Using cuffed and tunnelled central venous catheters as permanent vascular access for hemodialysis: a prospective study

BACKGROUND: Adequate care of a hemodialysis patient requires constant attention to the need to maintain vascular access (VA) patency. VA complications are the main cause of hospitalization in hemodialysis patients. The native arteriovenous fistula (NAVF), synthetic arteriovenous grafts fistula (GAVF) and silastic cuffed central venous catheters (CVCs) are used for permanent vascular access (PVA). CVCs are primary the method of choice for temporary access. But using this access modality is increasing more and more for PVA in elderly hemodialysis patients and when other PVA is not possible. The primary aim of this study is to investigate survivals and complications of the CVCs used for long-term VA. METHODS: We prospectively looked at 92 CVCs (Medcomp Ash Split Cath, 14 FR x 28 cm (Little, M.A.; O'Riordan, A.; Lucey, B.; Farrell, M.; Lee, M.; Conlon, P.J.; Walshe, J.J. A prospective study of complications associated with cuffed, tunnelled hemodialysis catheters. Nephrol. Dial. Transplant. 2001, 16 (11), 2194-2200) with Dacron cuff) inserted in 85 (50 females, 35 males) chronic hemodialysis patients (the mean age: 56.6 +/- 14.1 years) from July 1999 to January 2002. The overall survival and complications were followed up. Furthermore, the patients were evaluated for demographic and clinical characteristics. Data were analysed by chi-square, Wilcoxon rank and Kaplan-Meier survival tests. RESULTS: The median duration of CVC survival was 289 days (range: 10-720). Eleven (11.9%) CVCs were removed due to complications. In 79 (92.9%) patients, 1, in 5 (5.8%) patients, 2 and in 1 patient, 3 CVCs were inserted. Of the 85 patients, 56 have CVCs functioning. In addition, 27 (31.76%) patients have CVCs functioning for over 12 months, 17 (20%) patients have CVCs functioning for 6 months. The total incidence of CVC related infections was 0.82 episodes/1000 catheter days. Besides, thrombosis was occurred in 10 (10.8%) CVCs. The most frequent indications for CVC removal were patient death (69.4%), thrombosis (16.6%) and CVC-related infections (13.8%). CONCLUSIONS: CVCs are primarily used for temporary access. But this study indicates that CVC may be a very useful alternative permanent vascular access for hemodialysis patients when other forms of vascular access are not available.     

Axillary grafts for difficult hemodialysis access

Purpose: This study describes the largest reported experience to date with axillary artery to axillary vein or axillary artery to jugular vein polytetrafluoroethylene bridge fistulas for hemodialysis access. The purpose of the study was to determine the incidence of complications and the durability of the access to better determine the role of this procedure in the dialysis access algorithm.Methods: A single center's experience over a period of 5 years was retrospectively reviewed.Results: Twenty-six axillary grafts were placed in 24 patients. All but one were used for dialysis. At the time of access creation, the patients had been undergoing dialysis for a mean of 77 months (range, 5 to 256 months), had had a mean of 9.4 previous access procedures, and had exhausted all arm sites. The life-table patency rate at 3 years was 60%. The incidence of infection and thrombosis were comparable with conventional arm bridge fistulas. Neither vascular steal phenomenon nor neurologic injury occurred in this series.Conclusions: Axillary artery to axillary vein or axillary artery to jugular vein polytetrafluoroethylene bridge fistula is an excellent and durable secondary access strategy. We recommend that it be used after exhaustion of conventional arm sites. (J Vasc Surg 1996;24:457-62.)     

Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters

AIMS: In the existing literature, there is a paucity of data regarding large atrial thrombus (AT) formation occurring as a complication of tunneled cuffed hemodialysis catheter (TCC) use. This study was performed to determine the risk factors, mortality and the appropriate management of TCC-AT. METHODS: We report 6 new cases of TCC-AT and have amalgamated these data with data from 16 previously published cases of TCC-AT found by performing a PubMed literature search (total of 22 cases). Demographic data were collected prospectively over 2 years in 85 consecutive patients initiating hemodialysis who were using a TCC as their primary vascular access, so that comparisons could be made between the 6 patients with TCC-AT versus all patients with a TCC at our center. RESULTS: In patients with TCC-AT, the mean time from TCC insertion was 4.5 months, and infection was present at the time of diagnosis in 68% of cases. The mean thrombus size was 3.7 cm, range 1.5-8 cm. All but 1 case were visualized by echocardiography; the remaining case required magnetic resonance imaging. Management included TCC removal and thrombectomy (n = 9), TCC removal and anticoagulation (AC) (n = 6), TCC removal alone (n = 5), and no intervention (n = 2). The overall mortality was 27%, and 5 of the 6 deaths (83%) occurred in patients with bacteremia. The mortality associated with each management strategy was as follows: TCC removal and thrombectomy (0%), TCC removal and AC (33%), TCC removal alone (40%), and no intervention (100%). CONCLUSIONS: AT is a serious complication of TCC use in hemodialysis patients and may be associated with a high mortality rate. TCC-AT may occur more commonly than previously reported and therefore warrants a high index of suspicion.     

