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.     

Use of Permcath (Quinton) catheter in uraemic patients in whom the creation of conventional vascular access for haemodialysis is difficult

During the last 4 years, the Permcath Quinton double-lumen silicone catheter was inserted into the internal jugular vein of 57 uraemic patients with difficulty for creating conventional vascular access for haemodialysis. In 4 patients, with definitive contraindication of conventional vascular access, this catheter still permits haemodialysis after a duration of 8-25 months. In 25 further patients with terminal uraemia, but poor vein system, it allowed the maturation of an arteriovenous fistula after 2-14 months of use. In 17 patients already on chronic haemodialysis, but who lost abruptly their vascular access (15 grafts and 2 arteriovenous fistulae), it allowed a new arteriovenous fistula to mature in 16 cases after a mean duration of 7.3 +/- months. In 5 patients with short life expectancy because of neoplasia, it allowed to dialyse them until their death which occurred after 6.5 +/- 2.2 months. In 6 patients with acute renal failure and haemostasis problems, it allowed to perform not only dialysis, but also plasmapheresis in 3 and parenteral nutrition in 3 other cases. The complications were the following: sepsis (n = 3); episodes of hypocoagulability due to inadvertent injection of heparin stored in the lumen (n = 2), thrombosis of the lumen (n = 3), and insufficient flow (n = 6). In no case these complications prevented continuation of haemodialysis. The catheter had to be removed in 2 cases because of septis and in 1 case because of insufficient flow. In 3 cases the catheter had to be replaced because of thrombosis and in 1 case because of laceration. These complication rates are, however, fewer than those reported in the literature for arteriovenous shunts or rigid subclavian and femoral catheters. The Permcath catheter seems, therefore to be the method of choice for immediated vascular access in patients in whom the creation of conventional vascular access is difficult.     

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.     

Laparoscopic peritoneal dialysis catheter insertion using a Quinton percutaneous insertion kit.

OBJECTIVE: We assessed a unique technique of laparoscopic peritoneal dialysis (PD) catheter insertion which can minimize catheter dysfunction. METHODS: We performed a retrospective review of patients undergoing laparoscopic PD catheter placement with a Quinton percutaneous insertion kit between July 2000 and December 2004. RESULTS: Thirty-one catheters were placed laparoscopically. The mean operating time was 52 minutes. Adhesiolysis was required in 9 (29%) and omentectomy or omentopexy in 3 (10%) cases. Late complications included catheter dysfunction in 2 patients (6.5%), debilitating abdominal pain requiring catheter removal in 1 patient, and 1 trocar-site hernia. The mean follow-up was 17 months. CONCLUSIONS: Laparoscopic PD catheter insertion using a Quinton percutaneous insertion kit is safe, reproducible, and effective. It facilitates placement of the catheter tip into the pelvis and allows adhesiolysis, omentectomy, or omentopexy when necessary. Utilization of this technique results in a low rate of PD catheter dysfunction.     

A nationwide blood spot screening study for Fabry disease in the Czech Republic haemodialysis patient population.

BACKGROUND: Fabry disease (FD) is a genetic disorder characterized by accumulation of trihexosylceramide in lysosomes of various tissues leading to multiorgan manifestations, including progressive renal disease. Previous screening studies have shown that a non-neglectable proportion of haemodialysis(HD) patients have unsuspected FD. An extensive FD screening study, the largest to date, has been conducted in HD patients in Czech Republic. We aimed to uncover previously undiagnosed FD patients, to enable them to benefit from cause-specific therapeutic intervention with enzyme replacement therapy (ERT). METHODS: Large-scale screening was executed using a convenient automated enzymatic (alpha-galactosidose A, alpha-Gal A) dried blood spot on filter paper fluorescence method. RESULTS: In total, 3370 (45.1% males, 54.9% females) out of 4058 HD patients (83%) in Czech Republic participated in this blood spot screening (BSS) study. Abnormal low fluorescence readings were obtained in 117 patients (3.5%). Subsequent determination of plasma alpha-Gal A activity identified four males and three females with deficient plasma enzyme activity. Determination of alpha-Gal A activity in peripheral blood leucocytes and confirmatory molecular analysis resulted in four newly diagnosed Fabry males and one female. Subsequent family screening identified 10 family members with genotypically proven FD. Based on these screening results, ERT could be offered to five male FD patients. CONCLUSIONS: BSS represents a promising screening tool that has proven to be convenient and effective in uncovering unrecognized FD patients among the chronic HD population in Czech Republic.     

