Interventions for treating central venous haemodialysis catheter malfunction

Efficacy of Low-Dose Streptokinase Infusion in Late-Onset Permanent Tunnel Catheter Dysfunction: A Single-Center Interventional Study

Introduction Hemodialysis is a vital modality for patients with renal dysfunction, with venous access being a significant factor in its success. While arteriovenous fistulas are preferred, tunneled catheters serve as important alternatives, especially in challenging cases. Late-onset tunneled catheter dysfunction, often due to fibrin sheath formation, impedes hemodialysis efficiency. Streptokinase, a low-cost thrombolytic agent, has shown promise in resolving such complications, yet its efficacy in the Indian context remains unexplored. Methods We conducted a single-center interventional study at Mahatma Gandhi Mission (MGM) Hospital, Aurangabad, India, from May 2023 to October 2023. Ethical approval was obtained, and 10 eligible patients experiencing late-onset permanent tunnel catheter dysfunction were enrolled. Patients were treated with low-dose streptokinase, and outcomes were monitored for 60 days. Results Ten patients, evenly distributed by gender, participated, with a mean age of 48.2 ± 11.96 years. Diabetes was the predominant cause of chronic kidney disease (CKD) at 33% (3/10). All patients achieved the primary endpoint of blood flow rate (BFR) >300 ml/min post-streptokinase treatment, with an overall success rate of 100%. Group A had the highest average gain in catheter days (80.6 ± 7.59), followed by Group B (64 ± 1), while Group C showed variations in catheter days between the first (26.2 ± 6.8) and second insertion (32.5 ± 1.76). Eight patients maintained catheter patency during the 60-day follow-up. Adverse effects, primarily minor, were observed. The dosage rationale involved an eight-hour infusion at 4,000 units per hour. Conclusion Streptokinase emerges as cost-effective and efficacious for maintaining the patency of late-onset tunnel catheter dysfunction in resource-limited settings, particularly in younger patients. Caution is advised for older individuals with prolonged CKD.

Successful Removal and Replacement of a Stuck Hemodialysis Catheter via Thoracotomy: Report of Two Cases and Literature Review

Introduction

Stuck tunneled central venous catheters (CVCs) have been increasingly reported. In rare cases, the impossibility of extracting the CVC from the central vein after regular traction is the result of rigid adhesions to the surrounding fibrin sheath. Forced traction during catheter removal can cause serious complications, including cardiac tamponade, hemothorax, and hemorrhagic shock. Knowledge and experience on how to properly manage the stuck catheter are still limited.

Case Presentation

Here, we present two cases that highlight the successful removal of the stuck tunneled CVC via thoracotomy through the close collaboration of multidisciplinary specialists in the best possible way. Both patients underwent an unsuccessful attempt at thrombolytic therapy with urokinase, catheter traction under the guidance of digital subtraction angiography and intraluminal balloon dilation. And we reviewed the literature on stuck catheters in the hope of providing knowledge and effective approaches to attempted removal of stuck catheters.

Conclusion

There is no standardized procedure for dealing with stuck catheters. Intraluminal percutaneous transluminal angioplasty should be considered as the first-line treatment, while open surgery represents a second option only in the event of failure. Care must be taken that forced extubation can cause patients life-threatening.

[Catheter Replacement Methods in Hemodialysis Patients With Dysfunctional Tunneled-Cuffed Catheters With Fibrin Sheaths]

Objective

Tunneled-cuffed catheters (TCCs) are frequently used for establishing hemodialysis access for maintenance hemodialysis in older patients with exhausted resources of peripheral vessels. Fibrin sheath formation around the catheter is one of the most common complications of long-term use of indwelling catheter, which may cause the malfunction of the catheter. In this study, we intend to compare the prognosis of two catheter replacement methods, in situ replacement and replacement through a fibrin sheath crevice, with both being assisted by balloon dilation, and to explore the optimal catheter replacement process.

