1
|
Xie P, Tao M, Zhao H, Qiu J, Li S, Xu Y, Sun M, Sheng Y, Ronco C, Peng K. Unexpected Complication of Central Venous Catheter Exchange: Catheter Fragment Migration. Blood Purif 2020; 50:582-587. [PMID: 33341796 DOI: 10.1159/000512353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/12/2020] [Indexed: 11/19/2022]
Abstract
Tunneled central venous catheter (TCVC) placement is often an easy and uncomplicated procedure. As such, some clinicians pay little attention to the procedure, and different complications occurred. Catheter fragment loss in major vessels is a rare but serious complication of in situ catheter exchange with few reported cases in the literature. Once catheter fragments slip into a deep vein, endovascular retrieval should be attempted, due to its high success rate and minimal associated morbidity. A 37-year-old male patient underwent replacement of his temporary catheter with TCVC through a trans-right-internal-jugular-vein approach for maintenance of dialysis. As a major unintended outcome of the operation, a catheter fragment slipped into the right internal jugular vein, then migrated and lodged in the inferior vena cava. We retrieved it with a gooseneck snare without complications. We report the case hoping to emphasize on and raise awareness of the fact that catheter fragment loss is a completely evitable complication, provided the operator follows the correct safety measures and protocols. However, if catheter fragment loss occurred, the fragment should be retrieved as soon as possible. A gooseneck snare is an ideal option for retrieving catheter fragments that have migrated into deep veins.
Collapse
Affiliation(s)
- Pan Xie
- Department of Nephrology, Southwest Hospital, The First Hospital Affiliated to Third Military Medical University (Army Medical University), Chongqing, China.,IRRIV, International Renal Research Institute Vicenza, Vicenza, Italy.,International Renal Research Institute, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Min Tao
- Department of Paediatrics, Southwest Hospital, The First Hospital Affiliated toThird Military Medical University (Army Medical University), Chongqing, China
| | - Hongwen Zhao
- Department of Nephrology, Southwest Hospital, The First Hospital Affiliated to Third Military Medical University (Army Medical University), Chongqing, China
| | - Jun Qiu
- Department of Information, Southwest Hospital, The First Hospital Affiliated toThird Military Medical University (Army Medical University), Chongqing, China
| | - Shaohua Li
- Department of Nephrology, Southwest Hospital, The First Hospital Affiliated to Third Military Medical University (Army Medical University), Chongqing, China
| | - Yan Xu
- Department of Nephrology, Southwest Hospital, The First Hospital Affiliated to Third Military Medical University (Army Medical University), Chongqing, China
| | - Mei Sun
- Department of Nephrology, Southwest Hospital, The First Hospital Affiliated to Third Military Medical University (Army Medical University), Chongqing, China
| | - Yuxiu Sheng
- Department of Nephrology, Southwest Hospital, The First Hospital Affiliated to Third Military Medical University (Army Medical University), Chongqing, China
| | - Claudio Ronco
- IRRIV, International Renal Research Institute Vicenza, Vicenza, Italy.,International Renal Research Institute, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Kanfu Peng
- Department of Nephrology, Southwest Hospital, The First Hospital Affiliated to Third Military Medical University (Army Medical University), Chongqing, China,
| |
Collapse
|
2
|
Shrestha KR, Gurung D, Shrestha UK. Outcome of Cuffed Tunneled Dialysis Catheters for Hemodialysis Patients at a Tertiary Care Hospital: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2020; 58:390-395. [PMID: 32788754 PMCID: PMC7580349 DOI: 10.31729/jnma.4795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Kajan Raj Shrestha
- Department of Cardiothoracic Vascular Surgery, Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Dinesh Gurung
- Department of Cardiothoracic Vascular Surgery, Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Uttam Krishna Shrestha
- Department of Cardiothoracic Vascular Surgery, Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| |
Collapse
|
3
|
Kingsmore DB, Stevenson KS, Jackson A, Desai SS, Thompson P, Karydis N, Franchin M, White B, Tozzi M, Isaak A. Arteriovenous Access Graft Infection: Standards of Reporting and Implications for Comparative Data Analysis. Ann Vasc Surg 2020; 63:391-398. [DOI: 10.1016/j.avsg.2019.08.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 11/28/2022]
|
4
|
