Indication for the use of Central Venous Catheters as Vascular Access for Hemodialysis

Adequate treatment for uremic patients on hemodialysis requires valid and lasting access to central vessels.

The Central Venous Catheter (CVC) as a mean of immediate access is indispensable in all acute cases where it has not been possible to prepare an AVF in time and when the peripheral vascularization is highly compromised. We present our investigation on the best access route to central vessels and the selection of the type of catheters to adopt in different conditions.

On the basis of complications arising during the catheter life especially as permanent access, it seems to us that the right internal jugular catheterization with the 2 Tesio catheters Kit is the more useful and less dangerous catheterization.

Unusual Clot Formation following Insertion of Central Double Lumen Catheter for Hemodialysis

Background

We report a case of a patient with chronic renal failure (CRF) due to fibrillary glomerulonephritis, who was admitted to our Hospital with fever accompanied by chills, of two days duration. Due to aggravation of his CRF, accompanied by severe metabolic acidosis, an internal jugular double lumen central vein catheter was inserted, through which he was hemodialyzed.

Methods

Blood cultures were negative. The catheter was removed and the tip was cultured; it revealed colonization with hemolytic Staphylococcus sensitive to vancomycin and metilmycin. They were both given to the patient with excellent results. Trans-thoracic and trans-esophageal echocardiography revealed a clot in the right atrium with an abnormal circumference, connected to the tip of the second catheter. Anticoagulants were administered (calsium nadroparin, converted seven days later to acenocoumarol) and the size of the clot was significantly reduced.

Results

The case is presented in order to prove the significant contribution of trans-esophageal echocardiography as a non-invasive imaging technique for the detection of a clot in the right atrium and the impressive influence of appropriate therapeutic management in saving the patient's life and reducing the clot size.

Conclusions

The trans-esophageal echocardiogram provides invaluable information concerning the evolution, development and regression of right atrium clots formed at the tip of jugular catheters.

Direct US-guided puncture of the innominate veins for central venous access

Maintenance of functioning venous access is recognized as the Achilles heel of long-term hemodialysis treatment. In patients who require catheter-directed hemodialysis, the internal jugular veins are recognized as the optimal veins for insertion of dialysis catheters. When these sites are no longer available, alternative venous access sites are required. The authors describe two hemodialysis patients with limited access sites in whom hemodialysis catheters were successfully inserted directly into the innominate veins with use of ultrasound-guided punctures.

Supraclavicular approach to the subclavian/innominate vein for large-bore central venous catheters

Infraclavicular and internal jugular catheterization are commonly used techniques for hemodialysis access, but may at times be impeded in patients whose anatomy makes cannulation difficult. In an effort to enlarge the spectrum of alternative access sites, we evaluated the supraclavicular approach for large-bore catheters. During an 18-month period we prospectively collected data on success rate and major and minor complications of the supraclavicular access for conventional dialysis catheters as well as Dacron-cuffed tunneled devices in 175 adult patients admitted for various extracorporeal therapies and bone marrow transplantation. Two hundred eight large-bore catheters (99 conventional dialysis catheters, 63 semirigid tunneled Dacron-cuffed catheters, and 46 Hickman catheters) were successfully placed in 164 patients (success rate, 93.8%), 58 (33.1%) of whom had been previously catheterized. Complications included pneumothorax (one patient), arterial puncture (seven patients), and puncture of the thoracic duct (two patients) without sequelae. Postinsertional chest radiographs demonstrated impressive coaxial lie of most catheters. Catheter malpositions occurred only sporadically (1%). Difficulty of introducing the catheter via a placed sheath was rarely observed. There was no clinically significant evidence of catheter-induced venous thrombosis or stenosis. We conclude that the supraclavicular route is an easy and safe first approach for large-bore catheters, as well as a useful alternative to traditional puncture sites for precatheterized and anatomically problematic patients.

Right atrium thrombosis in patients on hemodialysis

Vascular access has been the Achilles heel of hemodialysis for many years, and placement of temporary subclavian and internal jugular vein catheters has been a daily practice for the nephrologist. Now, concern about central vein stenosis, well described with the use of subclavian catheters in end-stage renal disease (ESRD), has prompted the use of internal jugular vein permanent catheters to avoid this complication, so as not to hinder future arteriovenous grafts. Permanent catheter access is not without its own special problems, and we describe here two patients that developed thrombosis of the right atrium while receiving hemodialysis through a permanent internal jugular catheter.