Implantation of permanent jugular catheters in patients on regular dialysis treatment: ten years' experience

Dual-lumen cuffed central venous catheter proved an important alternative vascular access compared to conventional arteriovenous (Cimino-Brescia) shunt in a selected group of patients on regular dialysis treatment. Typically, these catheters are used as bridging access, until fistula or graft is ready for use, or as permanent access when an arteriovenous fistula or graft is not planned (NKF-DOQI). We conducted a prospective study on IJV permanent catheter insertion and its related earlier and long-term complications. From February 1991 to February 2001 we inserted in 124 patients in end stage renal disease 135 cuffed catheters (130 in the right IJV and 5 in the left IJV), 92 of which were Permcath, 27 Vascath, and 16 Ash-Split. We performed the insertion of catheters by puncturing the IJV under ultrasonographic guid-ance in the lower side of the Sedillot triangle and checking the accurate position of the tip by endocavitary electrocardiography (EC-ECG). The duration of catheter use was from 60 to 1460 days, mean 345 days. The actuarial survival rate at 1 year was 82%, at 2 years 56%, at 3 years 42% and at 4 years 20%. The exit site infection and septicemia rates were 5.2 and 2.86 per 1000 catheter days respectively. Catheter sepsis was implicated in the death of three patients, all of whom had multiple medical problems. Several episodes of thrombosis (6% of dialyses) occurred which required urokinase treatment, and catheter replacement in 12 patients (9.6%). In 3 cases the catheters were displaced and correct repositioning was performed. Two catheters (Ash-Split) were replaced due to accidental damage of the external portion of catheters (alcoholic disinfectant). Catheter tip embolism occurred on one occasion during elective catheter exchange over guide-wire. One of the common problems encountered with cuffed tunneled catheters is poor blood flow, most often secondary to the formation of a fibrin sheath around the lumen. Even if we conducted a non-randomized study, in our experience, the higher rate of malfunctioning catheters was in the group with no anticoagulation therapy. Therefore, we suggest anticoagulation treatment in all patients wearing central vascular catheters with no contraindication. Just one year ago, we followed NKF-DOQI clinical practice guidelines for vascular access that indicated that for patients who have a primary AV fistula maturing, but need im-mediate hemodialysis, tunneled cuffed catheters are the access of choice and the preferred insertion site is the right IJV. Considering recent reports of permanent central venous stenosis or occlusion after IJV can-nulation, currently, our first choice is femoral vein cannulation with smooth silicone rubber catheters, tunneled if long-term utilization is needed (more the 3-4 weeks). In our opinion, the right IJV puncture is to be avoided as much as the venipuncture of arm veins suitable for vascular access placement, particularly the cephalic vein of the non-dominant arm. Our data confirm that permanent venous catheters might rep-resent an effective long-term vascular access for chronic hemodialysis, particularly for older patients with cardiovascular disease and for cancer patients.     

Use of the Tesio catheter for hemodialysis in patients with end-stage renal failure: a 2-year prospective study

BACKGROUND: The Tesio catheter system has been proposed to be a reliable source of vascular access for the dialysis patient with low rates of infection and other complications. Whether such catheters provide reliable short- and long-term access remains undetermined. METHODS: This study prospectively examined all Tesio lines inserted over a 2-year period in patients with end-stage failure with careful recording of all catheter complications and reasons for catheter loss. RESULTS: 100 catheters were inserted in 82 patients giving a total experience of 13,749 catheter days; 74 catheters were inserted into the jugular veins, the remainder into the femoral veins; 82 insertions were covered with antibiotics. At the end of the study, 29 catheters remained in situ. Of the remaining 71 catheters, 27 catheters were removed because of fashioning of definitive access. Nine catheters were lost due to infection and 10 were lost due to non-function; 19 patients died with a functioning catheter. Episodes ofnon-function were the major complications, although catheter patency was restored in 90% of cases utilizing urokinase and warfarin. Overall 80% of femoral and 16% of jugular catheters required anticoagulation. CONCLUSIONS: Tesio catheters inserted into the jugular or femoral veins can provide excellent access whilst awaiting definitive dialysis access. They are well-tolerated with a low complication rate compared to standard temporary central venous catheters. Non-function remains a significant problem, especially in femoral catheters, which should be anticoagulated following insertion. Because of our results we suggest that these catheters be used as part of the co-ordinated approach to the management of vascular access in end-stage renal failure patients without definitive access.     