Experience of iron saccharate supplementation in haemodialysis patients treated with erythropoietin

We assessed the efficacy of intravenous (i.v.) iron saccharate (VENOFER) vs oral iron supplementation in haemodialysis patients treated with low-dose erythropoietin (EPO). Twenty haemodialysis patients with serum ferritin >200 ng/mL and transferrin saturation >30% were assigned to one of the two groups. In Group 1, 10 were given i.v. iron saccharate (100 mg i.v. twice weekly) post dialysis. In Group 2, oral ferrous sulphate 200 mg was given thrice daily. In both groups, subcutaneous EPO 25 units/kg body weight (BW) was started simultaneously, twice weekly. After 3 months (study completion) the mean haemoglobin and haematocrit was significantly increased in Group 1 than in Group 2 (Hb 11.60±0.64 G/dL vs 10.5 G/dL±1.14 P <0.01). The final mean EPO dose was 25% lower in Group 1 than in Group 2 (3400±1356 U/week vs 4600±1356 U/week P =0.10) and the mean serum ferritin was higher in the i.v. iron group than the oral group (671 ng/mL±388 vs 367 ng/mL±238 P =NS). The same was also observed with transferrin saturation (44.6%±19.8 in Group 1 vs. 29%±11.0 in Group 2 P =NS). No adverse effects were seen during the study. In conclusion, we observed that regular use of i.v. iron had a significantly enhanced haemoglobin response, better maintained serum ferritin and lower EPO dosage requirement than the oral iron group.     

Experience of iron saccharate supplementation in haemodialysis patients treated with erythropoietin

SUMMARY: We assessed the efficacy of intravenous (i.v.) iron saccharate (VENOFER) vs oral iron supplementation in haemodialysis patients treated with low-dose erythropoietin (EPO). Twenty haemodialysis patients with serum ferritin >200 ng/mL and transferrin saturation >30% were assigned to one of the two groups. In Group 1, 10 were given i.v. iron saccharate (100 mg i.v. twice weekly) post dialysis. In Group 2, oral ferrous sulphate 200 mg was given thrice daily. In both groups, subcutaneous EPO 25 units/kg body weight (BW) was started simultaneously, twice weekly. After 3 months (study completion) the mean haemoglobin and haematocrit was significantly increased in Group 1 than in Group 2 (Hb 11.60 ± 0.64 G/ dL vs 10.5 G/dL ± 1.14 P <0.01). the final mean EPO dose was 25% lower in Group 1 than in Group 2 (3400 ± 1356 U/week vs 4600 ± 1356 U/week P =0.10) and the mean serum ferritin was higher in the i.v. iron group than the oral group (671 ng/mL ± 388 vs 367 ng/mL ± 238 P =NS). the same was also observed with transferrin saturation (44.6%± 19.8 in Group 1 vs. 29%± 11.0 in Group 2 P =NS). No adverse effects were seen during the study. In conclusion, we observed that regular use of i.v. iron had a significantly enhanced haemoglobin response, better maintained serum ferritin and lower EPO dosage requirement than the oral iron group.     

Experience with the Hemasite device in haemodialysis and haemofiltration patients with vascular access problems

Multiple vascular access failure is a frequent problem and we report our experience with 32 Hemasite devices implanted in 28 patients with end-stage renal disease. All of the patients were on maintenance haemodialysis or haemofiltration with a range of treatment of 1-17 years. Their mean age was 58 +/- 14 years (range 28-72 years). The main indication for using this device as an alternative vascular access was the presence of high-risk patients with a high incidence of previous access failure (1-8 accesses per patient). The majority of the patients were considered as high risk, due either to old age (more than 60 years) (60%) or to the presence of diabetes mellitus (29%). The results of 5 years' experience and follow-up showed that the Hemasite device could be successfully used as a secondary vascular access in high-risk patients who have problems of multiple access failures. The 1-year cumulative survival of the device (55%) was affected by complications such as thrombosis and infection (47% and 16%) which were noted mostly among patients with diabetes mellitus. These complications are the major ones endangering the longevity of the Hemasite implant and were important causes of implant loss (31% and 6% respectively). Being needleless and painless, the Hemasite was well-accepted by the patients and it functioned well, with adequate blood flow. We conclude that the Hemasite device is a valuable alternative when vascular access becomes a problem in haemodialysis patients.     

Extradural haematoma in the Irish Republic: an analysis of 82 cases with emphasis on 'delay'

Eighty-two cases of extradural haematoma were analysed to elucidate the factors contributing to delay in treatment and poor outcome. The majority of cases occurred in the first three decades of life with falls being the commonest aetiological factor. Five distinct modes of presentation are described. Excessive delay occurred in recognizing the condition and in subsequent transfer of patients. This resulted in many patients being operated on while in coma. Associated intracranial and extracranial injury occurred in a significant number of cases. Recommendations for the management of these patients are outlined.     

