y). Catheter tip and blood culture (BC) results obtained during the event leading to catheter removal were recorded. Antimicrobial therapy before and after cultures was recorded. Medical records were reviewed for any indication that the treatment plan was influenced by tip culture results. RESULTS: Of 330 catheters, 134 had positive CTC findings; of these, complete records were available for 52 catheters. The treatment plan for patients with suspected catheter-related bloodstream infection (CRBSI) leading to TDC removal did not change in response to semiquantitative CTC results (51 of 52 patients; 98%). In a single case in which CTC results impacted management, this was because of a delay in processing BCs. Negative CTC findings (n = 108) never changed management (ie, resulted in cessation of antibiotic therapy). Seventy-three percent of patients (n = 38) received empiric antibiotics before any culture results. In these cases, the BC susceptibility profiles confirmed the appropriateness of the initial treatment (n = 10) or led to a change (n = 28). CONCLUSIONS: CTC did not alter management in the treatment of TDC infection. Because CTCs increase costs, their routine use should be abandoned in this population.     

Use of the femoral vein as insertion site for tunneled hemodialysis catheters

PURPOSE: To determine the outcome of tunneled hemodialysis catheters inserted through the common femoral vein. MATERIALS AND METHODS: From April 2000 to June 2003, 33 consecutive patients had 86 tunneled hemodialysis catheters inserted through the femoral vein. There were 14 male and 19 female patients with a mean age of 56 years. Seventeen patients had bilateral central venous and/or superior vena cava (SVC) occlusions, 12 patients had unilateral central venous occlusions and were to receive contralateral arteriovenous fistulas or arteriovenous polytetrafluoroethylene grafts, and 4 patients received femoral catheters for other reasons. The technical success, complications, and clinical outcomes of these procedures were retrospectively evaluated. RESULTS: All procedures were technically successful. Fifty-seven catheters were inserted into the right femoral vein and 29 into the left femoral vein. This included 25 catheter exchanges in 13 patients. Two patients developed thigh hematomas. Follow-up data were available for 68 catheters; mean follow-up period was 51 days with a total of 3,484 catheter days. The catheter-related infection rate was 6.3 per 1,000 catheter days; 22 catheters were removed for infection. Eighteen catheters were removed because of poor blood flows (<200 mL/min). Thirteen catheters were removed because they had become retracted. Primary catheter patency was 44% at 1 month. CONCLUSIONS: The femoral vein provides an alternative access site for insertion of tunneled hemodialysis catheters when conventional sites are not available. However, tunneled femoral hemodialysis catheters have low primary patency rates and significant complications. Catheter retraction is a unique and common problem.     

Outcome of polyester cuff retention following traction removal of tunneled central venous catheters

PURPOSE: To elucidate the factors that contribute to cuff retention during traction removal of tunneled catheters, as well as to determine the risk of complication associated with polyester cuff retention. MATERIALS AND METHODS: A total of 428 tunneled, cuffed catheters were removed with traction and local anesthesia. Polyester cuff retention was recorded when it occurred, and the effects of cuff retention were determined at a mean follow-up of 250 days. Statistical analysis was performed to determine the variables influencing cuff retention. RESULTS: Traction removal was successful in 428 (100%) patients. Of 428 catheters removed, 41 (10%) cuffs were retained. Silicone 10-F double-lumen and 9.6-F single-lumen catheters had a higher rate of cuff retention (27 [32%] of 84 and nine [39%] of 23, respectively) than did the split-tip polyurethane hemodialysis catheter (two [1%] of 196; P <.001). Cuff retention rates among other catheter types compared with that of the polyurethane catheter were not significantly different. Duration of catheter dwell did not significantly influence cuff retention. Of 41 retained cuffs, three required removal with cutdown for cuff migration to the exit site, which inhibited healing (n = 1); for suspected infection (n = 1); or for cosmetic purposes as requested by the patient (n = 1). The remaining patients had no complications associated with cuff retention. CONCLUSION: Traction removal of smaller-bore silicone catheters is more likely to result in cuff retention than removal of larger silicone and polyurethane catheters, and cuff retention is usually inconsequential.     

Efficacy of percutaneous fibrin sheath stripping in restoring patency of tunneled hemodialysis catheters.

