Outcome of tunneled hemodialysis catheters placed by radiologists

Low Posterior Internal Jugular Vein Approach for Tunnelled Haemodialysis Catheter Insertion: A Report on Outcomes at a Single Centre

AIM

The impact of technical differences in cannulation technique for tunnelled haemodialysis catheter insertion is undetermined. We aimed to assess clinical outcomes of the low posterior approach for internal jugular vein tunnelled catheter placement.

METHODS

A retrospective audit was undertaken on consecutive tunnelled catheter procedures performed at a single centre between January 2016 and June 2022. Only catheters specifically placed with a low posterior internal jugular approach were included. The study's primary outcome was 12-month catheter survival, evaluated using the Kaplan-Meier survival curve and log-rank test. Secondary outcomes included catheter performance and procedure-related complications.

RESULTS

During the study period, 391 tunnelled internal jugular haemodialysis catheters were inserted in 272 patients using the low posterior technique. The 12-month primary patency rate was 68%. Catheter insertion was successful in 96% of cases. Peri-procedural complications occurred in 4% of cases, most frequently bleeding. The most common reasons for catheter loss were dysfunction (10%) and bacteraemia (6%). The best predictors of catheter failure were advanced age (HR 1.02, 95% CI 1.00-1.04) and in-centre dialysis treatment locality (HR 2.04, 95% CI 1.19-3.45).

CONCLUSION

The low posterior approach for internal jugular vein tunnelled catheter insertion is effective and safe. We demonstrated a 12-month catheter survival rate of 68%. Further research comparing the low posterior approach with other internal jugular vein cannulation techniques is warranted.

Outcome of Cuffed Tunneled Dialysis Catheters for Hemodialysis Patients at a Tertiary Care Hospital: A Descriptive Cross-sectional Study

INTRODUCTION

Arteriovenous fistula is the most common vascular access for patients requiring hemodialysis, but it is not always possible or practical hence cuffed tunneled dialysis catheter comes into play. The aim of the study was to determine the outcome of cuffed tunneled dialysis catheter used for hemodialysis at a teaching hospital.

METHODS

A descriptive cross-sectional study was conducted between January 2014 and December 2019 on 103 chronic dialysis patients with end-stage renal disease presenting to a tertiary care hospital. Ethical approval was received from the institutional review board (2/(6-11) E2/076/77). Whole sampling was done. Data entry and analysis were done in Microsoft Excel 10.

RESULTS

The study included 103 patients with 117 cuffed tunneled dialysis catheters placed for hemodialysis. On assessing the outcome of the catheters, the primary and secondary patency rates of the catheters were 5.85±4.87 and 1.21±3.77 months. Thirty-one (30.1%) patients required one intervention, and 11 (10.68%) catheters required 3 or more interventions to maintain patency. Eighteen (17.48%) patients presented with catheter dysfunction while in 11 (10.68%) cases, the catheter was kinked or malpositioned at the notch. In one patient, procedure was abandoned due to severe bleeding and in 2 (1.94%) patients dialysis catheters could not be negotiated into the right atrium and left in brachiocephalic junction.

CONCLUSIONS

Cuffed tunneled dialysis catheter is effective for maintenance hemodialysis in patients with the end-stage renal disease if used with proper care during dialysis even in our setup. The results and outcomes of the procedure are at par with standards.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters (PASSPORT 1)

OBJECTIVES

Tunnelled central venous catheters dysfunction can be defined as failure to provide blood flow above 200 mL/min during dialysis often caused by thrombosis. Although urokinase is used routinely for thrombolysis, there is wide variation in dose regimens. A multidisciplinary group was formed to address this issue and offer guidance.

METHODS

Dialysis centres that used urokinase in the United Kingdom took part in a prospective study to determine the safety and outcomes of thrombolysis using agreed protocols. Data were collected anonymously from September 2017 until February 2018. Catheter blood flow was measured before and after the following interventions: catheter dwell or push locks with 12,500-50,000 IU or catheter infusion with 100,000-250,000 IU of urokinase. Interventions were repeated if the blood flow remained below 200 mL/min.

RESULTS

10 centres took part and recruited 200 patients; 45.5% were female and 54.5% were male with mean age of 63.6 (±15.2) years. The cumulative success rate for thrombolysis was 90.5% after first intervention, 97% after second intervention, and 99% after more than 2 interventions. Although there was trend towards benefit with dose increments, the success rate between push/dwell locks and high-dose infusion of urokinase was not significantly different (p = 0.069). Seventeen (8.5%) tunnelled central venous catheters were removed due to failure of treatment. No urokinase-related adverse events were reported.

