Principles of Tunneled Cuffed Catheter Placement

Arteriovenous Fistula Maturation in Patients with Ipsilateral Versus Contralateral Tunneled Dialysis Catheter: A Systematic Review and Meta-analysis

BACKGROUND

Although it is evident that a prior history of tunneled dialysis catheter (TDC) affects arteriovenous fistula (AVF) function, it is unclear whether its location (contralateral versus ipsilateral to AVF) has any effect on AVF maturation and failure rates. We aimed to document this possible effect.

METHODS

This systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing outcomes between patients with contralateral TDC (CONTRA group) and those with ipsilateral one (IPSI group) were examined for inclusion. A random effects model meta-analysis of the odds ratio (OR) was conducted. Primary outcomes were AVF functional maturation, assisted maturation, and failure rates.

RESULTS

Four eligible studies comprising 763 patients were included in the meta-analysis. There were no significant differences in terms of AVF functional maturation (OR: 1.49; 95% confidence interval [CI]: 0.64-3.47; I2 = 83.4%), assisted maturation (OR: 0.59; 95% CI: 0.29-1.19; I2 = 61.4%), and failure rates (OR: 0.67; 95% CI: 0.29-1.58; I2 = 83.3%) between the 2 study groups.

CONCLUSIONS

TDC laterality seems not to affect fistula maturation rate in patients requiring TDC placement and concurrent AVF creation, but rather, vein- and patient-related characteristics might play a more important role in choosing TDC access site. Further studies are needed to validate these results.

Brachial Tunneled Peripherally Inserted Central Catheters and the Risk of Catheter Complications: A Systematic Review and Meta-Analysis

INTRODUCTION

Situations involving increased workloads and stress (i.e., the COVID-19 pandemic) underline the need for healthcare professionals to minimize patient complications. In the field of vascular access, tunneling techniques are a possible solution. This systematic review and meta-analysis aimed to compare the effectiveness of tunneled Peripherally Inserted Central Catheters (tPICCs) to conventional Peripherally Inserted Central Catheters (cPICCs) in terms of bleeding, overall success, procedural time, and late complications.

METHODS

Randomized controlled trials without language restrictions were searched using PUBMED®, EMBASE®, EBSCO®, CINAHL®, and the Cochrane Controlled Clinical Trials Register from August 2022 to August 2023. Five relevant papers (1238 patients) were included.

RESULTS

There were no significant differences in overall success and nerve or artery injuries between the two groups (p = 0.62 and p = 0.62, respectively), although cPICCs caused slightly less bleeding (0.23 mL) and had shorter procedural times (2.95 min). On the other hand, tPICCs had a significantly reduced risk of overall complications (p < 0.001; RR0.41 [0.31-0.54] CI 95%), catheter-related thrombosis (p < 0.001; RR0.35 [0.20-0.59] IC 95%), infection-triggering catheter removal (p < 0.001; RR0.33 [0.18-0.61] IC 95%), wound oozing (p < 0.001; RR0.49 [0.37-0.64] IC 95%), and dislodgement (p < 0.001; RR0.4 [0.31-0.54] CI 95%).

CONCLUSIONS

The tunneling technique for brachial access appears to be safe concerning intra-procedural bleeding, overall success, and procedural time, and it is effective in reducing the risk of late complications associated with catheterization.

Chest radiographs of cardiac devices (Part 1): Lines, tubes, non-cardiac medical devices and materials

Chest radiographs (CXRs) are the most common imaging investigations undertaken because of their value in evaluating the cardiorespiratory system. They play a vital role in intensive care units for evaluating the critically ill. It is therefore very common for the radiologist to encounter tubes, lines, medical devices and materials on a daily basis. It is important for the interpreting radiologist not only to identify these iatrogenic objects, but also to look for their accurate placement as well as for any complications related to their placement, which may be seen either on the immediate post-procedural CXR or on a follow-up CXR. In this article, we discussed and illustrated the routinely encountered tubes and lines that one may see on a CXR as well as some of their complications. In addition, we also provide a brief overview of other important non-cardiac medical devices and materials that may be seen on CXRs.

Long-term follow-up of endovascular repair of iatrogenic superior vena cava injury: A case report

RATIONALE

This report aimed to present the long-term follow-up results of the management of superior vena cava (SVC) rupture during balloon angioplasty in an attempt to relieve SVC obstruction as a result of hemodialysis (HD) catheter-related central vein stenosis.

PATIENT CONCERNS

We present a case of a 42-year-old woman with end-stage renal disease on HD for 4 years, initially from an autogenous fistula for 2.5 years and then from a right internal jugular vein (IJV) catheter. She presented with clinical manifestations of SVC obstruction (dilated anterior chest wall and abdominal wall veins and facial swelling), which progressed over the last 1.5 years.

