Implantation of Permanent Jugular Catheters in Patients on Regular Dialysis Treatment: Ten Years’ Experience

Cuffed-tunneled Femoral Catheter for Long-term Hemodialysis

Background

Hemodialysis access is a challenging problem in patients with exhausted dialysis access sites of their upper extremities. Femoral arterio-venous polytetrafluoroethylene (PTFE) graft is often necessary. The safety and efficacy of cuffed tunneled catheters at the femoral site for long-term hemodialysis has not been extensively studied.

Methods

We inserted 14 cuffed-tunneled femoral catheters in 11 hemodialysis patients with exhausted dialysis access sites of their upper extremities. Access survival and risk of infection were compared with the 11 femoral PTFE grafts in 10 patients of our center during the same period. The choice of dialysis access was determined by the individual nephrologist. Access survival was defined as the achievement of a blood flow rate of at least 180 ml/min.

Results

The median survival of tunneled femoral catheter and PTFE graft were 166 days and 560 days respectively (log-rank test, p = 0.33). Seven of the 14 tunneled femoral catheter remained in use 3 months after insertion. The incidence of catheter- or graft-related infection was 0.38 and 0.23 episodes per 100 catheter / graft days for tunneled femoral catheters and PTFE graft respectively (p = 0.6). Five tunneled catheters and one PTFE graft had to be removed because of infection. Blood flow rates achieved were comparable between tunneled femoral catheter and PTFE graft.

Conclusions

Our preliminary data suggest that the cuffed tunneled femoral catheter has reasonable access survival and an acceptable risk of infection. It may provide a safe and effective access for long-term hemodialysis patients with exhausted access in their upper extremities, especially high risk patients who are not suitable for femoral PTFE graft creation.

Tunneled central venous catheters: Experience from a single center

In the past vascular surgeons were called in to place tunneled central venous catheter (TVC) for hemodialysis patients. Advent of percutaneous technique has resulted in an increasing number of interventional nephrologists inserting it. A single centre three year audit of 100 TVCs with a cumulative follow up of 492 patient months is presented here. From 2007 to 2010, 100 TVCs were placed by nephrologists in a percutaneous fashion in the operative room or the interventional nephrology suite. Those who completed minimum of three months on the catheter were included in analysis. There were 69 males and 31 females with a mean age of 52.3±13.6 years.(range: 25-76). Chronic glomerulonephritis was the commonest cause of CKD (45%) followed by diabetes (39%).Right internal jugular vein was the preferred site (94%). TVC was utilized as the primary access to initiate dialysis in 25% of patients in whom a live donor was available for renal transplant. The blood flow was 250-270 ml/min. The Kaplan-Meier analysis showed that 3 months and 6 months catheter survival rates were 80% and 55%, respectively. The main complications were exit site blood ooze, catheter block and kink. Catheter related bacteremia rate was low at 0.4/1000 patient days. Primary cause of drop out was patient death unrelated to the TVCs. Those under the age of 40 years showed better survival, but there was no bearing of gender, catheter site, and etiology of CKD on survival. Tunneled central venous catheters could find a niche as the primary access of choice for pretransplant live donor renal transplants in view of its immediate usage, high blood flows, low infection rates and adequate patency rates for 3-6 months.

Placement, performance and complications of the Ash Split Cath hemodialysis catheter

A tunneled catheter is the alternative vascular access for those patients in need of hemodialysis who cannot undergo dialysis through an arterio-venous fistula or a vascular graft. This study was undertaken to evaluate the performance of the Ash Split Cath, a 14 French chronic hemodialysis catheter with D-shaped lumens and a Dacron cuff. After tunneling through a transcutaneous portion the catheter enters the venous system, where it splits into two separate limbs. Data regarding catheter positioning, function and adequacy of dialysis were collected from two hemodialysis facilities. Twenty-eight Ash-split catheters were placed in 28 patients, with no complications, and immediate technical success was 100%. Patients were followed up for a total of 7,286 catheter days. No catheter-related infections were observed. Only one catheter failed after 15 days, with a primary catheter patency of 96% for the whole study length. Mean blood flow was 303 +/- 20 ml/min at 1 week after insertion, 306 +/- 17 ml/min at 3 months, 299 +/- 44 ml/min at 6 months, and 308 +/- 16 ml/min at 12 months. With a mean dialysis session duration of 234 +/- 25 minutes, adequate dialysis dose was observed for 96% of catheters, as reflected by a mean urea reduction ratio (URR) of 71% +/- 8 or a mean urea kinetic modeling, or Kt/V, value of 1.51 +/- 0.3 during follow up. In conclusion, compared with previous studies we report the best permanent catheter performance, confirming that the Ash-split catheter is a good alternative for vascular access in hemodialysis patients who are not candidates for surgical A-V fistula or graft placement.