Methods

A retrospective study was conducted with 52 patients who underwent a replacement of their TCCs. Among them, 27 cases had their TCC replaced by the modified method of replacement through a fibrin sheath crevice and were referred to as the sheath crevice group, while 25 cases underwent in situ catheter replacement and were referred to as the in situ group. The primary outcome indicators included maximum blood flow in hemodialysis catheter and the urea clearance rate calculated by Kt/V values at the 1, 3, and 6-month follow-ups. The secondary outcomes included dialyzer alarms being set off and catheter-related infections during follow-up.

Results

There was no significant difference between the general data of the two groups. There was no massive blood loss during the replacement procedure. Neither were there cardiac tamponade, catheter-associated infections, or other complications. Follow-ups were made 1, 3, and 6 months after the replacement procedure. The sheath crevice group had higher catheter blood flow and Kt/V values at the 6-month follow-up than the in situ group did ([241.85±9.62] mL/min vs. [234.40±11.21] mL/min, P=0.014 and 1.31±0.55 vs. 1.27±0.49, P=0.005, respectively). During the follow-up process, access alarms were reported in 5 patients (three in the in situ group and two in the sheath crevice group) during dialysis. No catheter-associated infection occurred in either group.

Conclusion

The catheter replacement method of balloon dilation-assisted catheter insertion through a fibrin sheath crevice is safe and effective, resulting in better long-term catheter blood flow compared with that of in situ catheter replacement.

Reduction in Thrombolytic Usage in Hemodialysis Patients Following a Quality Assurance Review: A Research Letter

Background

Catheter malfunction in hemodialysis (HD) is increasingly managed with recombinant tissue plasminogen activator (rt-PA, alteplase), though evidence of improved catheter function is lacking.

Objective

To evaluate the effect of a standardized rt-PA administration protocol on rt-PA usage, catheter function, and adverse events.

Design

Observational quality improvement study.

Setting

Single, urban, community HD unit in Calgary, Alberta.

Patients

Patients treated with maintenance in-center HD through central venous catheter.

Outcomes

Incidence of rt-PA usage, catheter interventions, hospitalizations, and measures of dialysis efficacy.

Methods

The rt-PA protocol was designed following a consultative and iterative design period with dialysis shareholders, which included focusing on standard objective criteria before use and targeting use to the problematic lumen. Protocol implementation occurred over a 6-month period in 2021. Patient and dialysis data were collected through our regional dialysis electronic health record.

Results

Implementation of the rt-PA protocol resulted in decreased rt-PA use (standardized per 100 dialysis sessions) compared to the preprotocol period (incidence rate ratio [IRR] of 0.57, 95% confidence interval [CI]: [0.34, 0.94]). Line procedures were also less frequent (IRR = 0.42, 95% CI: [0.18, 0.89]). Hospitalization rates and measures of dialysis efficacy were similar in both periods.

Limitations

Small sample size with single dialysis center and short duration of follow-up.

Conclusions

Implementation of a multidisciplinary designed rt-PA administration protocol decreased incident rt-PA usage.

Locked Away-Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis

Reliable vascular access is necessary for effective hemodialysis. Guidelines recommend chronic hemodialysis via an arteriovenous fistula (AVF), however, in a significant number of patients, permanent central venous catheters (CVCs) are used. The use of a tunneled catheter is acceptable if the estimated dialysis time is less than a year or it is not possible to create an AVF. The main complications associated with CVC include thrombosis and catheter-related bloodstream infections (CRBSIs), which may result in loss of vascular access. The common practice is to use locking solutions to maintain catheter patency and minimize the risk of CRBSI. This paperwork summarizes information on currently available locking solutions for dialysis catheters along with their effectiveness in preventing thrombotic and infectious complications and describes methods of dealing with catheter dysfunction. The PubMed database was systematically searched for articles about locking solutions used in permanent CVCs in hemodialysis patients. Additional studies were identified by searching bibliographies and international guidelines. Articles on end-stage kidney disease patients dialyzed through a permanent CVC were included. Information from each primary study was extracted using pre-determined criteria including thrombotic and infectious complications of CVC use, focusing on permanent CVC if sufficient data were available. Of the currently available substances, it seems that citrate at a concentration of 4% has the best cost-effectiveness and safety profile, which is reflected in the international guidelines. Recent studies suggest the advantage of 2+1 protocols, i.e., taurolidine-based solutions with addition of urokinase once a week, although it needs to be confirmed by further research. Regardless of the type of locking solution, if prophylaxis with a thrombolytic agent is chosen, it should be started from the very beginning to reduce the risk of thrombotic complications. In case of CVC dysfunction, irrespective of the thrombolysis attempt, catheter replacement should be planned as soon as possible.