DIAGNOSIS

A venogram confirmed right and left brachiocephalic vein and SVC obstruction.

INTERVENTIONS

She underwent balloon angioplasty of the SVC through the right IJV, during which the dilated area ruptured, resulting in right hemothorax and hypovolemic shock. A covered stent was placed over the bleeding site, and the patient recovered.

OUTCOMES

Rapid and skilled endovascular intervention through placement of a covered stent at the bleeding site can be lifesaving.

LESSONS

It is superior to open surgical management in terms of complexity and morbidity especially in patients who are poor surgical candidates, and its durability is proving to be comparable.

Vascular access considerations for extracorporeal photopheresis

Extracorporeal photopheresis is an immunomodulatory therapy indicated for patients with cutaneous T-cell lymphoma, graft-versus-host disease, and heart or lung allograft rejection. Whole blood from the patient is drawn into the photopheresis instrument where it is separated into its components. Plasma, red blood cells, and the treated buffy coat are subsequently returned to the patient. Consistent, adequate blood flow is necessary to successfully complete the procedure. Vascular access options for photopheresis include peripheral vein cannulation, tunneled central venous catheters, and subcutaneous ports. Photopheresis is a very safe procedure; however, the complications and impact on the patient's quality of life associated with vascular access devices can be significant.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Urea-based recirculation validation of the symmetrical palindrome catheter

BACKGROUND

High blood flow and low recirculation rates are central for adequate haemodialysis. A new symmetrical tip has been invented promising efficient haemodialysis even if the ports are reversed.

OBJECTIVE

To evaluate access recirculation of the 'palindrome' catheter and to report initial experiences in a clinical setting.

MATERIAL AND METHODS

After implantation of the new catheter in 20 patients (male: 14; female: 6; mean age 72 ± 12.2), access recirculation was evaluated using the urea-based recirculation test. After 30 minutes of haemodialysis, ultrafiltration was stopped and arterial and venous samples were taken. Afterwards, the blood flow rate was reduced to 120 ml/min. Another systemic arterial blood sample was taken 10 seconds after the blood pump was switched off.

RESULTS

All 20 interventions were performed successfully without complications. The average recirculation rate was 8.1% with a median of 2.5% ranging from 0 to 85.8%. Recirculation rates under 5% were measured in 13 patients and more than 10% recirculation were found in two patients. The median of days between catheter implantation and recirculation assessment was the day following implantation.

CONCLUSION

The new symmetrical catheter presented low recirculation rates in a clinical setting. Since there is just a single tip, fluoroscopic placement in the right atrium is facilitated.

Practical Aspects of Nontunneled and Tunneled Hemodialysis Catheters

Nontunneled hemodialysis catheters (NTHCs) are typically used when vascular access is required for urgent renal replacement therapy. The preferred site for NTHC insertion in acute kidney injury is the right internal jugular vein followed by the femoral vein. When aided by real-time ultrasound, mechanical complications related to NTHC insertion are significantly reduced. The preferred site for tunneled hemodialysis catheters placement is the right internal jugular vein followed by the left internal jugular vein. Ideally, the catheter should be inserted on the opposite side of a maturing or planned fistula/graft. Several dual-lumen, large-diameter catheters are available with multiple catheter tip designs, but no one catheter has shown significant superior performance.

Retrograde femoral vein catheter insertion. A new approach for challenging hemodialysis vascular access

INTRODUCTION

Venous catheters provide access for hemodialysis (HD) when patients do not have functioning access device. Obstruction of jugular, femoral or even external iliac vessels further depletes options. Subclavian approach is prohibited. Catheterization of inferior vena cava requires specialized equipment and skills.

PURPOSE

The purpose is to assess a new lifesaving HD vascular access approach for patients with nonfunctioning access device in the ordinary sites. This entails insertion of a retrograde temporary HD catheter in the superficial femoral vein, directing the catheter distally, toward the foot.

MATERIALS AND METHODS

We included six end-stage renal disease (ESRD) patients retrospectively who are on regular renal replacement therapy and need urgent HD with nonfunctioning access device in the ordinary sites.

RESULTS

Successful insertion of six retrograde femoral vein catheters in the superficial femoral vein. The mean catheter days were 2.5±0.5 days with one patient having 26 catheter days. The mean blood pump speed was 230.0±44.7 mL/min. Urea reduction ratio and Kt/V at 3 hours HD session were 47% and 1.5, respectively, which increased with increasing session duration. The ultrafiltration volume was 2-3 L/session which increased up to 6 L/session in case of using slow low-efficiency dialysis. No major complications were observed during insertion or the postinsertion period except thigh pain in one patient and exit site infection in the case of long duration.

CONCLUSIONS

This is a newly applied lifesaving HD vascular access approach for selected ESRD patients with no available HD vascular access at the ordinary sites with accepted HD adequacy. It needs more evaluation and more studies.