A Central Venous (W-B-W) Catheter for Multipurpose Vascular Access in Children

A central venous (W-B-W) catheter has been developed for vascular access in children of all ages and sizes. The catheter design and implantation technique permit nonsurgical bedside adjustment of catheter position and ease of removal. Multiple possible uses include intravenous fluid administration, blood sampling, central venous pressure monitoring, and plasma exchange therapy in addition to hemodialysis. Twenty-seven W-B-W catheters were placed in 24 patients in a 12-month period. The catheter provided adequate blood flow for hemodialysis. Seven catheters were removed nonelectively in five patients. One episode of catheter-associated sepsis occurred after renal transplantation in a patient on immunosuppressive therapy. It is concluded that the W-B-W catheter is a relatively safe, multipurpose, pain-free acute vascular access for children, which may also suffice for chronic hemodialysis.     

Usefulness of Groshong Catheters for Central Venous Access via the External Jugular Vein

This study was designed to evaluate the usefulness of central venous access via the external jugular vein (EJV) employing Groshong catheters, and to compare the complications with those of conventional internal jugular venous catheterization. Central venous access was achieved by insertion of a single-lumen 4.0 Fr Groshong catheter via the EJV or internal jugular vein (IJV) with a single puncture. Complications associated with insertion and central venous catheter-related bloodstream infection (CVC-RBSI) were evaluated from the database. Two hundred and twenty-five patients received 400 catheters for a total period of 5377 catheter-days. Ninety-six patients underwent 201 internal jugular venous catheter (IJV-C) procedures for 2381 catheter-days, and 129 patients underwent 199 external jugular venous catheter (EJV-C) procedures for 2996 catheter-days. Use of EJV-C was associated with a longer catheter insertion length (p <. 01) and period (p <. 01), a larger number of operations (p <. 01), and more frequent use of total parenteral nutrition (TPN) (p <. 01) and less frequent use of chemotherapy (p <. 01) than for IJV-C. However, there were no significant differences (NS) in complications associated with insertion and CVC-RBSI between IJV-C and EJV-C. There were no significant differences such complications as malposition, oozing or hematoma formation of insertion site, arterial bleeding, nerve damage, pneumothorax, and phlebitis between IJV-C and EJV-C. Moreover, EJV-C was not associated with morbidities such as pneumothorax, arterial bleeding, and nerve damage. Thus the study concluded that EJV-C using Groshong catheters has no severe complications and has the same rates of CVC-RBSI as conventional IJV-C for central venous access.     

Vascular Access for Hemodialysis

Abstract: Indwelling central venous catheters were consecutively used as access for acute and chronic hemodialysis, emergency treatment of pulmonary fluid overload, intoxication and electrolyte disturbances, plasmapheresis, and semiacute continuous dialysis strategies, such as continuous arteriovenous hemofiltration (CAVH). Modification in catheter structure also made it possible to use this access for long-term treatment (e.g., surgically insert-able catheters [Hickman], soft large-bore catheters for blind insertion). We discuss the remaining open questions in this field: Which is the insertion site of preference (i.e., subclavian, femoral, or deep jugular)? Should we prefer stiff or soft catheters? Should soft catheters be positioned surgically or is blind insertion by nonsurgeons as adequate? Is it necessary to couple catheter insertion to adjuvant techniques, such as echographic guidance, to reduce complications? Is the currently used polymer structure of the catheters acceptable? Should catheter dialysis be used with single or double vascular access?     

Polyurethane Catheters for Long-Term Hemodialysis Access

Abstract: Chronic hemodialysis patients with failed native fistulas and/or synthetic arteriovenous grafts are usually dialyzed via surgically placed silicone jugular catheters such as the PermCath (Quinton, Seattle, WA, U.S.A.). We report a successful experience with the use of double lumen polyurethane central venous catheters placed percutaneously. Catheters with poor flows were replaced over a guidewire at the bedside. Eleven long-term hemodialysis patients failed arteriovenous access, 9 of them having had multiple attempts at fistulas and/or grafts. Seven of these patients had also failed peritoneal dialysis. They were dialyzed with polyurethane catheters for a mean of 681 ± 280 days (range 282–1150 days), requiring a mean of 3.4 ± 0.4 new venous punctures and 8.2 ± 1.5 catheter changes over a guidewire over that period of time. Actuarial patient survival was 50% at 2 years, and mean urea reduction during dialysis was 64.2 ± 1.7%. The septicemia rate was only 1.2 episodes per 1,000 catheter-days, but about 20% of patients experienced central venous occlusion, attributable to the use of subclavian catheter placement in 82% of the sites. The success of this technique and its elimination of the need for urokinase, radiologic interventions, and surgical placement warrant its consideration as an acceptable form of long-term vascular access, provided jugular placement allows reduced central venous occlusion rates.     