Long-Term Follow-Up and Clinical Relevance of Incidental Findings of Fibrin Sheath and Thrombosis on Computed Tomography Scans of Cancer Patients with Port Catheters

Purpose

This retrospective study examined the incidence, progression, and clinical relevance of catheter-related thrombosis (CRT) and/or fibrin sheaths presenting as incidental findings on routine staging computed tomography (CT) scans performed in cancer patients.

Patients and Methods

Patients who underwent central venous port catheter (CVC) placement in a tertiary care hospital between September 2010 and August 2013 were followed up for up to five years. Two radiologists assessed the presence of fibrin sheath and thrombosis in consensus in staging CT scan. Patient demographics, type of cancer, preoperative comorbidities, date of CVC placement and CTs, preexisting anticoagulation, as well as the type and treatment of catheter-related complications were determined from the electronic medical record.

Results

A total of 194 patients with 530 CT scans and a mean follow-up time of 394 days were included. Fibrin sheaths and thromboses were seen on 46 scans (8.7%) in 30 patients and 80 scans (15.1%) in 35 patients. The incidence of fibrin sheaths and thromboses was found to be 15.5% and 18%, respectively. The comparison to initial CT reports results indicated that fibrin sheaths or thromboses were missed in 106 examinations (20%). Catheter-associated complications were reported in 14 patients (21.5%) without specific therapy.

Conclusion

Fibrin sheaths and CRTs are often overlooked on routine CT scans when patients are asymptomatic. The subsequent high complication rate demonstrates the clinical relevance of the initial incidental finding on CT scan. Further studies should elucidate the effect of thrombolytic agents and interventional radiologic treatment in asymptomatic patients.

Efficacy and safety of secondary procedures for maintaining arteriovenous hemodialysis access patency: protocol for a systematic review and network meta-analysis

BACKGROUND

Arteriovenous (AV) hemodialysis access creation is recommended by international guidelines as the preferred method of hemodialysis access. However, most AV access sites will require revision to maintain patency. Although several treatment options exist, many have not been directly compared. We intend to compare the relative effectiveness of methods to maintain post-intervention primary patency of failing AV access.

METHODS

We will search EMBASE, MEDLINE, CENTRAL, trial registries, the grey literature, and ancestry and citation search from January 1977 to present, for randomized controlled trials comparing interventions to maintain primary patency of AV access. Two investigators will independently and blindly review all identified citations and extract data from included studies. The primary outcome is the primary patency 6 months after intervention. Secondary outcomes include immediate technical and functional success, reinterventions, patency, and mortality. Risk of bias, subgroup analyses, and sensitivity analyses are planned.

DISCUSSION

There are a number of treatment modalities for the management of failing AV access. However, most modalities have only been directly compared with plain old balloon angioplasty, and currently synthesized evidence focuses on individual pairwise comparisons. In light of the lack of comprehensively synthesized evidence and clinical equipoise, our study intends to synthesize currently available evidence though it is unclear which treatment modality is most effective.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42020148224.

Solutions to stuck tunneled cuffed catheters in patients undergoing maintenance hemodialysis

OBJECTIVE

To study and discuss treatments for stuck tunneled cuffed catheter in patients undergoing maintenance hemodialysis.

