Survey of permanent central venous catheters for haemodialysis in the UK

BACKGROUND: Venous catheter haemodialysis may be necessary in some patientswithout arterio venous fistulae on dialysis for end-stage renalfailure. We conducted a survey to compare management of thesecatheters in different units in the UK. METHODS: Postal questionnaires were sent to nurses in charge of 81 renalunits in the UK for a twelve month study period in 1994 to findout the type of catheter used, catheter after insertion care,the rate and management of exit site infections, and bacteraemia. RESULTS: (1) Total number of questionnaires returned 66 (81.5%). (2)63.6% of renal units used double lumen Permcath catheters, 16.7%single lumen (Francis/Kimal, Gambro or Vascath), 10.6% use bothdouble and single lumen catheters and 9.1% of renal units onlyuse temporary polyurethane catheters. (3) Catheter exit siteaseptic dressing technique was used in 84.8% of renal units,clean technique in 15.2%. 66.8% changed dressings at each dialysissession, 22.7% weekly. The majority of renal units (63.6%) hadone nurse to change the dressing, used Betadine as a cleaningagent and Mepore to cover the exit site. (4) 75.8% did not knowthe exact incidence of episodes of sepsis and/or exit site infections.Flucloxacillin was the antibiotic of choice for each catheterrelated sepsis episode. CONCLUSIONS: During this study period most renal units used Permcaths asfirst choice for long term catheter dialysis, the after insertioncare of which varied. The number of episodes of sepsis was unknown.We suggest UK collection of data for all long term cathetersand related problems for audit purposes.     

Ultrasound guided vascular access: efficacy and safety

In the United Kingdom and United States, US guidance for internal jugular central venous catheterisation is recommended. Despite reluctance to adopt these guidelines, there is sufficient evidence to support routine use, as even proceduralists skilled in landmark techniques commonly encounter complications. Serious morbidity and mortality may result, which arguably is avoidable, if ultrasonography was used. Real-time 2D US demonstrates patient anatomy and anatomical variability in a manner not previously possible for anaesthetists. Unencumbered by reliance on surface landmarks, the needle path and tip can be visually directed into the target vessel lumen. This potent ability improves successful cannulation and first-attempt success, reduces the number of needle attempts and decreases mechanical complications associated with vascular access procedures.

Conflict of interest

AC has received honoraria from SonoSite and AstraZeneca as a workshop tutor for teaching ultrasound-guided procedures.     

Compared to tunnelled cuffed haemodialysis catheters, temporary untunnelled catheters are associated with more complications already within 2 weeks of use.

BACKGROUND: Comparison of outcome of untunnelled catheters (UCs) and tunnelled cuffed catheters (TCCs) is difficult because they are usually used for different patients and conditions. The aim of the present study is to compare the outcome of TCCs with UCs limiting as much as possible the influence of confounding factors. The second purpose was to see whether our results support the time recommendations for maximum use of UCs outlined in the NKF-DOQI guidelines. METHODS: Catheter and patient characteristics, catheter-related complications and all cultures taken from haemodialysis catheters inserted during a 3 year period were collected. RESULTS: We analysed the outcome of 272 catheters (149 patients, 11 612 catheter-days, 37 TCC and 235 UC). Patients with an UC suffered more often from acute renal failure (40 vs 8% for TCCs, P<0.001), their hospitalization rates were higher (54 vs 14%, P<0.001) and coumarins were used less (11 vs 27%, P<0.01). Rates of preliminary removal were 1.8 per 1000 catheter-days for TCCs, 35.3 for untunnelled femoral catheters (UFCs) and 17.1 for untunnelled jugular catheters (UJCs). Infection rates were 2.9 per 1000 catheter-days for TCCs, 15.6 for UJCs and 20.2 for UFCs. Hospitalization was an independent risk factor for an adverse outcome and more apparent in patients with an UC. After correction for patient differences, the strongest risk factor for preliminary removal (RR 9.69, P<0.001) and infection (RR 3.76, P<0.001) was having an UC inserted. Already, within 2 weeks actuarial and infection-free survival were better for TCCs (P<0.05 vs all separate groups). CONCLUSIONS: According to our results, a TCC should be used whenever it can be foreseen that a haemodialysis catheter is needed for more than 14 days.     

Video-assisted basilic vein transposition for haemodialysis vascular access: preliminary experience with a new technique.