CONCLUSION

In this study, urokinase was safe and efficacious; there was no difference between dwell and push locks. There was some benefit with high-dose infusion of urokinase compared to the dwell and push lock.

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.

Placement of tunneled cuffed catheter for hemodialysis: Micropuncture kit versus Angiocath IV catheter

INTRODUCTION

Tunneled cuffed catheters provide stable, instantaneous, long-term intravenous access for hemodialysis. Because catheterization is often performed in emergency situations, speed and accuracy are emphasized.

METHODS

We retrospectively compared the Micropuncture kit with the standard 18-gauge Angiocath IV catheter for tunneled cuffed catheter insertion in the right jugular vein. From June 2016 to May 2017, 31 tunneled cuffed catheters were successfully inserted via the Micropuncture kit and another 31 via the Angiocath IV catheter. All patients underwent the same ultrasound-guided procedure performed by a single experienced interventionalist. Procedure time was the time from draping of the patient to the completion of povidone dressing after the catheterization. In our center, the Angio Lab nurse maintains records, including procedure time and method for every procedure. All patient records were retrospectively tracked through electronic medical record review. The primary outcome was procedure time and the secondary outcomes were complications and cost-effectiveness.

RESULTS

There were no significant differences in the patients' demographic data between the two groups. However, procedure time was significantly shorter in the Angiocath group than in the Micropuncture group (12.4 ± 3.5 vs 17.6 ± 6.9 min, p = 0.001); there were no serious complications, such as hemorrhage, pneumothorax, or hematoma, in both groups. Moreover, cost-effectiveness was better in the Angiocath group than in the Micropuncture group (0.34 vs 52 US$, p < 0.01).

CONCLUSIONS

Using the Angiocath IV catheter can reduce procedure time and cost with no severe complications. Moreover, experienced practitioners can reduce the risk of complications when using Angiocath. There are several limitations to this study. First, it was retrospective; second, it was not randomized; and finally, it was conducted by only one experienced interventionalist.

Fluoroscopically Guided vs Modified Traditional Placement of Tunneled Hemodialysis Catheters: Clinical Outcomes and Cost Analysis

Tunneled cuffed internal jugular vein catheters are widely used to provide short to medium-term vascular access for hemodialysis. The NKF-K/DOQI guidelines state that fluoroscopy is mandatory for insertion of all cuffed dialysis catheters. The KDOQI recommendation makes it difficult for Nephrologists to perform this procedure without access to fluoroscopy. This results in unnecessary waiting times and the inappropriate use of acute, non-tunneled catheters. The purpose of this study is: 1) to compare the outcomes of fluoroscopically guided vs modified traditional catheter placement technique, and 2) to perform a cost analysis of the two techniques. We performed a retrospective investigation of 202 tunneled hemodialysis catheters performed at our tertiary care hospital. Procedural data were obtained from the University of Wisconsin Department of Medicine, Nephrology Section Interventional Nephrology procedural database. Patient demographics, laboratory tests were obtained from the University of Wisconsin Hospital electronic medical record (EMR). Logistic regression was used to evaluate the effect of blind vs fluoro-guided placement on clinical outcomes, corrected for side of procedure, age, gender, previous history of catheter placement, diabetes mellitus (DM), and pre-procedural coagulation parameters. Baseline characteristics of “blind” vs fluoro-guided groups differed with respect to side of procedure and DM (91.0% vs 79.6%, p= 0.02 and 43.30% vs 58.40%, p= 0.02, respectively). Non-fluoroscopic placement of catheters was associated with a decreased odds ratio of immediate success (OR = 0.1298, CI = 0.02 - 0.71). No difference in major or minor bleeding complications was discovered between the blind vs fluoro-guided group. Cost analysis revealed that performing the non-fluoroscopic technique as the preferred initial procedure would represent a substantial reduction in total bills submitted to third-party payers, including Medicare.

Safety of Percutaneous Internal Jugular Catheterization in Cancer Patients: Prospective Observational Study

Purpose

To determine predictors for failure and early complications of percutaneous internal jugular catheterization (IJC) in cancer patients.