Hemodialysis vascular access among chronic renal failure patients in Egypt

Background: Proper choice of the vascular access plays a crucial role in dialysis outcome. The prevalence and types of vascular access have not yet been investigated in Egypt. Our work aims to study prevalence, patency rate, complications and factors affecting different types of vascular access in Egypt. Patients and methods: We studied one thousand hemodialysis patients in eighteen dialysis centers in Egypt. Results: 93% of the patients had natural arteriovenous access while 7% had synthetic arteriovenous grafts. The patency rate of natural fistulae was significantly higher than that of synthetic grafts (3.07 +/- 3 versus 1.5 +/- 2 years respectively). Many arteriovenous grafts were done because natural arteriovenous fistula was unsuitable or after its failure. Natural radiocephalic fistula was the most prevalent type (67.3%), with a patency rate significantly higher than all other sites (3.3 +/- 3 years). Only 10.2% of patients had a fistula created before the start of dialysis. Thrombosis rate was significantly higher in synthetic arteriovenous grafts (32.4%) than in natural arteriovenous fistulae (9.3%). Diabetes and hyperlipidemia significantly decreased the patency rate of natural arteriovenous fistula but not that of synthetic grafts. Patency of arteriovenous fistula in non-diabetics was 3.2 +/- 3.1 years versus 2 +/- 1.9 years in diabetics. Patency of arteriovenous fistula in non-hyperlipidemic patients was 3.1 +/- 3 years versus 1.5 +/- 1.6 years with hyperlipidemia. Temporary vascular access prior to permanent access was used in 90% of patients, of which femoral catheters were used in 53.6%, jugular catheters in 38% and subclavian catheters in 8.4%. The incidence of primary access failure was significantly higher in patients with a previous subclavian catheter insertion. Conclusions: Natural arteriovenous fistula is the access of choice for hemodialysis patients in Egypt. It has higher patency rate, lower complication rate and nephrologists prefer it. Diabetes and hyperlipidemia decrease patency rate of natural arteriovenous fistula but not synthetic grafts. Subclavian catheter is better avoided due to increased incidence of primary access failure.     

RIGHT ATRIAL CATHETERS: RELIABLE,IMMEDIATE AND DURABLE VASCULAR ACCESS FOR HAEMODIALYSIS AND PLASMA EXCHANGE

This paper prospectively evaluates 33 dual lumen, right atrial catheters inserted into either an external or internal jugular vein by open operation in 29 patients, of whom 15 required haemodialysis and 14 required temporary plasma exchange. The median (range) catheter survival in the haemnodialysis and plasma exchange groups was 108 days (7–334 days) and 61 days (10–116 days), respectively. Life table analysis demonstrated that overall catheter survival was 58% at 200 days. The main causes of catheter failure were infection (four cases), poor flow (three cases) and accidental removal (one case). Another nine catheters were removed electively because of maturation of alternative methods of vascular access (five cases). completion of plasma exchange treatment (three cases), or successful renal transplantation (one case). Long-term silastic catheters, inserted into the right atrium via a jugular vein. have distinct advantages over temporary subclavian vein catheters and external arteriovenous (AV) shunts; this form of access is the method of choice for hamodialysis and plasma exchange patients who require immediate and short- to medium-term 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.     

Tesio-Caths provide effective and safe long-term vascular access.