Catheter‐related Infections via Temporary Vascular Access Catheters: A Randomized Prospective Study

Temporary vascular access catheters (VACs) are important devices used in acute blood purification therapies. The aim of this study was to determine whether a catheterization duration of 2 weeks increased the risk of nosocomial complications when compared with a 1‐week duration. Fifty‐six patients with 90 double lumen VACs were randomly chosen, and received either 1‐ or 2‐week catheterizations from operators experienced in the placement of such catheters at three sites such as the internal jugular, subclavian, or femoral vein. The characteristics of the VACs, including the sites, procedures, and lengths, were similar in both groups. No significant difference in the rate of catheter colonization was observed between the groups (14.6% vs 26.2%, P = 0.1371). No significant difference in the rate of catheter‐related bloodstream infections was observed between the groups (2.1% vs 4.8%, P = 0.5967). Two‐week indwelling did not increase the risk of infection compared with 1‐week indwelling at any of the sites in critically ill patients.     

股动脉-股深动脉人工血管旁路术建立长期血透通路14例报告

目的：探索一种适合传统方法难以建立自体动静脉内瘘和人工动静脉内瘘患者的新的血管通路建立方法,确保该部分透析患者血管通路的安全。方法：对我院2012年1月以来14例因自体血管条件差、周围血管耗竭等原因无法建立自体动静脉内瘘,而以人工血管动静脉内瘘方式建立移植血管通路则存在缺乏合适的静脉吻合口的患者,采用股动脉一股深动脉人工血管旁路术建立长期血透通路,并观察术后并发症、通畅率、血流量等以评估该种通路的可靠性、安全性。结果：14例患者均一次手术成功,随访2～13个月,通畅率100％,血流量达250～300ml／min,1例因透后压迫不当出现皮下血肿,1例发生切开处感染。1例发生切口脂肪液化。未发生血栓形成、狭窄、人工血管感染、肢体肿胀、心功能不全等并发症。结论：股动脉一股深动脉人工血管旁路术建立长期血透通路具有手术操作简单、符合生理、血流量充分、穿刺部位多、术后无静脉高压、不增加心脏负荷等优点。为传统方法难以建立长期血管通路的患者提供了一种全新的血管通路选择,具有一定的应用前景。     

Dyslipidemia Is Associated With Tunneled‐Cuffed Catheter‐Related Central Venous Thrombosis in Hemodialysis Patients: A Retrospective,Multicenter Study

The aim of this study was to explore the risk factors of tunneled‐cuffed catheter (TCC)‐related central venous thrombosis (CVT) for the maintenance of hemodialysis patients. In this study, 285 patients on maintenance hemodialysis were enrolled who had received their first TCC in the right jugular vein. Patients were divided into CVT and control groups according to the diagnosis of TCC‐related CVT 6 months after catheterization. Patients with CVT had a higher prevalence of dyslipidemia (50.74 vs. 26.85%, respectively) and low protein store compared with the control group. After adjusting for confounders, serum triglycerides (OR: 3.632; 95% CI: 2.105–6.267), non‐HDL cholesterol (OR: 1.463; 95% CI:1.067–2.007), and low‐density lipoprotein/high‐density lipoprotein (LDL/HDL) cholesterol ratio (OR: 2.904; 95% CI: 1.797–4.692) were positively correlated with TCC‐related CVT, while serum HDL cholesterol (OR: 0.097; 95% CI: 0.037–0.257) and serum albumin (OR: 0.922; 95% CI: 0.864–0.985) were negatively correlated. Dyslipidemia and low serum albumin levels were significantly associated with TCC‐related CVT in hemodialysis patients.     

