New tunneled hemodialysis catheter placement through the old exit site

Accidental loss of tunneled hemodialysis catheters has been observed in chronic hemodialysis patients. Although a new catheter could be inserted using a fresh site, catheter insertion can also be accomplished by utilizing the existing exit site. In this analysis, we report 10 cases of an extruded tunneled hemodialysis catheter. The catheters had been in place for 2-6 months. The time elapsed after catheter extrusion ranged from 6 to 72 hours. None of the patients demonstrated any evidence of exit site or tunnel infection. Patient age ranged from 45 to 77 years. Diabetes mellitus was the cause of renal failure in 40% of the cases. Catheter insertion was accomplished by inserting a guidewire into the exit site and navigating it through the tunnel to the central venous system and into the right atrium. A diagnostic catheter was then navigated over the wire and contrast study performed to confirm the position. The wire was reinserted and a new tunneled hemodialysis catheter fed over the wire and into the atrium. Nine catheters were successfully placed using this technique. One patient had nausea and hiccups upon wire insertion into the atrium. There were no hemodynamic consequences. The wire was removed and a new catheter inserted on the other side using the left internal jugular vein. All of the catheters inserted using this technique functioned appropriately. There were no exit site or tunnel infections for up to 4 weeks' follow-up. We conclude that patients with catheter extrusion can receive a new catheter through the existing exit site, tunnel, and venotomy.     

Avoiding problems in tunneled dialysis catheter placement

Tunneled dialysis catheters (TDCs) remain the predominant vascular access for initiation of hemodialysis (HD) worldwide. TDCs are also utilized in a significant number of prevalent patients for continuation of dialysis and during the periods of complications related to arteriovenous (AV) accesses. TDC placement is a routine procedure, but can be associated with mechanical and infectious complications related to placement. Imaging guidance with ultrasound and fluoroscopy has made the placement of TDC safer and more successful. Adequate operator training, careful technique, utilization of a checklist, and barrier precautions are essential to avoid problems related to TDC placement.     

Timing of secondary arteriovenous fistula creation avoids tunneled catheter placement

The concept of secondary arteriovenous fistula, though not novel, is seldom practiced for lack of initiative or hesitancy in deciding the appropriate timing to abandon the existing access. We report a case illustrating the benefits of implementing the strategy in an elderly diabetic dialysis patient, successfully avoiding a tunneled cuffed catheter placement.     

Concentrated heparin lock is associated with major bleeding complications after tunneled hemodialysis catheter placement

Vascular access complications, including thrombosis, are associated with significant patient morbidity and mortality. Currently, up to 60% of new patients and 30% of prevalent patients are using a catheter for dialysis. To prevent interdialytic catheter thrombosis, these devices are routinely locked with concentrated heparin solutions. Several recent studies have elucidated the potential for abnormal coagulation markers (aPTT) that may arise from this practice. This abnormal elevation in aPTT may be explained by significant early and late leakage from the catheter that occurs after performing a catheter lock. To date no study has evaluated the impact of this practice, or the elevation in aPTT that may result from it, on bleeding complication rates. We conducted a retrospective analysis comparing bleeding rates in subjects who received concentrated heparin catheter lock (5000 u/cc) [group 1, n = 52] to those who received citrate or dilute heparin catheter lock (1000 u/cc) [group 2, n = 91] immediately after tunneled hemodialysis catheter insertion. Baseline characteristics did not differ between the groups except for the preprocedure INR, which was higher in the postpolicy group compared with the prepolicy group (1.29 vs. 1.21, p = 0.04). Results from logistic regression analyses revealed that the likelihood of a composite bleeding event in group 1 was 11.9 times that of a composite bleeding event in group 2, p = 0.04. Concentrated heparin (5000 u/ml) is associated with increased major bleeding complications posttunneled catheter placement compared with low-dose heparin (1000 u/ml) or citrate catheter lock solution, p = 0.02. Given the findings of this study, a randomized controlled trial comparing the safety and efficacy of common anticoagulation lock solutions is warranted.     

Long-term management of the tunneled venous catheter

Despite their propensity for significant complications, tunneled central venous catheters have become a common means of vascular access in the United States for patients requiring maintenance hemodialysis for end-stage renal disease (ESRD). Reasons for their use include advanced patient age, peripheral vascular disease (arterial and venous), late referral for creation of vascular access, and more importantly, the lack of an interdisciplinary service line on vascular access among vascular surgeons, radiologists, and nephrologists. This review article summarizes complications commonly encountered in dialysis patients who use tunneled central venous catheters for vascular access-mainly thrombosis, stenosis, and infection. Special attention is given to novel approaches for the prevention of catheter-associated infections. Effective prevention and timely treatment of common catheter-associated complications can reduce the substantial morbidity associated with the use of these devices. However, these measures should not detract from the goal of avoiding or limiting the long-term use of catheters, thereby optimizing vascular access management by ensuring the timely availability of functioning arteriovenous fistulas.     