BACKGROUND: Vascular access is judged on its ability to provide good dialysis adequacy, its durability and complication rates. Formation of a functional arteriovenous fistula is desirable but difficult to achieve in a significant proportion of patients. We report the large-scale use of Tesio-Caths, a twin-line single-lumen central venous catheter, to maximize dialysis adequacy where formation of an arteriovenous fistula was not possible. METHODS: All patients who had Tesio-Caths inserted between 1 January 1999 and 1 October 2002 were studied. RESULTS: Six hundred and twenty-three Tesio-Caths were inserted from 1 January 1999 to 1 October 2002 in 435 patients, generating 7464 patient months of follow-up. Five hundred and ninety-four out of 623 (95.3%) Tesio-Caths were immediately functional. Mean dialysis adequacy measured by single-pool Kt/V was 1.5+/-0.3 for all Tesio-Caths for the entire period of study, with 68% of Tesio-Caths delivering a Kt/V >1.4. Cumulative functional Tesio-Cath survival to final failure was 77.8 and 44% at 1 and 3 years, respectively. Cumulative patient survival was 84.7, 71.4 and 63% at 1, 2 and 3 years, respectively. Access-related infection accounted for 0.28 admissions/1000 catheter days, and the death rate from access-related sepsis was 9.6 deaths/1000 patient years at risk. The admission rate for access dysfunction was 0.33/1000 patient years at risk. CONCLUSION: Tesio-Caths provide good dialysis adequacy for patients in whom an arteriovenous fistula cannot be formed. Patient and functional access survival for this group was comparable with current European data irrespective of vascular access type. Complication rates were acceptably low.     

Conversion of temporary hemodialysis catheters to permanent hemodialysis catheters: a retrospective study of catheter exchange versus classic de novo placement

Many clinicians believe that de novo access is required when converting temporary hemodialysis (HD) catheters to long-term or permanent catheters. However, since vascular access sites are at a premium in the dialysis patient, it is important to preserve existing central venous catheters and conserve future access sites. In this retrospective study, data from 94 patients referred to interventional radiology for placement of long-term, tunneled HD catheters between July 2001 and September 2002 were reviewed. The study group consisted of 42 patients in whom the temporary catheter was exchanged for a peel-away sheath and a tunneled catheter inserted using the existing venous access site. The control group included 52 patients who received traditional de novo placement of permanent catheters. Based on available follow-up data, we report a 100% technical success rate, with 72% patency at 30 days in the study group (n = 32; mean age 58 years). By comparison, de novo catheter placement (n = 35; mean age 59 years) yielded a 100% technical success rate, with 83% patency at 30 days. The overall infection rate was 0.30 per 100 catheter-days (total 3036 catheter-days) and 0.36 per 100 catheter-days (total 3295 catheter-days), respectively (chi2 = 0.64, p > or = 0.05). There was no incidence of exit site infection, tunnel infection, or florid sepsis in either group. Likewise, no stenosis or bleeding complication was noted. Thus conversion of a temporary HD catheter to a tunneled catheter using the same venous insertion site is safe, does not increase the risk of infection, and allows conservation of other central venous access sites.     

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.     

Outcomes of tunneled femoral hemodialysis catheters: comparison with internal jugular vein catheters

BACKGROUND: Tunneled femoral vein dialysis catheters are used as a last resort when all other options for a permanent vascular access or thoracic central vein catheter have been exhausted. There is little published literature on the complications or outcomes of tunneled femoral catheters. METHODS: Using a prospective, computerized vascular access database, we identified all tunneled femoral dialysis catheters placed at the University of Alabama at Birmingham during a five-year period. The clinical features, catheter patency, and complications in these patients were compared to those observed in a group of sex-, age-, and date-matched control patients with tunneled internal jugular vein dialysis catheters. RESULTS: During the study period, 27 patients received a tunneled femoral dialysis catheter, accounting for 1.9% of all tunneled catheters placed. Only 7 patients (26%) were able to convert to a new permanent dialysis access. The primary catheter patency (time from placement to exchange) was substantially shorter for femoral catheters than for internal jugular dialysis catheters (median survival, 59 vs. >300 days, P < 0.0001). Infection-free survival was similar for both groups (P= 0.66). Seven patients with femoral catheters (or 26%) developed an ipsilateral deep vein thrombosis, but catheter use was possible with anticoagulation. CONCLUSION: Tunneled femoral dialysis catheters have a substantially shorter primary patency, but a similar risk of catheter-related bacteremia, as compared with internal jugular vein catheters. An ipsilateral lower extremity deep vein thrombosis occurs commonly after placement of a femoral dialysis catheter, but does not preclude continued catheter use.     