Vascular screening prior to placement of tunnelled and cuffed hemodialysis catheters

Purpose: To demonstrate the importance of venous vascular screening before the placement of tunneled and cuffed hemodialysis catheters in patients requiring hemodialysis prior to placement and/or maturation of an arteriovenous fistula (AVF) or graft (AVG). Methods: Between October 1998 and March 2000, all patients requiring hemodialysis access placement were prospectively evaluated with duplex ultrasound for status of upper extremity vessels and central veins prior to selection of a permanent access site. When interim tunneled and cuffed hemodialysis catheters were required, they were placed on the side contralateral to proposed AVF/AVG placement. No catheters were placed without initial vascular screening. The study group was compared to historical controls during a similar period (April 1997 through September 1998) when no vascular screening was performed. Results: During the study period, 234 screening duplex ultrasound examinations were performed in 244 patients. Ten patients required no screening prior to access site placement. Overall, 353 catheters were placed, 243 (69%) on the right side and 110 (31%) on the left side. During the control period, 394 catheters were placed in 255 patients, 306 (78%) right-sided and 88 (22%) left-sided. The increase in left-sided catheters with ultrasound screening and careful planning for future access sites was significant (p<0.01). Conclusion: Vascular-screening-directed catheter placement significantly alters the side of catheter placement when compared to a management protocol without prior screening. Such screening helps identify the side of permanent access placement, while directing interim catheters to the contralateral side such that central veins may be preserved for permanent access.     

Prospective,randomized evaluation of a cuffed expanded polytetrafluoroethylene graft for hemodialysis vascular access

BACKGROUND: A cuffed expanded polytetrafluoroethylene (ePTFE) hemodialysis graft was developed to address the problem of recurrent stenosis at the graft-vein anastomosis. The purpose of this study was to compare graft patency and blood flow rates of cuffed and noncuffed (standard) ePTFE grafts placed for hemodialysis access. METHODS: Forty-eight patients were prospectively randomized and followed for up to 24 months after placement of a cuffed or standard ePTFE graft for hemodialysis access. Study end points included time to graft failure and blood flow rates on hemodialysis. RESULTS: Risk factors for graft failure were similar in both groups. However, the overall incidence of graft failure was significantly lower in the cuffed ePTFE graft group (P =.039). Graft patency rates in the cuffed versus standard groups were 64% versus 32% at 12 months (P =.037) and 58% versus 21% at 24 months (P =.0213). No cuffed ePTFE graft failed as a result of venous outflow stenosis. Average graft flow rates were similar when first measured 3 months postoperatively (845 mL/min, cuffed vs 715 mL/min, standard; P =.51) but declined more rapidly in the standard group (12 months, 623 vs 253 mL/min [P =.037]; 24 months, 531 vs 121 mL/min [P =.012]). CONCLUSIONS: The cuffed ePTFE graft was associated with increased blood flow rates during hemodialysis and improved graft patency compared with a standard ePTFE graft. Our results suggest a beneficial effect of the cuffed venous geometry for hemodialysis vascular access.     