Methods

Six hundred and thirty consecutive cancer patients who required central venous catheterization were included in a prospective observational study. The rates of failure (defined as the intervention of a second physician and/or failure at initial insertion site) and of early complications were prospectively ascertained. Logistic regression analysis estimated odds ratio (OR) and 95% confidence intervals (95% CI) for independent predictors for failure and early complications of percutaneous IJC.

Results

The failure rate was 6.7%, and the early complication rate was 6.7%. In multivariate analysis, left-side initial catheterization (p<0.01), prior catheterization at the same site (p=0.001) and physician inexperience (p<0.0001) were independently associated with failure. Placement requiring more than one needle pass (p<0.01 for two and p<0.0001 for three and more) and absence of fluoroscopy (p<0.0001) were independently associated with early complications.

Conclusions

Percutaneous IJC is a valid option in the central venous catheterization of cancer patients due to its reliability and safety. Skilled physicians must manage difficult placements. If placement requires more than one needle pass or is made without fluoroscopy, patients must be carefully followed for potential complications.

Salvage Insertion of Tunneled Central Venous Catheters in the Internal Jugular Vein after Accidental Catheter Removal

Purpose

Tunneled catheters are widely used for intermediate to long-term hemodialysis (HD) access, but are prone to several complications that can require catheter replacement. Replacing malfunctioning catheters with a new line, placed in a different access site, can lead to problems with multiple vein occlusions. This has led many nephrologists to continue using the same vein as long as possible by guidewire catheter exchanges, to preserve other veins for future use. We describe a guidewire exchange technique for the Ash-Split catheter in the internal jugular vein.

Methods

In three patients, the exchange was performed because of partial catheter removal, as evidenced by the outward dislocation of the Dacron cuff. In these patients, the guidewire was inserted through the catheter. In two additional patients, the catheter had been completely removed by accident: the replacement of the dislodged tunneled venous catheters was attempted 5 hr and 1 day after accidental removal. In these patients, the guidewire was inserted through the previous tunnel. After guidewire placement, a skin incision was made in the supraclavicular region. The metal guidewire was easily located inside the fibrous structure that had previously surrounded the catheter. The guidewire was then extracted from the subcutaneous tunnel and used to insert a new catheter safely and easily after creating a new tunnel. Patients were routinely given antibiotic prophylaxis (1 g of cefazolin) immediately before the procedure. A strict aseptic technique was used, including several sterile glove changes.

Results

No infections developed following this procedure, which has the potential for bacterial contamination. All procedures were successful. Only in one patient did we have to convert to a different catheter: it was not possible to replace the old Ash-Split catheter with the same dual-lumen catheter because of difficulties in inserting the peel away introducer-catheter complex. In this patient, rather than forcing it with larger dilators or trying to disrupt the fibrin sheath with balloon dilatation, a single lumen Tesio catheter was successfully placed. In both patients who completely lost the previous catheter, the guidewire was readily reinserted through the subcutaneous tunnel into the vein. Catheter function was excellent in all patients, with a test blood flow rate on the 1st catheter use >350 ml/min.

Conclusions

We described a new method for catheter exchange, which allows the easy insertion of a new catheter and the creation of a new and safer subcutaneous tunnel. In addition, we demonstrated that in cases of complete catheter removal, it is possible to reinsert a catheter in the same vein through a guidewire, even when reinsertion was attempted up to 1 day later.

Fibrin sheaths in central venous port catheters: treatment with low-dose, single injection of urokinase on an outpatient basis

Purpose

Evaluation of the efficacy of single-shot, low-dose urokinase administration for the treatment of port catheter-associated fibrin sheaths.

Methods

Forty-six patients were retrospectively evaluated for 54 episodes of port catheter dysfunction. The presence of a fibrin sheath was detected by angiographic contrast examinations. On an outpatient basis, patients subsequently received thrombolysis consisting of a single injection of urokinase (15.000 IU in 1.5 mL normal saline) through the port system. A second attempt was made in cases of treatment failure. Patients were followed up for technical success, complications and long-term outcome.

Results

Port dysfunction occurred at a median of 117 days after implantation (range: 7–825 days). The technical success after first port dysfunction by thrombolysis was 87% (40/46); thereof, initial thrombolysis was effective in 78% (36/46). Nine patients (20%) received a second dose of urokinase after previous treatment failure. Follow-up was available for 26 of 40 patients after successful thrombolysis. In 8 of these, rethrombosis occurred after a median of 98 days (range: 21–354 days), whereby rethrombolysis was effective in 5 of 7 (63%) patients. The overall success of all thrombolyses performed was 70% (45/64). No procedure-related technical or clinical complications occurred. After first favorable thrombolysis, a Kaplan–Meier analysis yielded a 30-, 90- and 180-day probability of patency of 96%, 87% and 81%.