Factors influencing permanent catheter performance

Permanent dual lumen catheters (PDLC) provide an alternative vascular access in patients considered unsuitable for arteriovenous fistula, graft or peritoneal dialysis. However, the use of PDLC is often complicated by inadequate blood flow. The aim of this study was to identify catheter dysfunctions. We studied prospec-tively 57 chronic hemodialyzed patients, 73+/-11 years of age, with PDLC for 18+/-14 (1-48) months. Catheters were tunneled in silicone (MedComp Tesio n= 40) or in polyurethane (Permcath Quinton n = 11, GamCath Gambro n = 6) in left or right internal jugular (n = 49), in left or right subclavian (n = 3) and in right femoral vein (n = 5). We studied the blood viscosity indices (hematocrit, total protein, cholesterol and triglycerides), catheter intra-dialytic parameters (pre-pump and venous pressure), localization of the catheter tip (superior vena cava = SVC, right atrium = RA, inferior vena cava = IVC), blood pressure before and after hemodialysis during the 3 last dialyses, use of anticoagulant (ACT) or antiaggregant therapy (AAT) and previous infectious episodes. The mean blood flow was 269+/-37 ml/min (median 280 ml/min). The patients were divided according to the median value into groups I (Qb < 280, n = 28) and group II (Qb > 280, n =29). Results: Blood viscosity, patients' mean arterial pressure and venous catheter line pressure did not differ between the two groups. Pre-pump pressure, at the start and at the end of treatment, was higher in group I. ACT, AAT and previous infectious episodes could not explain the low-performance. Blood flows of catheters localized in RA, SVC, and in IVC were respectively 287+/-20, 268+/-39, 244+/-27 ml/min. In the first case the Qb was significantly higher than IVC (p = 0.03) and SVC (p = 0.04). In conclusion, the most important factor influencing blood flow rates seems to be the position of the catheter tip in the venous system. The best blood flows were found in catheters with the tip localized in the right cardiac cavities, while PLDC placed in inferior vena cava showed lower blood flow.     

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.     

Five years experience with the Quinton Permcath for vascular access

Over a five-year period 64 Quinton Permcaths were inserted into 51 dialysis patients (age range 17-72 years, mean 52.1 SD 12.83). The duration of catheter use ranged from 5 to 1479 days, mean 315.7 SD 337. The actuarial catheter survival rate at 1 year was 74%, at 2 years 43%, at 3 years 25% and at 4 years 12%. The indications for use were: exhausted peripheral access; CAPD contraindicated; abrupt failure or lack of an arteriovenous fistula; acute renal failure; limited life expectancy; patient insistence; conventional access contraindicated. Only minor complications occurred during insertion: haemorrhage requiring exploration in three patients and a temporary left recurrent laryngeal nerve palsy in one patient. The exit site infection and septicaemia rates were 4.95 and 3.36 per 1000 catheter days respectively. Eighteen catheters failed due to infection (range of use 72-1479 days, mean 559 SD 388). Inadequate initial blood flow (less than 150 ml/min) occurred in 10% of dialyses but only six catheters failed due to intractable flow difficulties (range of use 5-49 days, mean 22 SD 17.5). Catheter sepsis was implicated in the death of two patients. One subclavan/innominate vein thrombosis occurred. The Quinton Permcath represents a significant advance providing immediate, durable, and relatively safe access in a variety of difficult circumstances.     