METHOD

Retrospectively analyzing clinical data of 13 patients with stuck tunneled cuffed catheter in the Kidney Disease Center of the First Affiliated Hospital, College of Medicine, Zhejiang University in the period between September 2012 and October 2018. All patients failed to remove hemodialysis catheters by regular technique. The stuck catheters were treated by thoracotomy, endoluminal percutaneous transluminal angioplasty with blunt dissection or embedded and left in situ.

RESULTS

In 13 patients, one was successfully treated by thoracotomy, one failed to remove the catheter by regular technique and blunt dissection, and the stump of the catheter was clamped and buried in the subcutaneous fascia of the neck, and the other 11 were treated by endoluminal percutaneous transluminal angioplasty with blunt dissection. The average time of catheter removal procedure is 25 min, the overall success rate is 92.3%, and the success rate of percutaneous transluminal angioplasty is 100%.

CONCLUSION

Thoracotomy is an efficient way to treat stuck catheter but is limited by its high risk and complications. Leaving part of catheter in situ may increase the risk of central vein stenosis. Comparing to the former two, endoluminal percutaneous transluminal angioplasty is a safe, efficient, and practical way for stuck catheters and should be recommended as the first choice.

Selective use of episiotomy: what is the impact on perineal trauma? Results from a retrospective cohort study

PURPOSE

To evaluate the effects of selective use of episiotomy on perineal trauma.

METHODS

We performed a retrospective cohort study on consecutive vaginal deliveries from January 2010 to December 2016. From January 2010 to December 2011 episiotomy was performed liberally, based only on individual midwife/doctor's decision. Since January 2012, a shared selective use of episiotomy policy has been introduced. To evaluate the range of perineal trauma in spontaneous second-degree perineal tears, a sub-classification of second-degree lacerations has been introduced dividing them into two sub-groups: A (smaller than the average episiotomy) and B (spontaneous vaginal tear larger than the average episiotomy). The primary outcomes were the incidence and type of perineal trauma, with the proportion of type A and type B second-degree spontaneous tears under a policy of selective episiotomy.

RESULTS

Deliveries not exposed to selective use of episiotomy were 1583 (Group 1), those exposed to selective use of episiotomy were 6409 (Group 2). In Group 2 episiotomy rate decreased, and incidence of intact perineum, first- and second-degree lacerations increased. The incidence of third- and fourth-degree lacerations did not change. Spontaneous second-degree lacerations occurred in 19.4% and 36.8% of women in group 1 and 2, respectively. With a selective episiotomy policy, 88.3% of second-degree tears was classified as type A.

CONCLUSIONS

The selective use of episiotomy is clinically feasible and effective. This policy seems to be associated with a lower delivery-related perineal trauma as showed by the sub-classification, that could be a useful tool to monitor obstetric care.

TuLIP (Tunnelled Line Intraluminal Plasty): An Alternative Technique for Salvaging Haemodialysis Catheter Patency in Fibrin Sheath Formation

Background

Renal patients with a tunnelled haemodialysis line are at risk of fibrin ‘sheath’ formation which can lead to occlusion. Dysfunctional lines are best treated by catheter exchange with a new subcutaneous tunnel; however, there is a risk of scarring, venous stenosis, potential loss of valuable access as well as the risk of infection.

Method

We report a retrospective review of our experience using tunnelled line intraluminal plasty (TuLIP) in 11 patients over 16 months with fibrin sheath formation on pre-existing tunnelled haemodialysis catheters.

Result

All patients responded well to treatment with median line patency post TuLIP reaching 112 days.

Conclusion

TuLIP may have a role in extending catheter lifespan and delaying more invasive intervention.

Interventions for treating central venous haemodialysis catheter malfunction

BACKGROUND

Adequate haemodialysis (HD) in people with end-stage kidney disease (ESKD) is reliant upon establishment of vascular access, which may consist of arteriovenous fistula, arteriovenous graft, or central venous catheters (CVC). Although discouraged due to high rates of infectious and thrombotic complications as well as technical issues that limit their life span, CVC have the significant advantage of being immediately usable and are the only means of vascular access in a significant number of patients. Previous studies have established the role of thrombolytic agents (TLA) in the prevention of catheter malfunction. Systematic review of different thrombolytic agents has also identified their utility in restoration of catheter patency following catheter malfunction. To date the use and efficacy of fibrin sheath stripping and catheter exchange have not been evaluated against thrombolytic agents.