Conclusion

Thrombolytic therapy on an outpatient basis appears to be a safe and efficient. Three-month patency rates are comparable to more invasive treatment options, including catheter exchange over a guide wire and percutaneous fibrin sheath stripping.

Complications of the Arteriovenous Fistula: A Systematic Review

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.

Comparison of treatment delay associated with tunneled hemodialysis catheter placement between interventionists

BACKGROUND/AIMS

Fragmented care in nephrology can cause treatment delays. Nephrologists are qualified to perform vascular access-related procedures because they understand the pathophysiology of renal disease and perform physical examination for vascular access. We compared treatment delays associated with tunneled hemodialysis catheter (TDC) placement between interventional radiologists and nephrologists.

METHODS

We collected data by radiologists from January 1, 2011 through December 31, 2011 and by nephrologists from since July 1, 2012 through June 30, 2013. We compared the duration from the hemodialysis decision to TDC placement (D-P duration) and hemodialysis initiation (D-H duration), catheter success and the complication rate, and the frequency and the usage time of non-tunneled hemodialysis catheters (NDCs) before TDC placement.

RESULTS

The study analyzed 483 placed TDCs: 280 TDCs placed by radiologists and 203 by nephrologists. The D-P durations were 319 minutes (interquartile range [IQR], 180 to 1,057) in the radiologist group and 140 minutes (IQR, 0 to 792) in the nephrologist group. Additionally, the D-H durations were 415 minutes (IQR,260 to 1,091) and 275 minutes (IQR, 123 to 598), respectively. These differences were statistically significant (p = 0.00). The TDC success rate (95.3% vs. 94.5%, respectively; p = 0.32) and complication rate (16.2% vs. 11%, respectively; p = 0.11) did not differ between the groups. The frequency (24.5 vs. 26%, respectively; p = 0.72) and the usage time of NDC (8,451 vs. 8,416 minutes, respectively; p = 0.91) before TDC placement were not statistically significant.

CONCLUSIONS

Trained interventional nephrologists could perform TDC placement safely, minimizing treatment delays.

Elimination of pneumothorax and hemothorax during placement of implantable venous access ports using ultrasound and fluoroscopic guidance

Implantable venous access ports are essential for patients requiring chronic venous access. Ultrasound guided catheter placement has been recognized as a valuable adjunct for reducing complications during placement of access ports in the radiology and critical care medicine literature. We reviewed the medical records of patients undergoing insertion of implantable venous access ports from June 2006 through June 2009. All procedures were performed using ultrasound guidance with the internal jugular vein as the access site. There were 500 implantable venous access ports placed and included for review. There were no post-procedure pneumothoraces or hemothoraces. Carotid puncture was documented in 4 (0.8%)cases. Routine use of ultrasound guidance during placement of implantable venous access ports has eliminated the complications of pneumothorax and hemothorax during placement of internal jugular venous access ports on our vascular surgery service. Elimination of these complications and decreased use of chest x-rays should also provide increased cost savings for this procedure.

Biofilms in periprosthetic orthopedic infections

As the number of total joint arthroplasty and internal fixation procedures continues to rise, the threat of infection following surgery has significant clinical implications. These infections may have highly morbid consequences to patients, who often endure additional surgeries and lengthy exposures to systemic antibiotics, neither of which are guaranteed to resolve the infection. Of particular concern is the threat of bacterial biofilm development, since biofilm-mediated infections are difficult to diagnose and effective treatments are lacking. Developing therapeutic strategies have targeted mechanisms of biofilm formation and the means by which these bacteria communicate with each other to take on specialized roles such as persister cells within the biofilm. In addition, prevention of infection through novel coatings for prostheses and the local delivery of high concentrations of antibiotics by absorbable carriers has shown promise in laboratory and animal studies. Biofilm development, especially in an arthoplasty environment, and future diagnostic and treatment options are discussed.