Central venous dialysis access: experience with a dual-lumen, silicone rubber catheter

The central venous dialysis catheter has gained wide acceptance for short-term hemodialysis with the realization of the need to spare peripheral extremity vessels for the creation of more durable internal arteriovenous fistulas. The Hemocath (Quinton Instrument Co., Seattle, Wash.), a soft, silicone rubber, double-lumen central venous dialysis catheter, was introduced as a permanent access device in 1984. A prospective evaluation of 53 catheters placed in 51 patients over a 9-month period is presented. Forty-nine catheters were placed for temporary access and four were placed for permanent access. All 53 catheters were discontinued after functioning an average of 63.9 days (range, 5 to 324 days). No major complications occurred during insertion or on dialysis. One catheter fragmented during removal and was retrieved in the operating room. Infection led to the removal of 17 catheters (34.7%). Thrombosis occurred in 11 catheters and was the cause of removal in two (4.1%). Excluding the two catheters that functioned at the time of the patient's deaths and those placed for permanent access, 91.5% of the catheters performed successfully as temporary accesses devices until permanent access sites were available for use. The catheter provided reliable, relatively safe, and easily maintained central venous access for hemodialysis.     

Surgical Management of Long-Term Central Venous Access in Uraemic Patients

Over a 5-year period, 1980–1985, 39 patients from a dialysispopulation of over 400 treated at this centre experienced majordifficulties in achieving adequate access for dialysis by conventionaltechniques (i.e. arteriovenous fistula or CAPD). This studyhas evaluated the long-term results of a new approach to circulatoryaccess, central venous catheterisation (CVC) for so called "highrisk" patients. CVC consists of inserting a single-lumen CAPD-typesilastic catheter into the right atrium via an external or internaljugular vein. Forty-seven catheters have been inserted into39 uraemic patients. All patients had failed on, or were unsuitablefor, conventional access to haemodialysis or CAPD. Ten patients(26%) had previous failed renal transplants. The median durationof catheter use was 7 months (range 1–60 months) and atotal of 6500 high-performance dialyses have been performedusing this technique. No patient has died of catheter-relatedproblems. The catheters were easily managed by nurses and welltolerated by the patients. The incidence of complications amongpatients was low: displacement (1), catheter thrombosis (2),skin exit-site infections (5), septicaemia (2). Central venouscatheterisation is a method of providing safe and reliable long-termvascular access which is immediately usable by high-risk patientswho have either failed on or are unsuitable for conventionalcirculatory access.     

Use of a silicone dual-lumen catheter with a Dacron cuff as a long-term vascular access for hemodialysis patients

We evaluated our experience over a 4-year period with a silicone dual-lumen catheter with a Dacron cuff (SDLCDC) to determine if the catheter represents an alternative to the polytetrafluoroethylene graft for long-term vascular access for hemodialysis patients. Records of 131 patients who used 168 catheters were reviewed for catheter function, duration of use, and occurrence and response to treatment of complications. Eighty-five percent of catheters functioned adequately until their use was no longer required or the end of the study. One-year catheter survival estimate was 65% and median survival estimate was 18.5 months. Mean blood flow rate achieved was 243 mL/min and recirculation was 7.5%. Exit-site infection occurred in 21% of patients and bacteremia in 12%. There were significantly more exit-site infections in diabetics than nondiabetics (33% v 11%, P less than 0.02). Exit-site infections resolved with parenteral antibiotic therapy in 90% and bacteremia in 25% of cases without catheter removal. Unresolved bacteremia was the most common cause of catheter removal and led to the loss of 7% of catheters. Thrombotic complications occurred in 46% of catheters. Urokinase instillation successfully treated catheter occlusion in 81% of cases. When urokinase instillation failed, streptokinase infusion restored catheter patency 97% of the time. The literature on the polytetrafluoroethylene (PTFE) graft was reviewed, and the SDLCDC was found to be similar to the graft in function, duration of use, and frequency of infectious and thrombotic complications. We conclude that the catheter represents an alternative to the graft for long-term vascular access in hemodialysis patients. Because of the frequent complications with both accesses, neither should be considered optimal. Further research is required to improve vascular access for patients in whom placement of an arteriovenous fistula is not possible.     