BACKGROUND: The brachio-basilic vein arteriovenous (AV) fistula is increasingly used as a secondary method for haemodialysis vascular access. The conventional surgical technique of brachio-basilic vein AV fistula creation consists of a long incision with dissection of the basilic vein and transposition of it to a subcutaneous anterior position in the upper arm. The aim of this study was to investigate whether minimal invasive basilic vein dissection with an endoscopic technique is feasible. METHODS: In 12 patients, brachio-basilic vein AV fistulas were created by means of a video-assisted technique with semi-closed dissection and harvesting of the basilic vein with the use of an endoscope and standard endoscopic instruments. All patients underwent pre- and post-operative duplex ultrasound investigation. RESULTS: In all patients, a successful endoscopic dissection was possible without peri-operative complications. One patient suffered from post-operative thrombotic occlusion, which was successfully treated by thrombectomy. One patient developed a haematoma in the upper arm. No wound complications occurred and all AV fistulas could be used satisfactorily for dialysis treatment. CONCLUSIONS: Video-assisted basilic vein transposition is a feasible minimal invasive technique to create secondary vascular access for haemodialysis.     

Trials and trade-offs in haemodialysis vascular access monitoring.

There are currently more than 300 000 patients receiving haemodialysisin the US and similar numbers are estimated in Europe. Despitethe recognition that vascular access is the ‘Achillesheel’ of the dialysis procedure, haemodialysis vascularaccess failure and related complications continue to be oneof the most difficult obstacles in the optimal care of dialysispatients. In the US, haemodialysis vascular access proceduresand complications account for more than 20% of hospitalizationsof haemodialysis patients and result in more than $1 billionper year of government paid expenditures [1]. Additional, oftenunrecognized costs stem from missed treatments, the placementand use of dialysis catheters and the significant     

Significance of platelet activation in vascular access survival of haemodialysis patients.

BACKGROUND: Vascular access failure is the most common cause of morbidity and hospitalization in haemodialysis (HD) patients. Although there are reports that anti-platelet agents can prevent vascular access thrombosis, the relationship between platelet activation and vascular access failure is not clear. The aim of this study was to investigate the role of platelet activation in recurrent vascular access failure. METHODS: The studied subjects were divided into three groups: group I included 23 HD patients with recurrent vascular access failure (native arteriovenous fistula <2 year survival or synthetic arteriovenous graft <1 year survival), group II included 15 HD patients with longer vascular access survival (>5 year survival) and group III included 10 healthy volunteers as controls. The expression of platelet activation markers (CD62P and fibrinogen receptor) and the numbers of platelet-derived microparticles were measured and compared between groups. RESULTS: CD62P-positive platelets were significantly higher in group I than in both group II (7.3+/-3.7 vs 3.5+/-1.3%; P<0.0005) and group III (2.9+/-0.9%; P<0.00005). Fibrinogen receptor-positive (PAC-1-positive) platelets were also significantly higher in group I than in group II (2.2+/-2.1 vs 0.9+/-0.7%; P<0.01) and group III (0.8+/-0.6%; P<0.01). CONCLUSIONS: A higher level of circulating activated platelets is associated with shorter survival of vascular access in HD patients. The higher level of circulating activated platelets may be a predictor of recurrent vascular access failure. The potential advantageous effects of anti-platelet therapy on this patient population warrant further investigation.     

Bovine ureter graft for haemodialysis access surgery.

Bovine ureter SynerGraft (SG) (CryoLife, Inc.) has been recentlyintroduced into haemodialysis access surgery. It is a non-glutaraldehydefixed acellular collagen and elastin matrix conduit that maywithstand arterial pressures. There has only been one publishedreport in humans with this graft for vascular access, exceptfor a canine model which Matsuura et al. reported [1]. In thisstudy, we report the early and mid-term outcome of bovine ureteras a haemodialysis access graft in chronic haemodialysis. Four female patients with     

Assessing the utility of ultrasound-guided vascular access placement with longer catheters in critically ill pediatric patients

Background

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long-dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.

Aim

The study sought to compare longevity, catheter-associated complications, and the need for additional vascular interventions when using ultrasound-guided longer peripheral intravenous catheters comparing to a traditional approach using standard-sized peripheral intravenous catheters in pediatric critically ill patients with difficult vascular access.

Methods

This single-center retrospective cohort study included children 0–18 years of age with difficult vascular access admitted to the pediatric intensive care unit between 01/01/2018–06/01/2021.