OBJECTIVE: Our objective was to determine the effectiveness of percutaneous fibrin sheath stripping as a method of restoring function to failing tunneled hemodialysis catheters. SUBJECTS AND METHODS: A total of 131 percutaneous fibrin sheath stripping procedures were performed on 100 failing tunneled hemodialysis catheters in 91 patients. Only the initial stripping procedure of the first catheter inserted in each patient was included for analysis. Patients were excluded if an additional cause of catheter failure was noted at the time of percutaneous fibrin stripping. Failure of the hemodialysis catheter was defined as inability to sustain an average blood flow rate of 250 ml/min or more in a hemodialysis session. Patients were followed up until the time of catheter failure, catheter removal, or a second stripping. Poststripping primary patency and complication rates were determined. RESULTS: The technical success of the procedure was 95.6%. Median follow-up was 16 weeks (range, 0-128 weeks). The overall median duration of primary patency after the first stripping was 89 days (3 months). No statistically significant difference in primary patency rates was seen between patients who underwent fibrin sheath demonstration by contrast injection and those who did not (p = .71). Female patients were statistically more likely to have catheter failure after catheter stripping than were male patients (p = .02). The route of catheter insertion did not significantly influence poststripping patency rates. No complications were associated with the procedure. CONCLUSION: Percutaneous fibrin sheath stripping is a safe, effective method of restoring patency to failing hemodialysis catheters when the failure is due to fibrin sheath formation and other causes are excluded.     

The natural history of tunneled hemodialysis catheters removed or exchanged: a single-institution experience

PURPOSE: To track the natural history of tunneled hemodialysis catheters requiring removal or exchange at a single institution. MATERIALS AND METHODS: Over a 2-year period, tunneled hemodialysis catheters that presented to interventional radiology for removal or exchange were entered into this retrospective study. Patient demographics, catheter location, dwell time, and indication for removal were recorded. Pull-back contrast venography was performed with imaging over the chest. Catheters were then removed or exchanged. RESULTS: Three hundred thirty-four tunneled dialysis catheters were removed or exchanged in 207 patients; 108 male, median age 53 years. Dwell time, available from 296 catheters, ranged from 1 to 114 days (median, 66 days) for a total of 32,847 catheter days. One hundred three catheters were removed for infection, yielding a rate of infection requiring catheter removal of 3.0 per 1,000 catheter days. One hundred catheters were removed for other working access, and 96 catheters were exchanged for poor function. Two hundred sixty-five were removed or exchanged from the internal jugular vein, 22 from the subclavian vein, and 24 from the femoral vein. One hundred seventy-two (76%) of the 226 catheters studied with contrast had fibrin sheaths; of which 42 had thrombus identified along the catheter tract. One hundred ninety-three catheters were removed, and 141 catheters were exchanged for new catheters with 82 catheters receiving balloon disruption of the fibrin sheath. CONCLUSIONS: Approximately one third of tunneled dialysis catheters are removed for infection, one third for other working access, and one third for poor function. Catheters usually remain in the patient for a median of 2 months. Fibrin sheaths associated with hemodialysis catheters are very common. Thrombus formation around the sheath is frequent.     

Conversion of indwelling chest port catheters to tunneled central venous catheters

PURPOSE: To determine the safety and efficacy of the conversion of subcutaneous chest wall infusion ports to tunneled central venous catheters. MATERIALS AND METHODS: During a period of 34 months, 67 patients were referred for conversion of indwelling subcutaneous chest wall ports to tunneled central venous catheters as part of a bone marrow transplant protocol. Six patients were deemed unacceptable for conversion and the remaining 61 underwent successful conversion. All patients had functioning surgically placed single-lumen (n = 50) or double-lumen (n = 11) chest ports, which were removed to maintain the original venous access sites for placement of a tunneled central venous catheter, incorporating the chest wall pocket for tunneling, in 46 patients (75%). A new tunnel was created in the other 15 patients. There were no immediate complications and all patients were followed until catheter removal or patient demise with the catheter in place. RESULTS: 57 of 61 (93%) catheters were used without evidence of infection for 23-164 days (mean, 57 d) after placement. Two (3%) were removed (both at 26 days) because of persistent neutropenic fever without physical signs or laboratory evidence of catheter infection, and two (3%) were removed (at 11 and 77 days) because of proven catheter infection, yielding an overall infection rate of 1.2 per 1,000 catheter days. Two catheters required exchange and two required stripping because of decreased function, resulting in an overall catheter-related complication rate of 2.4 per 1,000 catheter days. CONCLUSIONS: Indwelling subcutaneous chest wall infusion ports can be safely converted to tunneled central venous catheters, even in an immunocompromised patient population, with a low risk of complications such as infection.     