Prospective evaluation of a Dacron cuffed hemodialysis catheter for prolonged use

Double lumen subclavian venous hemodialysis catheters are in wide use in the United States to provide temporary vascular access. The disadvantages of these catheters include a high infection rate and short use-life (2 to 3 weeks). We evaluated a felt cuffed tunnelled jugular venous hemodialysis catheter (PermCath) to determine its ability to overcome these shortcomings and compared it with standard noncuffed double lumen dialysis catheters. Eighty PermCaths were inserted during this prospective study in patients needing temporary vascular access in excess of 1 month. Median use-life of these catheters was 8 weeks with a use range of 3 weeks to 5.4 months. Only four functioning catheters failed before elective removal. Despite the prolonged use-life there was only one episode of catheter mediated bacteremia. Seven catheters (9%) failed to function immediately after insertion. These failures were caused by catheter kinking in the region of the felt cuff. Thrombosis of the catheter lumen was the most frequent complication (137 episodes) but resolved in over 95% of the instances with urokinase instillation. Exit site infections (23 instances) were successfully treated conservatively. We conclude that the PermCath (Quinton Instrument Co, Seattle) is a safe and reliable new device with a low complication rate and a longer use-life than standard subclavian dialysis catheters. This longer use-life allows more time for maturation of primary arteriovenous (AV) fistulas and Tenckhoff peritoneal dialysis catheters, and provides time for the healing of infected vascular access grafts. Its primary disadvantage is the need for surgical insertion.     

Use of a subclavian venous catheter for short- and long-term hemodialysis in children

Vascular access for hemodialysis in children poses problems not encountered in adults because of the small size of the vessels available. The increasing use of peritoneal dialysis has created a large number of patients who need prompt access for hemodialysis for days to weeks during episodes of peritonitis. There are also occasional patients who have exhausted available fistula sites and still require hemodialysis. To address these problems, we designed a series of catheters for insertion in the subclavian vein. The catheters are stiffer than the Hickman type catheter to allow for higher flow rates without collapse. Seventy-five catheters were implanted in 58 patients with a mean age of 14 years. Twelve catheters were inserted in ten children for long-term (over 3 months) access; they have been in place for a mean of 259 days and used for a mean of 64 dialyses. In two children, the catheter has been the sole site for hemodialysis for over a year. Fifty-eight catheters were implanted in 43 patients for short-term hemodialysis. They were in place for a mean of 29 days and used for a mean of 13 dialyses. The major complications encountered were clotting of the catheter and migration out of position. Four catheters were removed because of infection. These new catheters provide effective hemodialysis for children as small as 7 kg with an acceptable morbidity rate and may be used for extended periods of time if necessary.     

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.     

Inpatient and outpatient use of the Hickman catheter for adults with osteomyelitis

One hundred five Hickman catheters were inserted in 96 patients with a diagnosis of osteomyelitis. There were 78 men and 18 women with a mean age of 36.4 years. The catheters were present for a total of 6903 days with a mean of 66.4 days. Sixty-five percent of the catheters were used for outpatient as well as inpatient antibiotic therapy. The mean duration of outpatient antibiotic therapy was 30 days. Nine patients had more than one catheter inserted. The overall complication rate was 20% (21/105 catheters). The infectious complication rate was 11/105 (10.5%) or 0.16/100 catheter days. The noninfectious complication rate was 10/105 (9.5%) or 0.14/100 days. The catheter had to be removed prematurely before the completion of antibiotic therapy in only five of the 105 (4.8%) catheter insertions. The Hickman catheter is a safe and effective intravenous access device for long-term antibiotic therapy in patients with osteomyelitis. Inpatient management and intravenous antibiotic therapy are facilitated by a stable and long-term access to the venous circulation. The simplicity of the device also enables it to be used in the outpatient setting, reducing the time of hospitalization and the costs of treatment.