Results

One hundred and eighty seven placements were included in the study, with 99 ultrasound-guided long intravenous catheters placed and 88 traditionally placed standard-sized intravenous catheters. In the univariate analysis, patients in the traditional approach were at a higher risk of intravenous failure compared to those in the ultrasound-guided approach (HR = 2.20, 95% CI [1.45–3.34], p = .001), with median intravenous survival times of 108 and 219 h, respectively. Adjusting for age, patients in the traditional approach remained at higher risk of intravenous failure (HR = 1.99, 95% CI: [1.28–3.08], p = .002). Adjusting for hospital length of stay, patients in the ultrasound-guided approach were less likely to have additional peripheral intravenous access placed during hospitalization (OR = 0.39, 95% CI [0.18–0.85] p = .017).

Conclusion

In critically ill pediatric patients with difficult vascular access, ultrasound-guided long peripheral intravenous catheters provide an alternative to traditional approach standard-sized intravenous catheters with improved longevity, lower failure rates, and reduced need for additional vascular interventions.     

Vascular access survival and morbidity on daily dialysis: a comparative analysis of home and limited care haemodialysis.

BACKGROUND: Concerns about vascular access failure may have limited the widespread use of daily haemodialysis (DHD). We assessed the incidence and type of vascular access complications during DHD and other schedules, both at home and on limited care haemodialysis. METHODS: All patients were treated in a limited care and home haemodialysis unit with a stable caregiver team (November 1998-November 2002). Vascular access failure, surgical treatment, angioplasty and declotting were studied alone or in combination by univariate and multivariate models. We analysed the effects of age, sex, comorbidity, previous vascular events, schedule, setting of treatment (home, limited care), dialysis follow-up, vascular access (native vs prosthetic, first vs subsequent) and setting of vascular access creation. 'Intention to treat' and 'per protocol' analyses were performed. RESULTS: In 2160 patient-months (home dialysis: DHD 400 months, non-DHD 655 months; limited care: DHD 208 months; non-DHD 897 months), 57 adverse events occurred (27 failures), in which 30 were at home (nine DHD) and 27 were in limited care (five DHD). The probability of remaining free from adverse events at 6 and 12 months was 89% and 80% on DHD and 79% and 76% on other schedules ('intention to treat'). Univariate analyses revealed a significant difference for the setting of the vascular access creation (lower risk of vascular access complications in our centre) and sex (male sex was protective). Logistic regression and Cox analyses confirmed the role for the setting of the vascular access creation. CONCLUSIONS: Although DHD did not appear as a risk factor for vascular access morbidity or failure at home or in a limited care centre setting, the setting of vascular access creation may influence its success.     

Repeated femoral vein puncturing for maintenance haemodialysis vascular access.

BACKGROUND: When access cannot be achieved using a native arteriovenous fistula or a synthetic prosthetic graft, central venous catheters are usually placed. This mode of access is short-lived, prone to infection, stenosis and thrombosis of central veins. To overcome access problems, we developed a new native vascular access ('femoral vein access') and devices. We report here on our experience with the availability, longevity, procedure and morbidity of haemodialysis (HD) using femoral vein access. METHODS: Repeated (three times a week) patient's native femoral vein puncturing has been used as the vascular access (femoral vein access) for maintenance HD in 30 patients (mean age +/- SD: 61.70 +/- 15.27 years old; 18 female/12 male). The femoral vein was punctured beneath the inguinal ligament (on a length ranging from 30 to 100 mm) after disinfection and local anaesthesia. Long (effective length 56 mm) 19- and 18-gauge needles with four side holes were used for the femoral vein puncture as an arterial site of the extracorporeal circuit of HD and shorter (effective length 40 mm) similar gauge needles for the subcutaneous vein puncture used as the return site. The needle is inserted blind into the femoral vein after the femoral artery has been located by palpation and the perception of a pulse. Patients returned home the same day. RESULTS: The mean duration of HD treatment using femoral vein repeated puncture was 4.99 +/- 3.42 years (up to 16.0 years). This represented a total experience of 23 369 femoral vein punctures. The mean blood flow achieved on dialysis was 165 +/- 20 ml/min. The average Kt/V was 1.74 +/- 0.48 per session. CONCLUSIONS: The femoral vein repeated puncture technique has substantial advantages over venous catheters. It does not require surgery, while permitting adequate blood flow. This method can be used as a long-term (over 10 years) blood access. Apart from a few local haematomas, no serious complications have been observed. Moreover, it does not carry a heavy financial burden.     