Central venous catheters as a vascular access modality for pediatric hemodialysis

Background The use of hemodialysis catheters is an essential component of dialysis practice. Children are particularly likely to require multiple courses of dialysis over their lifetime, hence the repeated need for vascular access. These catheters remain a significant source of morbidity and mortality. Methods All catheters inserted for hemodialysis at the Center of Pediatric Nephrology and Transplantation, Cairo University over a period of 40 months were studied. Patient data as well as data of catheter insertion, dwell, cause of removal and complications were reported. Results A total of 195 uncuffed central venous catheters were used for temporary access in 131 patients for a mean duration of 35.7 days. Of attempted insertions, 87.4% achieved successful access, of which 56% remained for the required period, 8.9% were accidentally dislodged, and 35.1% were removed due to complications—mostly infection. The overall rate of possible catheter-related bacteremia was 9.6 episodes/ 1,000 catheter days. Infection increased with longer catheter dwell. Nineteen cuffed tunneled catheters were surgically inserted and used for up to 11 months (mean 117 days). Loss of these catheters was attributed mainly to infection (ten episodes) and catheter thrombosis (six episodes). During the study, 317 femoral catheters were inserted. Conclusion Uncuffed central venous catheters are both needed and useful for short-term hemodialysis. Vascular access for extended durations may be provided by cuffed tunneled catheters. Infection is the major serious concern with both uncuffed and cuffed catheters.     

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     

Complex bypasses and fistulas for difficult hemodialysis access: a prospective, single-center experience

The purpose of this article is to describe several complex vascular access procedures and the outcomes achieved with them in 24 patients (mean age 60 years) undergoing hemodialysis in whom all other accesses had failed and neither peritoneal dialysis nor transplantation was possible. Patients underwent either a necklace bypass (n = 5), axillary loop (n = 1), contralateral internal jugular vein bypass (n = 6), femorofemoral crossover bypass (n = 1), superficial femoral vein transposition (n = 5), axillary artery to popliteal vein bypass (n = 5), or femoral artery to right atrium bypass (n = 1). All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (Gore-Tex Intering Vascular Graft). Postoperatively patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and adequacy of dialysis were reviewed. A bimonthly ultrasound dilution assessment that included estimation of the graft inflow rate, recirculation rate, and cardiac output was also performed. There was one serious postoperative complication: rapid-onset severe steal syndrome that required immediate tie off of the fistula. During the median follow-up time of 22 months, three patients died of causes unrelated to their vascular access. Nineteen dilatations and 10 surgical revisions were done. Primary patency rates were 83%, 63.5%, and 63.5%, respectively, at 6 months, 1 year, and 2 years; secondary patency rates were 91%, 77%, and 77%. Complex vascular access procedures can provide patients some additional good-quality time on hemodialysis.     

Percutaneous, non-surgical placement of tunneled, cuffed, external jugular hemodialysis catheters: a case report

The right internal jugular vein is widely accepted as the vessel of choice for placement of long-term central venous catheters for hemodialysis. As vascular access sites become progressively depleted, alternate anatomic locations for access must be sought. We describe a non-surgical (fluoroscopy assisted, percutaneous) technique for placement of external jugular, tunneled, cuffed hemodialysis catheters, and provide long-term blood flow and dialysis adequacy data for EJV catheters.     

Large bore catheters with surface treatments versus untreated catheters for vascular access in hemodialysis

Infection, thrombosis, and stenosis are among the most frequent complications associated with blood-contacting catheters. Complications resulting from infection remain a major problem for hemodialysis catheters, with significant numbers of catheters being removed due to catheter-related sepsis. Numerous strategies have been employed to reduce the occurrence of infection and im-prove long-term outcomes, with varying degrees of success. The most important is the careful and sterile handling by the attending staff of the catheters during hemodialysis treatments to minimize or stop a microbial colonization of the skin and the catheter. Another approach is coating the external surface of the catheters with substances which are antibacterial like silver and/or substances with low thrombogenicity like silicone. This investigation reviews results of animal and clinical experiments conducted to assess the efficacy and biocompatibility of silver and silicone coated dialysis catheters. It is concluded that silver coatings can reduce bacterial colonization and occurrence of infection associated with these devices. The catheters employing ion implantation of silicone rubber showed low thrombogenicity. Results of the studies indicate that ion beam based processes can be used to improve thrombus and infection resistance of blood contacting catheters. A new development is the microdomain structured surface (PUR-SMA coated catheters). Preliminary results with these catheters are very encouraging.     