Systematic review and meta-analysis on management of hemodialysis catheter-related bacteremia

Hemodialysis catheter-related bacteremia is a common clinical problem with several management options. We performed a systematic review and meta-analysis to determine cure proportions with systemic antibiotics, antibiotic lock solution, and guidewire exchange. We searched databases and registries; conference proceedings from relevant medical societies; and article reference lists. Data regarding management approach, cure, follow-up, recurrence, complications, and microbiology were abstracted and pooled from 28 selected publications. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated from a mixed effects logistic regression model. In total, 1596 patients with tunneled hemodialysis catheter-related bacteremia were divided into groups on the basis of treatment with systemic antibiotics (n=697), antibiotic lock solution (n=546), or guidewire exchange (n=353). Antibiotic lock solution and guidewire exchange had similar cure proportions that were superior to systemic antibiotics alone (OR, 2.08; 95% CI, 1.25 to 3.45; P<0.01 for antibiotic lock solution; OR, 2.88; 95% CI, 1.82 to 4.55; P<0.001 for guidewire exchange versus systemic antibiotics). Cure proportions were highest for coagulase-negative staphylococci followed by gram-negative rods and Staphylococcus aureus. Among S. aureus infections, guidewire exchange led to a higher cure proportion than systemic antibiotics or antibiotic lock solution (OR, 3.33; 95% CI, 1.17 to 9.46; P=0.02; OR, 4.72; 95% CI, 1.79 to 12.46; P=0.002, respectively). Thus, results of this study suggest that tunneled hemodialysis catheter-related bacteremia should be treated with either guidewire exchange or antibiotic lock solution. Future studies should address prospectively whether one strategy is better than the other overall and for specific pathogens.

Use and safety of heparin-free maintenance hemodialysis in the USA

BACKGROUND

Although heparin is used to anticoagulate the extracorporeal circuit for most patients on maintenance hemodialysis (HD), some patients undergo heparin-free HD. We describe the determinants of heparin-free HD and its association with adverse outcomes using data from a national dialysis provider merged with Medicare claims.

METHODS

We identified patients aged ≥67 years with no recent history of warfarin use who initiated maintenance HD from 2007 to 2008. We applied the Cox regression to a propensity score-matched cohort to estimate the hazards of all-cause mortality, bleeding (gastrointestinal hemorrhage, hemorrhagic stroke, other hemorrhage), atherothrombosis (ischemic stroke, myocardial infarction) and venous thromboembolism (VTE) (deep vein thrombosis, pulmonary embolism).

RESULTS

Among 12 468 patients, 836 (6.7%) were dialyzed heparin-free. In multivariable-adjusted analyses, a history of gastrointestinal bleeding, hemorrhagic stroke and lower hemoglobin and platelet counts were associated with higher odds of heparin-free HD. Heparin-free HD use also varied as much as 4-fold by facility region. We found no significant association of heparin-free HD with all-cause mortality [hazard ratio (HR) 1.08; 95% confidence interval (CI): 0.94-1.26], bleeding (HR 1.15; 95% CI: 0.83-1.60), atherothrombosis (HR 1.09, 95% CI: 0.90-1.31) or VTE (HR 1.23, 95% CI: 0.93-1.64) compared with HD with heparin.

CONCLUSIONS

Patient markers of increased risk of bleeding and facility region associated with heparin-free HD use. Despite the potential benefits of avoiding heparin use, heparin-free HD was not significantly associated with decreased hazards of death, bleeding or thrombosis, suggesting that it may be no safer than HD with heparin.

Imaging and management of complications of central venous catheters

Central venous catheters (CVCs) provide valuable vascular access. Complications associated with the insertion and maintenance of CVCs includes pneumothorax, arterial puncture, arrhythmias, line fracture, malposition, migration, infection, thrombosis, and fibrin sheath formation. Image-guided CVC placement is now standard practice and reduces the risk of complications compared to the blind landmark insertion technique. This review demonstrates the imaging of a range of complications associated with CVCs and discusses their management with catheter salvage techniques.

Antibiotic lock technique for prevention of cuffed tunnel catheter associated bacteremia

BACKGROUND

Central venous cuffed tunnel catheters are commonly used for short term or long term hemodialysis access. However, catheter-associated bacteremia is a common complication. It has been suggested that the addition of antibiotics to the catheter during the interdialytic interval results in a decrease in bacterial colonization and thereby a decrease in catheter associated infections. To test this hypothesis, a prospective, randomized study was performed comparing a gentamicin citrate mixture to standard heparin as the catheter lock. The effect of covering the catheter hub in a sterile bag on the infection rate was additionally tested.