A Prospective Analysis of the Cephalic Vein Cutdown Approach for Chronic Indwelling Central Venous Access in 100 Consecutive Cancer Patients

Background: Chronic indwelling central venous access devices (CICVAD) generally are placed by the percutaneous subclavian vein approach. The cephalic vein cutdown approach is used only infrequently. Although the technique has been well described, few prospective data are available on the cephalic vein cutdown approach.Methods: From September 9, 1998, to July 20, 1999, the cephalic vein cutdown approach was attempted in 100 consecutive cancer patients taken to the operating room with the intention of placing CICVAD. Median patient age was 54.5 years (range 18–88), with 46 men and 54 women. Twenty-five patients had gastrointestinal malignancies, 17 had breast cancer, 15 had lymphoma, 13 had lung cancer, 12 had leukemia, 5 had multiple myeloma, and 13 had other malignancies. Patients were followed prospectively for immediate and long-term outcome.Results: CICVAD placement via the cephalic vein cutdown approach was successful in 82 patients; the remaining 18 patients required conversion to a percutaneous subclavian vein approach. The reasons for inability to place CICVAD via cephalic vein cutdown approach were a cephalic vein that was too small (10 patients), an absent cephalic vein (7 patients), and inability to traverse the angle of insertion of the cephalic vein into the subclavian vein (1 patient). There were 56 subcutaneous ports and 26 tunneled catheters. Median operating time was 44 minutes (range, 26–79 minutes). No postoperative pneumothorax occurred. Median catheter duration was 198 days (range, 0–513 days). Long-term complications included catheter-related bacteremia (6%), site infection (2%), deep venous thrombosis (5%), port pocket hematoma (1%), and superior vena cava stricture (1%). Thirty-seven percent of patients have died since CICVAD placement. Twenty-nine percent of the CICVADs have been removed.Conclusions: The cephalic vein cutdown approach was successful in 82% of patients. This approach is a safe and useful alternative to the percutaneous subclavian vein approach.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, March 16–19, 2000, New Orleans, Louisiana     

Femoral Vein Tunneled Catheters as a Last Resort to Vascular Access: Report of Five Cases and Review of Literature

Vascular access (VA) remains a thorny problem in at least some patients requiring hemodialysis (HD). When options like arterio-venous fistulae, grafts, and thoracic tunneled central catheters are exhausted, the patient survival becomes endangered. The choices left are limited to transplantation, peritoneal dialysis, and translumbar and femoral catheter insertion. The latter may, in many instances, be the only possibility. We report our experience in six patients, in whom all the vascular accesses were exhausted and transplantation or peritoneal dialysis could not be performed. Hence, we opted for femoral tunneled catheters (FTC) as a permanent and sole VA. The mean follow up period was 16 months (8–22 months). The mean age of the patients was 53.1 (35–72) years, the mean time on HD was 3.125 years (2–4.5), and the mean number of vascular accesses was 4.7 (4–7). In five patients, a Permcath (Quinton, Kendall) was inserted, and in one patient, a twin Tessio catheter (MPS, Germany) was inserted. All patients were administered aspirin or clopidogrel to prevent catheter thrombosis. Aseptic nursing procedures and personal hygiene were emphasized. All catheters were functional at 2.5 months. The mean blood flow was 220 mL/min (200–240 mL/min). One patient died at 18 months, with a functional catheter, due massive gastro-intestinal bleed not directly related to the FTC. In one patient, the site of the catheter was changed at 6.5 months due to accidental pulling of the catheter by the patient. One catheter flow became inadequate after nine months, which could be reversed with streptokinase or tissue plasminogen activator. One patient presented excessive bleeding at the time of insertion that was controlled after 25 minutes of compression against the pelvic bone. One patient presented deep vein thrombosis with catheter thrombosis that required reinsertion of the catheter three months later. In one patient, the catheter functioned for 19.5 months after insertion. It is noteworthy that no patient developed catheter-related septicemia. None of the patients developed late hemorrhage. We conclude that tunneled femoral catheter is a viable option in patients with exhausted VA. Strict aseptic nursing technique and personal hygiene are essential. A multi-center study would give a better insight into this type of VA.     