Long-term indwelling silicone catheters: a simple, safe method for venous access

The increasing long-term use of intravenous chemotherapy has resulted in problems of venous access for a number of reasons, one being the sclerosing action of the drugs used. Silastic catheters were introduced to ameliorate this problem, initially with some caution because of potential complications and the lack of necessary equipment. The purpose of this paper was to show that the procedure is simple, effective and associated with few complications. Ninety-six patients (32 men, 64 women) with lymphoma (25), leukemia (28), metastatic breast cancer (28) or other malignant lesions (15) were referred for insertion of a Silastic permanent indwelling catheter into the superior vena cava. The catheter was inserted through a subclavian vein using a Cordis Vein Dilator Kit, itself introduced over a guide wire inserted initially under fluoroscopic control. Local sepsis at the insertion site occurred in 6 of the first 43 patients treated but in none of the remainder. Six catheters became thrombosed and required revision. There were no instances of bleeding, air embolism or pulmonary complications. Patient acceptance of this method of venous access was high compared with that for peripheral, repeated venepuncture.     

深静脉长期留置导管与动静脉内瘘在血液透析患者中的应用比较

目的比较深静脉长期留置导管与自体动静脉内瘘作为血管通路的透析充分性及并发症,探讨深静脉长期留置导管在血液透析中的意义。方法选择徐州市中心医院肾脏内科新建立长期留置导管患者24例（导管组）,新建立自体动静脉内瘘患者30例（内瘘组）,随访36-40个月,比较2组患者年龄、最大血流量及观察终点前1个月内射血分数（EF）、尿素清除指数（Kt／V）以及观察期间2组感染、血栓、死亡发生情况。结果导管组使用时间（30．2±7．0）个月,内瘘组使用时间（37．9±2．4）个月;导管组最大血流量、通路使用时间、Kt／V值均低于内瘘组,但差异无统计学意义（P〉0．05）;导管组年龄、EF值高于内瘘组,差异无统计学意义（P〉0．05）;导管组感染率、血栓发生率及病死率均高于内瘘组（P〈0．05）。结论导管组与内瘘组均可达到充分透析,虽然导管组感染率和血栓发生率较高,深静脉长期导管仍为维持性血液透析患者建立血管通路的良好替代。     

Indication for the use of central venous catheters as vascular access for hemodialysis

Adequate treatment for uremic patients on hemodialysis requires valid and lasting access to central vessels. The Central Venous Catheter (CVC) as a mean of immediate access is indispensable in all acute cases where it has not been possible to prepare an AVF in time and when the peripheral vascularization is highly compromised. We present our investigation on the best access route to central vessels and the selection of the type of catheters to adopt in different conditions. On the basis of complications arising during the catheter life especially as permanent access, it seems to us that the right internal jugular catheterization with the 2 Tesio catheters Kit is the more useful and less dangerous catheterization.     

A randomized trial of minidose warfarin for the prevention of late malfunction in tunneled, cuffed hemodialysis catheters

BACKGROUND: Minidose warfarin (1 mg/day) has been associated with a 74% reduction in the thrombosis rate of central venous catheters used in oncology patients. To determine the efficacy of minidose warfarin on late malfunction caused by thrombosis or fibrin sheath formation in tunneled, cuffed catheters (TCC) used for hemodialysis (HD), we performed a randomized, placebo-controlled trial. METHODS: One hundred five chronic HD patients with TCCs were initially randomized. Of these, 85 (warfarin 41 and placebo 44) completed the first two weeks of the protocol and were followed for the first year of TCC life or until TCC removal. RESULTS: Sixteen TCCs failed with late TCC malfunction, eight in each group. In a multivariate analysis, there was no significant effect of warfarin on thrombosis-free TCC survival or time to the first urokinase (UK) instillation for incipient thrombosis. The presence of a low hemoglobin (Hgb; <10.5 g/dL) or a low international normalized ratio (INR; <1.00) was significantly associated with a higher risk of late TCC malfunction (RR 5.2 and 4.0, respectively), a higher risk of incipient TCC thrombosis requiring UK (RR 2.0 and 2.8, respectively), and higher rates of UK dosing. Diabetics had a 3.6-fold higher risk of late TCC malfunction and a twofold higher risk of incipient thrombosis requiring UK, although these findings were not statistically significant. Aspirin use, race, age, number of hospitalizations, erythropoietin dose, intradialytic heparin dose, serum albumin, and the number of episodes of TCC-associated infection were not significantly associated with late TCC malfunction. CONCLUSIONS: Thrombosis prophylaxis using fixed minidose warfarin is not efficacious in TCCs used for HD. However, the present data suggest improved TCC survival in patients with an INR> 1.00. Patients with diabetes and those with a low Hgb or INR have a higher risk of late TCC malfunction.