Bacterial colonization and peripheral bacteraemia associated with central venous haemodialysis catheters: A cross-sectional study

Summary: Septicaemia related to internal luminal colonization of central venous catheters has been described in many clinical settings including haemodialysis. the prevalence and consequence of intraluminal colonization of central venous haemodialysis catheters is unknown. A cross-sectional study of asymptomatic patients receiving haemodialysis through central venous catheters was performed. Differential (central line and peripheral) quantitative blood cultures were taken on three occasions. Twenty-one patients were studied and 20 had colonized central venous catheters. the organisms isolated were Coagulase negative Staphylococci (16 cases), Bacillus species (three), Corynebacterium (three), Pseudomonas species (three), and others (three). Fifteen patients also had significant peripheral bacteraemia associated with the same organism that was cultured from their central line. Seven patients had septic episodes associated with these same organisms. Swabs taken of the internal catheter surfaces also cultured these organisms. the vast majority (95%) of central venous haemodialysis catheters are colonized by bacteria. Seventy-six per cent have associated peripheral bacteraemia, which can lead to systemic infection.     

Factors affecting long-term survival of tunnelled haemodialysis catheters--a prospective audit of 812 tunnelled catheters.

BACKGROUND: In 2001, in the US, 23% of haemodialysis patients were dialysing through tunnelled venous catheters (TVCs), and in the UK (2006) there were 28% of prevalent patients using catheters. It is unlikely that numbers will significantly decrease. We present the results of a prospective audit of the survival of 812 TVCs placed in 492 patients at our institution over a 6-year period (comprising 212 048 patient catheter days or 7068 patient catheter months of follow-up). Four different designs of catheter were studied: Split-Cath III (Medcomp), HemoSplit (Bard), Tesio twin catheter (Medcomp) and Permcath (Quinton). METHODS: We used Kaplan-Meier survival analysis with log-rank test, to compare the effect of different parameters on catheter survival.The relative importance of significant parameters was determined by Cox regression analysis. RESULTS: We have shown a significant catheter survival advantage of first catheters over second and subsequent insertions, of right internal jugular site over left internal jugular and thereafter over femoral site, and of non-diabetic over diabetic patients. Patient age, sex and operator (physician in ward-based procedure room under ultrasound control or surgeon in operating theatre under fluoroscopic assistance) did not significantly affect survival. The Permcath design demonstrated inferior survival in all but first catheter insertions in catheter-na?ve patients. The HemoSplit and Tesio twin catheter designs demonstrated best survival overall. By Cox proportional hazard modelling the design and the position of the TVC seemed to be the most significant independent survival factors. CONCLUSIONS: Clinicians need accurate data regarding catheter survival, mode of insertion and design, to inform practice.     

Alternative puncture site for implantable permanent haemodialysis catheters

BACKGROUND.: Vascular access represents a major problem in long-term haemodialysispatients. In patients without patent internal arteriovenousfistula, the implantation of cuffed catheters to provide a temporaryor permanent central venous access is often necessary. Catheterizationof the subclavian vein should be avoided because of the highrisk of stenosis or thrombosis. The puncture of the internaljugular vein can be impossible in cases with stenosis or thrombosisdue to previous catheterization. To overcome these limitationswe evaluated an alternative puncture site for implantation ofpermanent central venous catheters. METHODS.: The very low, most central jugular approach, first describedby Rao et al., with the site of puncture just above the medialnotch of the clavicle, was used to introduce Dacron cuffed dialysiscatheters into the innominate vein in four chronic dialysispatients with impeded conventional vascular access. RESULTS.: In all four patients puncture of the internal jugular vein usingRao's technique was successful at the first attempt. All fourcatheters were introduced without any problems. Even in a casewith thrombosis of the internal jugular vein and the ipsilateralsubclavian vein, this technique was successfully applied. Nocomplications such as haematoma, pneumothorax, or catheter-associatedinfection were observed. The catheters remained in situ for2–12 months with excellent blood flow and without clinicalevidence of venous stenosis or thrombosis. CONCLUSIONS.: In case of failure to cannulate the internal jugular vein bya conventional approach, the technique of Rao et al. can beused before sacrificing the subclavian vein or changing to exotictechniques such as translumbar, transfemoral or transhepaticmethods.