Great vein catheterization according to Seldinger in haemodialysis. Experience with 213 cases

In prolonged intermittent haemodialysis either Scribner's shunt [25] or subcutaneous arteriovenous fistula [3,7] are currently in use.A serious problem arises in cases requiring prolonged haemodialysis, if neither of the above-mentioned two procedures can be applied because of a fragile vascular system or unsuitable blood vessels in the extremities, due to previous accident or surgery. The same holds true for emergency cases requiring immediate dialysis. For the treatment of these patients we have initiated the double percutaneous catheterization of the femoral or subclavian vein. In the present paper the eperience obtained with this method is presented.     

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.     

Tunnelled catheters for the haemodialysis patient.

Haemodialysis depends upon the establishment of a durable means of vascular access. Although the creation of a successful arterio-venous Fistulae (AVF) is the ideal, this is not always possible or practical. Tunnelled catheters play an important role as an interim/bridge technique for emergency access or while an AVF matures, but may be associated with significant morbidity. The aim of this review is to highlight recent evidence based developments in tunnelled catheters, including methods of placement, complications and possible management strategies.     

Monitoring of heparins in haemodialysis using an anti-factor-Xa-specific whole-blood clotting assay

In haemodialysis low-molecular-weight (LMW) heparin is increasinglyused for anticoagulation. The advantages over unfractionated(UF) heparin are the lower bleeding risk and the lack of influenceon lipid metabolism. However, no reliable and rapid method isavailable so far to control the efficacy and safety of LMW heparinduring haemodialysis. The specific anti-factor Xa (aXa) chromogenicsubstrate assays are laborious and time consuming. In the presentstudy we have compared chromogenic assay with a coagulationassay (heptest), which was performed from plasma and whole-bloodsamples. The effects were compared with unfractionated heparinduring haemodialysis. The aXa activity in the chromogenic S2222assay ranged between 0.2 and 0.5 U/ml with UF heparin and between0.4 and 0.8 U/ml with LMW heparin during haemodialysis. Thecoagulometric aXa activity in heptest assay from plasma was0.6–1.0 U/ml with UF heparin and 1.2–2.0 U/ml withLMW heparin. The Heptest coagulation values from citrated wholeblood samples ranged from 0.4 to 0.8 U/ml with UF heparin andfrom 0.8 to 1.4 U/ml with LMW heparin. The prolongation of theheptest clotting times with UF and LMW heparin was in the rangeof 4.4 for UF heparin and 5.2 for LMW heparin using the whole-bloodassay. Heptest assay from plasma samples yielded prolongationsof 6.1 with UF heparin and 6.6 with LMW heparin. The data showthat the coagulation assay is rapid and reproducible using plasmaor uncentrifuged whole-blood samples and is valid to monitorUF heparin or LMW heparin in patients undergoing chronic intermittenthaemodialysis.     

Vascular access for chronic haemodialysis in Lombardy

To evaluate the organisation of vascular access surgery, the techniques used to monitor surgical access and the central catheters, a survey was conducted amongst dialysis Units of Lombardy. A questionnaire was sent out to the 43 dialysis centres in Lombardy, 96% of which replied. In almost 90% of dialysis units nephrologists perform vascular access albeit in close cooperation with vascular surgeons for the more complex cases. First choice access is by distal arteriovenous fistula (AVF): 36% end-to-end, 31.7% side-to-end, and 19.5% side-to-side with distal ligature of the vein. As second choice proximal AVF is more widely used than AV grafts, which are implanted only when all native vessels and related surgical procedures are exhausted. Central venous catheters offer valid solutions not only as temporary access, but also as an alternative permanent one. In both cases the jugular vein is the most frequent site of insertion. Despite the documented incidence of related episodes of stenosis/obstruction, the subclavian vein is used as a temporary access in quite a high per-centage of cases. Only in selected cases are diagnostic procedures (mainly Venography and Doppler studies) performed prior to permanent access choice. Similarly vascular access is monitored mainly using a recirculation test albeit not routinely. In case of vascular access thrombosis, surgical revision is the most common approach.     

Hickman catheter for haemodialysis in paediatric patients

Twelve Hickman catheters were inserted in nine children in order to establish access for haemodialysis or plasmapheresis. Catheters were implanted either through the external or internal jugular vein and the tip located in the right atrium or superior vena cava. Mean blood flow was 25–55 ml/min with single lumen catheters and 83–100 ml/min with double lumen catheters. Three catheters had to be removed because of obstruction, whilst seven remained in situ until an arteriovenous fistula had matured or renal function was restored. Infection in two cases was successfully treated with antibiotics and transient obstruction by urokinase instillation. Following catheter removal, angiographic studies showed that with one exception all catheterized vessels were obstructed, but this did not prevent from ipsilateral arteriovenous fistulas to mature satisfactorily.