Complications of Central Venous Catheters in Patients on Home Parenteral Nutrition: An Analysis of 68 Patients over 16 Years

Purpose To determine the incidence of central venous catheter (CVC) complications and to analyze the potential risk factors for complications necessitating CVC removal in patients on home parenteral nutrition (HPN). Methods We studied 68 patients on HPN (44 men and 24 women), examining the incidence of CVC complications and CVC-related infections. The risk factors for CVC-related infection were investigated using multivariate logistic regression analysis. Results the incidences of CVC complications were 0.29 episodes per CVC-year in 45 patients with an external tunneled CVC, and 0.66 episodes per CVC-year in 23 patients with an implanted port device. The incidences of CVC-related infections were 0.17 episodes per CVC-year for external tunneled CVCs and 0.17 episodes per CVC-year for implanted port devices. There were no significant differences in the incidences of CVC complications (P = 0.095), and CVC-related infections (P = 0.406). The incidences of CVC-related infections were 0.04 episodes per CVC-year in 54 patients with malignancies, and 0.68 episodes in 14 patients with benign diseases (P < 0.001). Multivariate logistic regression analysis revealed the types of diseases that influenced the incidence of CVC-related infections (P < 0.05). Conclusions The incidence of CVC complications did not differ between the two groups. The type of disease was the most important predictive factor of CVC-related infections.     

Transposed Basilic Vein-Brachial Arteriovenous Fistula: An Alternative Vascular Access for Hemodialysis

Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated one-year patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachial-basilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels.     

Sites of Implantation for Central Venous Access Devices (Ports): A Study of the Experiences and Preferences of Patients

OBJECTIVE: To obtain information which might guide vascular specialists and their patients in the choice of site for implantation of central venous access devices (CVADs). DESIGN: Questionnaire study. METHODS: Questionnaires were sent to 69 patients with cystic fibrosis and 54 (78%) responded (39 females: age 5-63, median 24 years). They had received a total of 79 CVADs placed in the upper chest (60), lower chest (13), thigh (3) and arm (3). Only 46% patients had been offered a choice of site. RESULTS: Questions about 14 specific areas of disability or concern found problems most frequently with discomfort (54%), wearing a seatbelt (51%), cosmetic appearance (44%), scarring (44%), choice of clothing (42%) and lying in bed or sleeping (42%). There were no significant differences between upper and lower chest CVADs. Patients with upper chest CVADs seldom had any problems with use of their arm (12%). 81% CVADs could not be accessed by the patients, and in 39% of these cases patients would have liked to do so. CONCLUSIONS: Many patients complain of few problems with their CVADs, regardless of site, but half have some persistent discomfort. Cosmetic considerations frequently cause concern and patients should be given choice in the site of their CVADs.     

Internal Jugular Vein Cannulation with Two Silicone Rubber Catheters: A New and Safe Temporary Vascular Access for Hemodialysis. Thirty Months'' Experience

Temporary and immediately usable vascular access is a vital need in treating uremic patients. Subclavian vein cannulation, although a major progress, has been associated with significant morbidity and mortality. Accordingly, for the last 2.5 years the authors have been developing an alternative technique consisting of internal jugular vein cannulation (IJVC) with two silicone rubber catheters with a long-term, proved biocompatibility. One hundred sixty-five pairs of cannulas were inserted in 153 patients. Mean duration of use was 57 days (1 day to 17 months). More than 3,000 high-performance hemodialysis sessions were performed. IJVC handling and care were easily managed by nurses. A low incidence of complications was observed: two thrombosis episodes, four skin infections with three septicemia, one air embolism, and one anaphylactoid reaction. No death was related to the technique itself. IJVC offers a new, safe, and reliable temporary vascular access immediately usable for all kinds of extracorporeal treatment.     

Balloon Dilatation for Removal of an Irretrievable Permanent Hemodialysis Catheter: The Safest Approach

Long‐term hemodialysis catheter dwell time in the central vein predisposes to fibrin sheath development, which subsequently causes catheter malfunction or occlusion. In very rare cases, the catheter can be overgrown with fibrin and rigidly connected with the vein or heart structures. This makes its removal almost impossible and dangerous because of the possibility of serious complications, namely vein and heart wall perforation, bleeding, or catheter abruption in deep tissues. We describe two cases in which standard retrieval of long‐term catheters was not possible. Balloon dilatation of catheter lumens was successfully used to increase the catheter diameter with simultaneous tearing of the fibrin sheath surrounding it. This allowed the catheter to be set free safely. Based on this experience, we present recent literature and our point of view.