Wagner JK, Fish L, Weisbord SD, Yuo TH. Hemodialysis access cost comparisons among incident tunneled catheter patients. J Vasc Access 2019; 21:308-313. [DOI: 10.1177/1129729819874307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Arteriovenous fistula is the ideal hemodialysis access, but most patients start with tunneled dialysis catheter. Arteriovenous fistula and arteriovenous graft surgery may reduce tunneled dialysis catheter use and also increase procedural expenses. We compared Medicare costs associated with arteriovenous fistula, arteriovenous graft, and tunneled dialysis catheter. Methods: Using the US Renal Data System, we identified incident hemodialysis patients in 2008 who started with tunneled dialysis catheter, survived at least 90 days, and had adequate Medicare records for analysis. We followed them until death or end of 2011; access modality was based on billing evidence of arteriovenous fistula or arteriovenous graft creation. We assumed patients without such records remained with tunneled dialysis catheter. We generated multivariate linear regression models predicting Medicare expenditures, censoring costs when patients died; we included all payments to physicians and institutions. We also created algorithms to identify access-related costs. Results: There were 113,505 patients in the US Renal Data System who started hemodialysis in 2008, of whom 51,002 Medicare patients met inclusion criteria. Of that group, 41,532 (81%) began with tunneled dialysis catheter; 27,064 patients were in the final analysis file. In the first 90 days after hemodialysis initiation, 6100 (22.5%) received arteriovenous fistula, 1813 (6.7%) arteriovenous graft, and 19,151 (70.8%) stayed with tunneled dialysis catheter. Annualized access costs by modality were tunneled dialysis catheter US$13,625 (95% confidence interval: US$13,426–US$13,285); arteriovenous fistula US$16,864 (95% confidence interval: US$16,533–US$17,194); and arteriovenous graft US$20,961 (95% confidence interval: US$20,967–US$21,654; p < .001). Multivariate linear regression demonstrated that staying with tunneled dialysis catheter had lowest access-related costs, arteriovenous fistula was intermediate, and those who underwent arteriovenous graft surgery were highest (p < .021). Access type was not significantly associated with total costs. Additional arteriovenous fistula and arteriovenous graft creation (US$3525 and US$3804 per access per year, respectively) and open and endovascular access-related interventions (US$3102 and US$3569 per procedure per year, respectively; all p < .001) were important predictors of increased cost. Conclusions: Among patients starting hemodialysis with tunneled dialysis catheter, continued tunneled dialysis catheter use is associated with lowest access-related cost. Both endovascular and open interventions are associated with significant additional costs. Further investigation is warranted to develop efficient patient-centered strategies for hemodialysis access.
Collapse
Affiliation(s)
- Jason Kane Wagner
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Vascular Surgery, UPMC Presbyterian Hospital, UPMC Heart and Vascular Institute, Pittsburgh, PA, USA
| | - Larry Fish
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Steven D Weisbord
- Division of Renal-Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Theodore H Yuo
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
5
|
Vowels TJ, Mohamed A, Bennett ME, Peden EK. Early cannulation of the Hemodialysis Reliable Outflow graft. J Vasc Access 2019; 21:186-194. [PMID: 31379255 DOI: 10.1177/1129729819867518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE In complex dialysis patients, central venous stenosis may preclude additional upper extremity access options. The Hemodialysis Reliable Outflow graft (Merit Medical Systems, Inc.) can bypass this stenosis providing patients with an additional upper extremity long-term access option. We report our experience with early-cannulation Hemodialysis Reliable Outflow grafts and compare them to traditional Hemodialysis Reliable Outflow grafts. METHODS We retrospectively reviewed all patients undergoing Hemodialysis Reliable Outflow graft placement from 1 January 2013 through 15 August 2017 at our institution and compared those undergoing placement of traditional Hemodialysis Reliable Outflow grafts and simultaneous tunneled dialysis catheter insertion to those undergoing Hemodialysis Reliable Outflow graft placement using an early-cannulation Hemodialysis Reliable Outflow graft without a tunneled dialysis catheter. RESULTS A total of 88 patients had 98 Hemodialysis Reliable Outflow grafts inserted throughout this time period. Of these, 61 (62%) were early-cannulation Hemodialysis Reliable Outflow grafts, while 37 (38%) were traditional Hemodialysis Reliable Outflow grafts. Primary, primary-assisted, and secondary patency rates at 1 year were higher for the traditional Hemodialysis Reliable Outflow graft cohort (53.1% vs 25.2%, p < 0.01; 70.1% vs 30.5%, p < 0.01; and 80.4% vs 55.4%, p = 0.07, respectively). There was no difference in the rate of postoperative hematoma, seroma, pseudoaneurysm formation, steal syndrome, or overall graft thrombosis between the two cohorts. Early-cannulation Hemodialysis Reliable Outflow grafts required earlier reintervention for thrombosis and earlier reintervention for any cause when compared to traditional Hemodialysis Reliable Outflow grafts (146 ± 184 days vs 417 ± 272 days, p < 0.01, and 123 ± 169 days vs 401 ± 311 days, p < 0.01, respectively). CONCLUSION In complex dialysis patients, early-cannulation Hemodialysis Reliable Outflow grafts have significantly lower 1-year primary and primary-assisted patency rates and require earlier reintervention to maintain this patency compared to traditional Hemodialysis Reliable Outflow grafts.
