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.     

The great saphenous vein for central venous access and haemodialysis

Background. Utilising an open surgical technique the Great Saphenousvein in the proximal thigh can be used for the insertion ofcentral venous catheters for haemodialysis. This approach issafe and efficacious, and may be performed under local or generalanaesthesia. This technique is of particular importance in patientsrequiring vascular access for haemodialysis in whom the uppercentral veins are stenosed and the femoral vessels are not amenableto percutaneous cannulation. Methods. The Great saphenous vein is exposed via a surgicalincision in the thigh. The central venous catheter is then insertedand advanced until in the desired position, as confirmed onfluoroscopy. Results. Seven Great saphenous catheters were placed over aperiod of six months. All catheters insertions were technicalsuccesses with completion of at least one dialysis session.Primary patency rates were 57%, 49%, 23% at 30, 60 and 90 daysrespectively. Conclusion. The great saphenous vein offers an additional sitefor the insertion of central venous catheters. These data demonstrateequivalence in patency between this novel technique and percutaneousfemoral vein cannulation.     

Implantable injection port for long-term venous access

In recent times, totally implantable devices using a Silastic right atrial catheter connected to a subcutaneous injection chamber have been introduced for long-term venous access. This study reports the experience of 39 patients in whom 41 such devices have been implanted. It totals 9697 patient days so far. There has been no incidence of major vein or catheter thrombosis and an infection rate of 0.41 per 1000 catheter days has been achieved. Catheter related complications have occurred in 20% of the cases after a mean duration of usage of 237 days. It is concluded that implantable injection ports provide a safe and reliable method of prolonged venous access.     

Central venous catheters for haemodialysis: looking for optimal blood flow

Central venous catheters are commonly used for haemodialysis patients and represent, in our centre, about 15% of the permanent vascular accesses with a total number of more than 230 central venous catheters over the last 10 years. Inadequate blood flow may occur and upsets the nurses, the patients, and the nephrologist. The aim of this study was to identify the factors of the catheter dysfunction. We studied prospectively 25 chronic haemodialysed patients with central venous catheters, 14 women and 11 men, 65±16 (55-89) years of age, treated with haemodialysis for 6.7±7 (1-26) years. Catheters were tunnelled silicone twin catheters (Permcath Quinton® n=18, Twincath Hemotec® n=7) in right (n=19) and left internal jugular (n=6) inserted by percutaneous Seldinger techniques. We studied the localization of the catheter tip (superior vena cava, right atrium, right ventricular, inferior vena cava), the central venous pressure before and after haemodialysis, the blood pressure (BP) before and after haemodialysis, the interdialytic weight gain, the number of symptomatic hypotensions during the 10 last dialyses. The patients were divided into two groups: group I with usual adequate catheter function (n=18) and group I with frequent dysfunctions (n=7). Central venous pressure before dialysis was significantly higher in group I with adequate blood flow and the catheter's tip was more frequently found localized in the right cardiac cavities than in the vena cava. When central venous pressure before dialysis was over 5 mmHg, no dysfunction occurred. Blood pressure was not different between the two groups. We found no correlation between central venous pressure and BP, interdialytic weight gain and symptomatic hypotensions. We could not predict the central venous pressure from the mean BP but there was a higher frequency of hypotensions in the hypovolaemic patients. Optimal haemodynamic conditions will be provided by a catheter tip in the right cardiac cavities and a central venous pressure over 5 mmHg which can be provided with vascular filling or dry weight revaluation.     

Central venous access in pediatric patients

Occlusion of traditional sites for central venous cannulation is a challenging problem in patients that require a permanent central venous line for chronic administration of nutrients or drugs. In rare cases, extensive central venous thrombosis of the superior and inferior vena cava may preclude catheterization, and uncommon routes should be used. We describe our approach for placement of chronic central venous lines in two pediatric patients with short bowel syndrome and extensive caval occlusion.     

Vascular access for haemodialysis

BACKGROUND: The recent expansion of renal replacement therapy programmes has been associated with an increase in the number and complexity of patients requiring permanent vascular access. The introduction of strategies designed to maximize secondary access patency is, therefore, increasingly important as a means of prolonging patient survival on dialysis, reducing morbidity and reducing the escalating cost of such programmes. METHODS: A review of the current literature on the planning of vascular access, access surveillance methods and treatment of the most common complications was performed. RESULTS: Multidisciplinary vascular access planning, increased use of preoperative imaging and the preferential use of autogeneous vein are essential to obtain the best long-term results. While vascular access surveillance, in particular protocols involving direct measurement of access flow, enables the prospective detection and treatment of venous stenosis, the precise indications for treating venous stenosis remain unclear. Surgical revision remains the gold standard for the treatment of failing arteriovenous fistulas, but recent advances in interventional radiological techniques along with the suitability of arteriovenous fistulas for percutaneous intervention may offer an effective alternative. The effect of both these interventions on access patency requires comparison in a randomized trial. CONCLUSION: The introduction of strategies to improve access patency rates will change vascular access surgical practice away from the construction of new fistulas towards an increase in outpatient percutaneous intervention and surgical revisional procedures. The role of surgical interventions requires clearer definition.     

Arteriovenous fistula for long-term venous access for boys with hemophilia

OBJECTIVES: Hemophilia is a sex-linked condition affecting about 1 of every 5000 males in the United States. The management of children with hemophilia can be improved with regular intravenous infusion of factor VIII or IX, thus preventing crippling and sometimes fatal hemorrhage. Maintaining this vital intravenous access is often hampered by gradual loss of superficial veins or repeated central catheter sepsis and thrombosis. This study reviewed an experience with arteriovenous fistula in selected hemophilia patients with limited venous access. METHODS: Consecutive patients operated on between October 2000 and July 2006 for venous access with the creation of an arteriovenous fistula were reviewed. They were selected because of repeated problems with other venous access. Patency, ease of use, duplex scan derived brachial artery diameter, and arm length were assessed. RESULTS: During a 69-month period, 10 arteriovenous fistulas (five brachial artery-basilic vein fistulas, 5 brachial artery-cephalic vein fistulas) were created for nine patients. The patients were a median age of 5.5 years (range, 1 to 27 years), and all were <13 except the 27-year-old patient. There were no postoperative hematomas requiring evacuation. One arteriovenous fistula failed to mature and was redone in the opposite arm, which subsequently occluded after 13 months. Of the mature fistulas, patency was 100% at 1 year, 80% (4/5) at 3 years, and 75% (3/4) at 4 years, with mean follow-up of 22 months. Brachial artery diameter increased in the involved arm by a ratio of 1.95 (range, 1.51 to 2.5) compared with the opposite arm. Arm length disparity was increased by 0.5 cm (range, 0.8 to 1.5 cm) in the involved arm. All fistulas allowed good access at home by a care provider. CONCLUSIONS: For hemophilia patients with compromised venous access, arteriovenous fistulas provide good early patency. Brachial artery diameter and arm length require continued follow-up.     

Central venous access with occlusive superior central venous thrombosis.

Thrombotic occlusion of the entire superior central venous system is a rare complication of central venous catheterization. Three patients are presented with complete occlusion of the superior vena cava secondary to prolonged central venous catheterization. Thrombotic occlusion of the superior vena cava precludes central venous access by conventional techniques. Thoracotomy with direct catheterization of the right atrium and inferior vena cava cannulation represent alternative approaches but may be associated with significant morbidity. The present report describes a unique combined angiographic/operative technique designed to obtain central venous access with low morbidity in patients with occlusive thrombosis of the superior central venous system.