How I do it: preferential use of the right external jugular vein for tunneled catheter placement

We describe a case in which the right external jugular vein (REJ) was preferentially used to place a tunneled catheter, even though the left internal jugular vein (LIJ) was widely patent. The possible advantage of placing REJ catheters over LIJ is that doing so may function to preserve better the left-sided vasculature in general, and, in particular, when future left-sided access is planned. Contrast venography was required. While REJ is a viable option for catheter insertion, the effect of REJ vs. LIJ catheter placement on long-term vessel patency as well as catheter function must be more rigorously defined to conclusively establish the superiority of one over the other.     

Screening for carotid artery stenosis and renal artery stenosis in patients undergoing tunneled cuffed hemodialysis catheter placement

In this study, we noted the common risk factors with atherosclerosis and chronic renal disease. We, therefore, hypothesized that the placement of a dialysis catheter would be a useful marker in identifying populations at increased risk of vascular disease (carotid, renal, and aortic). To further explore this issue, we examined the results of duplex scanning of the carotid arteries and aortorenal arteries in patients undergoing dialysis catheter placement. Over 49 months, each of the 123 patients who underwent permanent tunneled dialysis catheter placement received a carotid duplex study. Twelve patients (9.8%) had ≥ 60% stenosis and 8 patients (6.5%) had 70% to 99% stenosis. Furthermore, 109 patients who underwent a aortorenal artery duplex study were also analyzed. The study population demonstrated a prevalence rate of 3.7% for abdominal aorta aneurysm (AAA) and 4.6% for renal artery stenosis (RAS). Based upon these data, we suggest performing routine carotid duplex scans in patients who will also receive dialysis catheter placement. However, the data did not support routine screening of AAA or RAS.     

Radiological placement of the AshSplit haemodialysis catheter: a prospective analysis of outcome and complications.

BACKGROUND: The AshSplit catheter has recently been introduced as an alternative permanent tunnelled haemodialysis catheter, combining ease of insertion with good long-term patency and flow rates. METHODS: Data were collected prospectively on all the long-term tunnelled haemodialysis (AshSplit) catheters inserted radiologically between January 1998 and March 1999. Information was obtained regarding the initial insertion, ongoing catheter function and re-intervention up to September 1999. RESULTS: A total of 118 catheters were inserted in 88 patients (50 male), median (range) age 64 (20-86) years. Ultrasound guidance was used routinely and the right internal jugular vein was used in 80 (68%) cases. Initial complications occurred in 14 (11.9%) cases, which included local haemorrhage, carotid artery puncture, and air embolism. Infection occurred in 34% of catheters (2.4/1000 catheter days). Line thrombosis was documented in 20% (1.2/1000 catheter days). Satisfactory mean urea reduction ratio (URR) of 63 was obtained for all catheters. There were 47 re-interventions, mainly for fibrin sheath stripping (34) and/or thrombectomy (25). Total catheter duration was 21600 days with a 1 month cumulative survival of 87% (Kaplan-Meier probability 85%). At the end of the study, 20 (17%) catheters were still functioning, 39 (33%) had been removed electively, and 22 (18%) patients had died with a functioning catheter in situ. Catheter infection was implicated in four deaths. CONCLUSIONS: Radiological insertion of the AshSplit catheter is well tolerated, providing reliable short- and long-term dialysis access. Radiology also has a role in maintaining patency. As with all tunnelled catheters, infection remains a problem.     

Chronic catheter placement

Since the 1997 publication of the Disease Outcomes Quality Initiative (DOQI) vascular access guidelines for cuffed, tunneled catheter placement, additional evidence supporting these recommendations has been published, including additional documentation supporting the right internal jugular vein as the preferred site for insertion. Placing the catheter tip in the right atrium rather than in the superior vena cava will provide adequate blood flow to support effective hemodialysis. The right atrial positioning of the catheter tip will also accommodate catheter tip retraction and decrease the likelihood of malfunction. Overwhelming evidence now supports the use of ultrasound guidance to assist cannulation of the internal jugular vein. This evidence is based on several studies documenting anatomical variations of the internal jugular vein. Ultrasound guidance has significantly decreased the incidence of serious complications of jugular vein cannulation. Finally, a specific technique of catheter placement with variations for catheter types is described.     