OBJECTIVES

This review aimed to evaluate the benefits and harms of TLA, preparations, doses and administration as well as fibrin-sheath stripping, over-the-wire catheter exchange or any other intervention proposed for management of tunnelled CVC malfunction in patients with ESKD on HD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 17 August 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

We included all studies conducted in people with ESKD who rely on tunnelled CVC for either initiation or maintenance of HD access and who require restoration of catheter patency following late-onset catheter malfunction and evaluated the role of TLA, fibrin sheath stripping or over-the-wire catheter exchange to restore catheter function. The primary outcome was be restoration of line patency defined as ≥ 300 mL/min or adequate to complete a HD session or as defined by the study authors. Secondary outcomes included dialysis adequacy and adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed retrieved studies to determine which studies satisfy the inclusion criteria and carried out data extraction. Included studies were assessed for risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using GRADE.

MAIN RESULTS

Our search strategy identified 8 studies (580 participants) as eligible for inclusion in this review. Interventions included: thrombolytic therapy versus placebo (1 study); low versus high dose thrombolytic therapy (1); alteplase versus urokinase (1); short versus long thrombolytic dwell (1); thrombolytic therapy versus percutaneous fibrin sheath stripping (1); fibrin sheath stripping versus over-the-wire catheter exchange (1); and over-the-wire catheter exchange versus exchange with and without angioplasty sheath disruption (1). No two studies compared the same interventions. Most studies had a high risk of bias due to poor study design, broad inclusion criteria, low patient numbers and industry involvement.Based on low certainty evidence, thrombolytic therapy may restore catheter function when compared to placebo (149 participants: RR 4.05, 95% CI 1.42 to 11.56) but there is no data available to suggest an optimal dose or administration method. The certainty of this evidence is reduced due to the fact that it is based on only a single study with wide confidence limits, high risk of bias and imprecision in the estimates of adverse events (149 participants: RR 2.03, 95% CI 0.38 to 10.73).Based on the available evidence, physical disruption of a fibrin sheath using interventional radiology techniques appears to be equally efficacious as the use of a pharmaceutical thrombolytic agent for the immediate management of dysfunctional catheters (57 participants: RR 0.92, 95% CI 0.80 to 1.07).Catheter patency is poor following use of thrombolytic agents with studies reporting median catheter survival rates of 14 to 42 days and was reported to improve significantly by fibrin sheath stripping or catheter exchange (37 participants: MD -27.70 days, 95% CI -51.00 to -4.40). Catheter exchange was reported to be superior to sheath disruption with respect to catheter survival (30 participants: MD 213.00 days, 95% CI 205.70 to 220.30).There is insufficient evidence to suggest any specific intervention is superior in terms of ensuring either dialysis adequacy or reduced risk of adverse events.

AUTHORS' CONCLUSIONS

Thrombolysis, fibrin sheath disruption and over-the-wire catheter exchange are effective and appropriate therapies for immediately restoring catheter patency in dysfunctional cuffed and tunnelled HD catheters. On current data there is no evidence to support physical intervention over the use of pharmaceutical agents in the acute setting. Pharmacological interventions appear to have a bridging role and long-term catheter survival may be improved by fibrin sheath disruption and is probably superior following catheter exchange. There is no evidence favouring any of these approaches with respect to dialysis adequacy or risk of adverse events.The current review is limited by the small number of available studies with limited numbers of patients enrolled. Most of the studies included in this review were judged to have a high risk of bias and were potentially influenced by pharmaceutical industry involvement.Further research is required to adequately address the question of the most efficacious and clinically appropriate technique for HD catheter dysfunction.