METHODS

From January 1999 to April 2000, all patients who underwent tunnel catheter placement or change (55 catheters) in the Nephrology Interventional Laboratory at Louisiana State University Health Sciences Center in Shreveport, were prospectively randomized as follows: group 1 (n=14): Antibiotic lock with tricitrasol (46.7%), gentamicin (40 mg/ml) and saline in a ratio of 1:5:5 and catheter hub covered with a sterile plastic bag after cleaning with a 10% povidone iodine solution; group 2 (n=22): Heparin lock and sterile plastic bag over catheter hub after cleaning with povidone iodine; and group 3 (n=19): Heparin lock alone. The primary end points of the study were catheter-associated bacteremia and thrombosis. Catheter loss due to access maturation, transplant or transfer were censored.

RESULTS

There were a total of 4,805 at risk patient-days. The total number of catheter associated bacteremias were one in group 1, four in group 2 and four in group 3. The number of catheter associated bacteremias per 1000 patient-days in each group was 0.62, 3.05, and 2.11 respectively. The sixty day percent survival of catheters in each group was 74 +/- 12, 55 +/- 12 and 59 +/- 11 respectively.

CONCLUSIONS

1) Tricitrasol and gentamicin as an antibiotic lock reduced the incidence of catheter associated bacteremia; 2) Covering the catheter hub with a sterile bag did not provide an additional advantage; 3) The antibiotic lock improved overall survival of catheters.

Central venous access port devices - a pictorial review of common complications from the interventional radiology perspective

Portacaths are tunnelled and totally implanted central venous access port devices (CVAPD). They are commonly used for intravenous antibiotic delivery in patients with cystic fibrosis. More recently, they are being used in oncology to deliver chemotherapy and apheresis. It is therefore important to be aware of portacath associated complications and their imaging features. This pictorial review illustrates and discusses common complications associated with Portacath devices.

A guide to antibiotics for the interventional radiologist

Antibiotics are among the most common pharmaceutical agents used by the interventional radiologist. This article updates some of the practical aspects of the use of antibiotics in interventional radiological practice and provides some general guidelines with respect to indications for and selection of antibiotics. In particular, the objectives of this article are to review the basic pharmacology of the common antibiotic agents, the interventional radiological procedures in which prophylactic antibiotics are usually administered, the specific antimicrobial agents recommended for prophylaxis before common interventional radiological procedures, the appropriate antibiotics for patients allergic to penicillins, and the indications for antibiotic prophylaxis to prevent bacterial endocarditis.

The risk of sedation/analgesia in hemodialysis patients undergoing interventional procedures

Data derived from a large cohort of hemodialysis patients (12,896) undergoing dialysis access maintenance procedures being performed by interventional nephrologists were analyzed to determine the safety of sedation/analgesia (S/A) in a freestanding facility. Data collected included patient demographics, procedures performed, time of procedures, drugs used, doses used, and complications that occurred. Four high-risk groups were identified based upon age, pulmonary status, and over all physical status. These were compared to the total cohort. Midazolam, fentanyl, or a combination of the two were used. Within the total cohort of patients, midazolam alone was used most commonly (94.7%). The total mean dose of midazolam when used alone was 3.4 mg. The dosages used in the high-risk groups tended to be only slightly lower (3-3.2 mg). This setting appears to be safe for hemodialysis patients, even those in high-risk subgroups having these types of procedures. The types of drugs and the dosages that are commonly used do not appear to be associated with an unacceptable risk to the hemodialysis patient. A nephrologist that is not specialty trained in anesthesia is able to provide S/A safely in a freestanding facility.

Transhepatic hemodialysis catheters: functional outcome and comparison between early and late failure

PURPOSE

To describe the authors' experience with transhepatic placement of catheters, highlighting early and late complications, and to determine if this procedure is a viable option in patients in whom central venous occlusions present a significant challenge.

MATERIALS AND METHODS

The records of all the patients who underwent placement of transhepatic hemodialysis from January 2003 to October 2008 were retrospectively reviewed. Selected patients were dialysis-dependent, having undergone multiple access procedures and revisions. Kaplan-Meier analysis was used to estimate primary and secondary patency.

RESULTS

Twenty-two patients (mean age 42 years, range 22-70 years, 59% women) underwent a total of 127 transhepatic catheter placements at 24 transhepatic access sites; technical success was achieved in all cases. There were no hepatic injuries (bleeding or fistula formation). There were 105 exchanges in 14 patients, with a mean of 7.5 exchanges, a median of 5 exchanges (range 1-18 exchanges), and a catheter migration rate of 0.39 per 100 catheter-days. The sepsis rate was 0.22 per 100 catheter-days, and the catheter thrombosis rate was 0.18 per 100 catheter-days. The mean cumulative catheter duration in situ was 506.2 days, and the mean time catheter in situ was 87.7 days. The mean total access site interval was 1,046 catheter-days (range of 423-1,413 catheter-days).