Diagnosis of unexplained bleeding from tunneled dialysis catheter.

Bleeding after hemodialysis catheter placement is commonly seen and can happen because of anticoagulation, poor platelet function in dialysis patients, and trauma to the vessel and tunnel tract during placement. We wish to present here two cases of prolonged exist site bleeding with tunneled dialysis catheters (SchonCath dialysis catheter, Angio-Dynamics, Queensbury, N.Y.) due to unsuspected catheter leak within the tunneled portion of the catheter, which was identified with angiogram.     

Monitoring of central venous dual-lumen catheter placement in haemodialysis: improvement of a technique for the practising nephrologist

Mismanagement in the placement of central venous catheter (CVC)may occur in up to 20% of cases. The catheter can be inadvertentlyplaced in the contralateral brachiocephalic vein, the ipsi orcontralateral internal jugular vein, and usually a thoracicradiograph is necessary to evaluate its location. We proposea technique first described by Serafini et al. to establishthe position of a CVC by endocavitary electrocardiography (EC-ECG)and its employment in a large number of uraemic patients requiringhaemodialysis. This technique uses the tip of the CVC as referencelead in a standard electrocardiograph. The best employment ofthis technique has been obtained by echotomographic visualizationof the internal jugular vein executed just before transcutaneouspuncture of the vessel. For 13 months we have successfully appliedthis technique in CVC placement in 81 patients requiring haemodialysis.In our opinion this method is a safe and simple technique thatavoids the need for thoracic radiographs and time lost waitingfor radiographs that prolong the start of the haemodialysissession. According to our experience, we confirm that the EC-ECGtechnique provides a method for ensuring compliance with Foodand Drug Administration guidelines regarding catheter tip locationin uraemic patients.     

Monitoring of central venous dual-lumen catheter placement in haemodialysis: improvement of a technique for the practising nephrologist

Mismanagement in the placement of central venous catheter (CVC)may occur in up to 20% of cases. The catheter can be inadvertentlyplaced in the contralateral brachiocephalic vein, the ipsi orcontralateral internal jugular vein, and usually a thoracicradiograph is necessary to evaluate its location. We proposea technique first described by Serafini et al. to establishthe position of a CVC by endocavitary electrocardiography (EC-ECG)and its employment in a large number of uraemic patients requiringhaemodialysis. This technique uses the tip of the CVC as referencelead in a standard electrocardiograph. The best employment ofthis technique has been obtained by echotomographic visualizationof the internal jugular vein executed just before transcutaneouspuncture of the vessel. For 13 months we have successfully appliedthis technique in CVC placement in 81 patients requiring haemodialysis.In our opinion this method is a safe and simple technique thatavoids the need for thoracic radiographs and time lost waitingfor radiographs that prolong the start of the haemodialysissession. According to our experience, we confirm that the EC-ECGtechnique provides a method for ensuring compliance with Foodand Drug Administration guidelines regarding catheter tip locationin uraemic patients.     

Hickman catheter placement simplified

A simplified technique to place the Hickman indwelling right atrial catheter has been devised. This involves securing the catheter to a trocar, which is easily advanced to the cutdown site of the selected vein. Experience in more than 75 patients shows this technique to be associated with less discomfort and fewer complications than seen with standard techniques.     

Central venous catheter placement using the ECG-guided cavafix-certodyn SD catheter

Study Objective: To evaluate the clinical use of a new ECG-guided central venous catheter with regard to positioning in the superior vena caves (SVC).

Design: Prospective study.

Setting: Operating rooms of a university hospital and a general hospital.

Patients: 89 elective and emergency adult surgical patients requiring central venous catheterization perioperatively.

Interventions: We performed ECG-guided placement of the central venous catheter from several insertion sites. After we observed an intra-atrial p-wave (p-atriale), the catheter was withdrawn 3 cm back into the SVC. Postoperative anterior-posterior chest radiographs were performed for verification of tip localization.

Measurements and Main Results: In all 81 patients who exhibited a p-atriale that reverted to a normal-size p-wave (p-SVC) after withdrawal of the catheter 3 cm, the tip was located in the SVC or the SVC-right atrial junction on the chest radiograph. In 7 of the 8 cases without a p-atriale, the catheter tip was shown to be located at an incorrect position on the chest radiograph. The size of the p-atriale was always at least twice that of the p-SVC.

Conclusions: Use of this wire-conducted intravascularECG signal is a reliable tool for positioning the central venous catheter via various insertion sites. The technique proved to be an inexpensive, easy, and clear method. When a p-atriale is seen, uncomplicated insertions do not require radiologic guidance to control catheter tip position.