Vascular Access for Placement of Tunneled Dialysis Catheters for Hemodialysis: A Systematic Approach and Clinical Practice Algorithm

The role of interventional radiology in the overall management of patients on dialysis continues to expand. In patients with end-stage renal disease (ESRD), the use of tunneled dialysis catheters (TDCs) for hemodialysis has become an integral component of treatment plans. Unfortunately, long-term use of TDCs often leads to infections, acute occlusions, and chronic venous stenosis, depletion of the patient's conventional access routes, and prevention of their recanalization. In such situations, the progressive loss of venous access sites prompts a systematic approach to alternative sites to maximize patient survival and minimize complications. In this review, we discuss the advantages and disadvantages of each vascular access option. We illustrate the procedures with case histories and images from our own experience at a highly active dialysis and transplant center. We rank each vascular access option and classify them into tiers based on their relative degrees of effectiveness. The conventional approaches are the most preferred, followed by alternative approaches and finally the salvage approaches. It is our intent to have this review serve as a concise and informative reference for physicians managing patients who need vascular access for hemodialysis.

Use of the femoral vein as insertion site for tunneled hemodialysis catheters

PURPOSE

To determine the outcome of tunneled hemodialysis catheters inserted through the common femoral vein.

MATERIALS AND METHODS

From April 2000 to June 2003, 33 consecutive patients had 86 tunneled hemodialysis catheters inserted through the femoral vein. There were 14 male and 19 female patients with a mean age of 56 years. Seventeen patients had bilateral central venous and/or superior vena cava (SVC) occlusions, 12 patients had unilateral central venous occlusions and were to receive contralateral arteriovenous fistulas or arteriovenous polytetrafluoroethylene grafts, and 4 patients received femoral catheters for other reasons. The technical success, complications, and clinical outcomes of these procedures were retrospectively evaluated.

RESULTS

All procedures were technically successful. Fifty-seven catheters were inserted into the right femoral vein and 29 into the left femoral vein. This included 25 catheter exchanges in 13 patients. Two patients developed thigh hematomas. Follow-up data were available for 68 catheters; mean follow-up period was 51 days with a total of 3,484 catheter days. The catheter-related infection rate was 6.3 per 1,000 catheter days; 22 catheters were removed for infection. Eighteen catheters were removed because of poor blood flows (<200 mL/min). Thirteen catheters were removed because they had become retracted. Primary catheter patency was 44% at 1 month.

CONCLUSIONS

The femoral vein provides an alternative access site for insertion of tunneled hemodialysis catheters when conventional sites are not available. However, tunneled femoral hemodialysis catheters have low primary patency rates and significant complications. Catheter retraction is a unique and common problem.

The Natural History of Tunneled Hemodialysis Catheters Removed or Exchanged: A Single-Institution Experience

PURPOSE

To track the natural history of tunneled hemodialysis catheters requiring removal or exchange at a single institution.

MATERIALS AND METHODS

Over a 2-year period, tunneled hemodialysis catheters that presented to interventional radiology for removal or exchange were entered into this retrospective study. Patient demographics, catheter location, dwell time, and indication for removal were recorded. Pull-back contrast venography was performed with imaging over the chest. Catheters were then removed or exchanged.

RESULTS

Three hundred thirty-four tunneled dialysis catheters were removed or exchanged in 207 patients; 108 male, median age 53 years. Dwell time, available from 296 catheters, ranged from 1 to 114 days (median, 66 days) for a total of 32,847 catheter days. One hundred three catheters were removed for infection, yielding a rate of infection requiring catheter removal of 3.0 per 1,000 catheter days. One hundred catheters were removed for other working access, and 96 catheters were exchanged for poor function. Two hundred sixty-five were removed or exchanged from the internal jugular vein, 22 from the subclavian vein, and 24 from the femoral vein. One hundred seventy-two (76%) of the 226 catheters studied with contrast had fibrin sheaths; of which 42 had thrombus identified along the catheter tract. One hundred ninety-three catheters were removed, and 141 catheters were exchanged for new catheters with 82 catheters receiving balloon disruption of the fibrin sheath.

CONCLUSIONS

Approximately one third of tunneled dialysis catheters are removed for infection, one third for other working access, and one third for poor function. Catheters usually remain in the patient for a median of 2 months. Fibrin sheaths associated with hemodialysis catheters are very common. Thrombus formation around the sheath is frequent.