CONCLUSIONS

Transhepatic hemodialysis catheter placement is associated with low rates of morbidity. In this series, transhepatic catheters provided the possibility of long-term functionality, despite associated high rates of catheter-related maintenance, provides a potentially viable access for patients with exhausted access options.

Insertion of tunneled hemodialysis catheters without fluoroscopy

BACKGROUND

The tunneled cuffed catheter (TCC) is used as a bridge access for hemodialysis. Few prospective studies have been designed to evaluate conversion from non-tunneled to TCC without the use of fluoroscopy when performed by nephrologists.

METHODS

We performed an observational prospective cohort in incident patients receiving hemodialysis through a non-tunneled right jugular vein catheter.

RESULTS

130 procedures were performed in 122 patients (51+/-18 years). The success rate was 100%. There was a total of 26,546 catheter days. Ninety-one of the 130 catheters were removed during the study period. Life table analysis revealed primary patency rates of 92%, 82%, and 68% at 30, 60, and 120 days, respectively. Infection requiring catheter removal occurred at a frequency of 0.09 per 100 catheter days. Catheter malfunction requiring intervention occurred at a rate of 0.03 per 100 catheter days. Hypertension and duration of existing non-tunneled catheter of less than 2 weeks were independently associated with better TCC survival.

CONCLUSION

The conversion from non-tunneled to TCC performed by nephrologists and without fluoroscopy may be safe by using the internal right jugular vein. The ideal time to do this procedure is within less than 2 weeks of existing non-tunneled catheter.

Saving Infected Catheters: Why and How

Conventional management of dialysis catheter-related bacteremia involves administration of systemic antibiotics, as well as removal of the infected catheter. This approach adds burdensome and expensive procedures, and creates short-term problems for dialysis access. Recent research has shown that bacterial biofilms form routinely in the catheter lumen, and act as the nidus for bacteremic episodes. Instillation of a concentrated antibiotic-anticoagulant solution into the catheter lumen ('antibiotic lock') may permit successful treatment of the infection, while salvaging the patient's catheter. A number of recent studies have reported the success of an antibiotic lock protocol in about two thirds of cases of catheter-related bacteremia. Catheter replacement is only performed in those patients with protocol failures (persistent fever or positive surveillance blood cultures). In conclusion, routine application of an antibiotic lock protocol may reduce substantially the need for routine catheter replacement in hemodialysis patients with catheter-related bacteremia.

[Femoral venous catheterization. Does it really need to be avoided?]

The guidelines to prevent central venous catheter related bloodstream infections (CVCBSI) of the Centers for Disease Control and Prevention (CDC) of 2002, Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias/ Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEMICYUC/SEIMC) of 2004, and the recently published guidelines of the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA(IDSA) of 2008 have recommended using the subclavian vein and avoiding the use of the femoral vein. They also recommend considering the use of antiseptic- or antimicrobial-impregnated CVCs for hospital units or groups of patients with a high incidence of CVCBSI. When implementing these guidelines, two questions could be asked: 1) Could the abuse of the subclavian vein and avoiding the use of the femoral vein imply a decrease in the incidence of CVCBSI, but an increase in the rate of mechanical complications as pneumothorax and/or hemothorax? 2) Couldn't antimicrobial-impregnated CVCs be used to prevent CVCBSI when the femoral venous access is used?

Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Peripherally inserted tunnelled catheters: a new option for venous access

We evaluated the feasibility and optimal technique for placing peripheral tunnelled central venous catheters. Fourteen peripherally inserted central catheters (PICC) were placed using a 2-3 cm subcutaneous tunnel created in the upper arm. An additional 29 PICC lines containing a cuff were placed, using a slight modification of the same technique. Indications for placement were the same as those for a conventional PICC line. All catheters were placed successfully. There were no procedural complications. The upper arm basilic vein was used in all cases. Catheters remained in place for 1-70 days. Catheters in place for only a short period of time were removed at the bedside, longer-term catheters required a minimal amount of blunt dissection for removal of the cuff portion. We conclude that tunnelled catheters can be safely placed in the upper arm with a reliable technique. The ease of placement and lack of procedural complications, suggests that follow-up studies are warranted, to determine if these catheters can be used for applications currently requiring tunnelled subclavian or internal jugular catheters.