Fibrin sheath stripping versus catheter exchange for the treatment of failed tunneled hemodialysis catheters: randomized clinical trial

PURPOSE: To compare the effectiveness of two treatments for tunneled hemodialysis catheter malfunction: percutaneous fibrin sheath stripping (PFSS) and over-the-wire catheter exchange (EX). MATERIALS AND METHODS: Adult patients with poorly functioning tunneled hemodialysis catheters (flow rates < 200 mL/min) were randomly assigned to receive either PFSS or EX. Over the course of 20 months, 30 patients (37 encounters) referred to a single institution met the inclusion criteria and consented to participate. PFSS employed transcatheter snares via femoral vein puncture, whereas EX was performed over a guide wire with use of fluoroscopic guidance. Patients were followed up to determine the duration of continued adequate hemodialysis via manipulated catheters for up to 4 months (primary outcome measure). RESULTS: Overall technical success rate was 97%. Mean catheter patency for the PFSS group was 24.5 +/- 29.3 days, and 52.2 +/- 43 days for the EX group (P < .0001). After EX, patency rates at 1, 2, 3, and 4 months were 71%, 33%, 27%, and 27%, compared to 31%, 16%, 7%, and 0% after PFSS (P = .04, logrank test). Exchanged catheters were significantly more likely to be patent for as long as 4 months (23% versus 0%; P < .05, chi2 test). CONCLUSIONS: Malfunctioning tunneled hemodialysis catheters treated by means of EX are significantly more likely to remain patent for up to 4 months than are those treated by means of PFSS. According to the results of this trial, PFSS should not be performed as a routine therapy for catheter malfunction.     

Radiologically placed tunneled peritoneal catheter in palliation of malignant ascites

The purpose of this study was to evaluate retrospectively the safety and effectiveness of radiologically placed tunneled peritoneal catheter in palliation of malignant ascites.Between July 2005 and June 2009, 41 tunneled peritoneal catheters were placed under ultrasonographic and fluoroscopic guidance in 40 patients (mean age, 55 years; 22 women) who had symptomatic malignant ascites. No procedure related mortality was observed. Major complication occurred in one patient (2.5%) in the form of serious bacterial peritonitis that necessitated catheter removal. Minor complications such as minor bacterial peritonitis, catheter dislodgement, tunnel infection, and catheter blockage occurred in 11 patients (27.5%). The mean duration of survival after catheter placement was 11.8 weeks. All patients expired of their primary malignancies in the follow-up.Radiologically placed tunneled peritoneal catheter is safe and effective in palliation of symptomatic malignant ascites.     

Treatment of malignant pleural effusions with tunneled long-term drainage catheters

PURPOSE: To assess the effectiveness of tunneled pleural catheters (TPCs) in the treatment of malignant pleural effusions (MPEs). MATERIALS AND METHODS: Twenty-eight patients with symptomatic MPEs had 31 hemithoraces treated with TPCs placed under image guidance. Chemical sclerotherapy had failed in two patients and two had symptomatic locules. Drainage was accomplished by intermittent connection to vacuum bottles. Pleurodesis was considered achieved when three consecutive outputs were scant and imaging showed no residual fluid. RESULTS: All catheters were successfully placed. Dyspnea improved in 94% (29 of 31 hemithoraces) at 48 hours and 91% (20 of 22 patients) at 30 days. Control of the MPE was achieved in 90% of hemithoraces (28/31), although five required ancillary procedures. Pleurodesis occurred in 42% (13 of 31) of hemithoraces, including both that underwent an earlier attempt at chemical sclerotherapy and one treated locule. Continued drainage without pleurodesis controlled the effusion in 48% (15 of 31). In only 7% was hospital time necessary for care related to the TPC. Early, transient catheter-related pain was common, but only three complications (in two patients) occurred. Neither of these altered patient care. CONCLUSIONS: Regardless of whether pleurodesis is achieved, TPCs provide effective long-term outpatient palliation of MPEs.     

Radiologic placement of tunneled hemodialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion

PURPOSE: To evaluate interventional radiologic placement of tunneled hemodialysis catheters in small thyrocervical collateral veins or in occluded veins in the neck or chest in patients with limited venous access. MATERIALS AND METHODS: A femoral venous approach was used to recanalize occluded veins or catheterize small collateral veins in 24 patients in whom all major central veins were occluded. A loop snare or catheter was used as a target for antegrade puncture. Metallic stents were deployed if necessary. Once antegrade access was secured, catheters were placed in a conventional fashion. RESULTS: Technical success was achieved in 22 (88%) of 25 procedures (one patient underwent two procedures). All catheters functioned immediately after placement. There were two procedural complications: a vasovagal episode requiring intravenously administered atropine sulfate and an episode of respiratory distress requiring intubation. There were no instances of pneumothorax, nerve injury, or bleeding complications. Catheter malfunction requiring exchange occurred at a rate of 0.67 per 100 catheter days. Infection requiring catheter removal occurred at a rate of 0.06 per 100 catheter days. Primary patency was 90% at 1 month, 71% at 6 months, and 25% at 12 months. Secondary patency was 100% at 6 months and 70% at 12 months. CONCLUSION: In patients undergoing hemodialysis in whom conventional venous access sites have been exhausted, interventional radiologic venous recanalization for the placement of permanent catheters is safe and effective. Catheters placed in recanalized veins or small collateral veins have shorter primary patency rates compared with those of conventionally placed catheters, but the former can be maintained for relatively long periods.