Circulating bacterial-derived DNA fragments and markers of inflammation in chronic hemodialysis patients

BACKGROUND AND OBJECTIVES

Bacterial-derived DNA fragments (BDNAs) have been shown to be present in dialysis fluid, to pass through dialyzer membranes, and to induce IL-6 (IL-6) in mononuclear cells. The present study aimed at assessing the eventual presence of BDNAs in the blood of hemodialysis (HD) patients and if this is associated with markers of chronic inflammation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Fifty-eight HD patients and 30 controls were included in the study. A blood sample was collected from a peripheral vein and from the central venous catheter (CVC) or the arteriovenous fistula (AVF) and examined for presence of BDNAs by 16S rRNA gene PCR amplification, bacterial growth, and measurement of C-reactive protein and IL-6. Thirty minutes after the start of HD, a sample of dialysis fluid was collected before the entry into and at the exit of the dialyzer and examined for presence of BDNAs.

RESULTS

Controls had negative blood cultures and absence of blood BDNAs. All HD patients had negative blood cultures, but in 12 (20.7%), BDNAs were present in the whole blood. In five of the latter, BDNAs were also found in the dialysis fluid. C-reactive protein serum levels (mg/L) were significantly higher in patients with than in those without BDNAs. Likewise, IL-6 serum levels (pg/ml) were significantly higher in patients with BDNA than in those without.

CONCLUSIONS

Circulating BDNAs are associated with higher levels of C-reactive protein and IL-6 in HD patients.

Replacement of inadvertently discontinued tunneled jugular high-flow central catheters with tract recannulation: technical results and outcome

PURPOSE

To determine the technical and clinical outcomes of recannulating the tracts of inadvertently discontinued high-flow tunneled internal jugular central venous catheters.

MATERIALS AND METHODS

Retrospective review was performed of 49 patients who underwent 57 replacements of inadvertently discontinued catheters by recannulation from January 1997 through January 2005. The study group was divided into successful and failed recannulation groups. Technical results were evaluated for duration the catheter had been out, tract age, and laterality (ie, right vs left). Infection rate was calculated by Kaplan-Meier method and the infection rate per 100 catheter days was calculated. Intent-to-treat function rate (including failed recannulations) was calculated by the Kaplan-Meier method.

RESULTS

Seventy percent (n = 40) of discontinued catheters were right-sided and 30% (n = 17) were left-sided. The overall technical success rate was 86% (n = 49). The technical success rates were 100% (n = 10), 89% (32 of 36), and 64% (seven of 11) for catheters that had been outside the body for less than 12 hours, 12-24 hours, and more than 24 hours, respectively. P values for successful versus failed recannulations for tract age, the time the catheter was out, and laterality were .02, .04, and .68, respectively. The infection rate for successful recannulations at 6 months was 24% +/- 9% (0.22 infections per 100 catheter days). Functional catheter rates at 3, 6, 9, and 12 months were 55% +/- 8%, 46% +/- 8%, 29% +/- 10%, and 5% +/- 3%, respectively.

CONCLUSIONS

Recannulating tunneled high-flow jugular catheter tracts has a high technical success rate, particularly when they have fallen out less than 24 hours earlier and have a mature tract. The outcomes of recannulated catheters (ie, infection and function rates) are within the upper limit of results of de novo placement and over-the-wire exchange of catheters in the literature.

Malfunctioning central venous catheters in children: a diagnostic approach

Central venous access is increasingly becoming the domain of the radiologist, both in terms of the insertion of central venous catheters (CVCs) and in the subsequent management of these lines. This article seeks to provide an overview of the CVC types available for paediatric patients and a more detailed explanation of the spectrum of complications that may lead to catheter malfunction. A standard catheter contrast study or 'linogram' technique is described. The normal appearances of such a study and a detailed pictorial review of abnormal catheter studies are provided, together with a brief overview of how information from catheter investigations can guide the management of catheter complications.

Catheter malfunction due to spontaneous permcath displacement into medium suprahepatic vein

One of the last options, when the other possibilities of vascular access present malfunction, is the insertion of a permanent catheter in a central vein, preferentially internal jugular vein. This option is considered when arteriovenous access is impossible. We report a case of malfunction due to a permanent catheter dis-placement solved by vascular interventional radiology.