Collapse
Affiliation(s)
- Travis J Vowels
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Ahmed Mohamed
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew E Bennett
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Eric K Peden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| |
Collapse
|
6
|
Maintaining lower limb access with the HeRO device. J Artif Organs 2018; 22:141-145. [PMID: 30406438 DOI: 10.1007/s10047-018-1079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/18/2018] [Indexed: 10/27/2022]
Abstract
Central venous catheters (CVC) remain a mainstay of vascular access particularly for incident patients,
but lead to central vein stenosis (CVS) in up to 1 in 6 patents. This often leads to establishing dialysis access in the groin which in turn may result in development of CVS in the lower body, although this is poorly reported. The HeRO device was designed to address CVS by bypassing the stenosed veins with a nitinol-reinforced silicone tube into the right atrium, which acts as an outflow conduit attached to an arterial inflow. The efficacy and safety of the HeRO device in the upper limb is well established, but there is no data on its use in the lower limb. We describe 2 cases of HeRO in the lower limb, one primary and one secondary, which remain in use. Lower limb HeRO is feasible in the lower limb and can work well either as de novo (to achieve vascular access) or as a salvage procedure (to maintain vascular access).
Collapse
|
7
|
Difficulties with tunneling of the cuffed catheter: a single-centre experience. Sci Rep 2018; 8:3314. [PMID: 29463817 PMCID: PMC5820247 DOI: 10.1038/s41598-018-21338-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/01/2018] [Indexed: 11/25/2022] Open
Abstract
Tunneling of the cuffed catheter for hemodialysis is an important part of insertion procedure with faulty techniques being the cause of catheter dysfunctions. We retrospectively analyzed 737 double-lumen cuffed catheter procedures between 2008 and 2015 in patients aged 60 ± 15years, requiring renal replacement therapy. Complications of tunneling included kinking, bleeding and other problems. In 20 of 737 (2.7%) procedures, the catheter kinked, which was observed in 7.7% of silicone and 0.6% of polyurethane catheters. Repositioning was attempted in 4, but was successful in only 2 cases. Catheter exchange was necessary in 16 cases, but the function was adequate in 2 cases, despite radiological signs of kinking. In 6 cases (1 patient with diabetes, 2 with chest anatomy changes and medical devices, 2 with systemic sclerosis and 1 with greatly enlarged superficial jugular veins) we faced particular difficulties requiring an individual solution by tunneling; these are described in detail. The cumulative catheter patency rate were 69%, 52% and 37% at 3, 6 and 12 months, respectively. In conclusion, the most frequent complication of tunneling was kinking, usually necessitating catheter exchange. The silicon catheter kinked more often than the polyurethane one. An individual approach is sometimes needed by patients with diabetes and anatomical changes of the chest.
Collapse
|
8
|
Early use of autogenous arteriovenous fistula in patients with urgent hemodialysis. Int Urol Nephrol 2017; 49:1087-1093. [PMID: 28255638 DOI: 10.1007/s11255-017-1557-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 02/22/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE This study was designed to evaluate the long-term patency rate and complications associated with early use of the autogenous forearm arteriovenous fistula (AFAVF) in patients needing urgent hemodialysis. METHODS The clinical data of all patients undergoing AFAVFs for hemodialysis access between June 1996 and June 2016 were retrospectively evaluated. The primary and secondary patencies were estimated using the life table method. RESULTS A total of 104 AFAVFs were created for 102 patients. All patients had entered hemodialysis when fistulas were constructed. The mean time to the first cannulation of the AFAVF was 17.33 ± 4.60 (5-27 days). Four AFAVFs (3.8%) became occluded within 30 days of creation of the access, and five AFAVFs (4.8%) had hematomas after cannulation. There were no cases of infection of the wound or steal syndrome or prolonged arm edema. The primary patency rate was 77.81% at 1 year, 73.05% at 2 years, 64.64% at 3 years, 60.75% at 5 years and 47.48% at 10 years. The secondary patency rate was 96.78% at 1 year, 95.18% at 5 years and 85.81% at 10 years. CONCLUSIONS In this study, the patency rates following the early use of the AFAVFs were not inferior to the previously reported patency rates in the literature. For patients entering hemodialysis with an inserted central catheter, the early use of the AFAVFs decreases the complications associated with catheters.
Collapse
|
9
|
Aitken E, Thomson P, Bainbridge L, Kasthuri R, Mohr B, Kingsmore D. A randomized controlled trial and cost-effectiveness analysis of early cannulation arteriovenous grafts versus tunneled central venous catheters in patients requiring urgent vascular access for hemodialysis. J Vasc Surg 2017; 65:766-774. [DOI: 10.1016/j.jvs.2016.10.103] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 10/19/2016] [Indexed: 11/16/2022]
|
10
|
Are early cannulation arteriovenous grafts (ecAVG) a viable alternative to tunnelled central venous catheters (TCVCs)? An observational "virtual study" and budget impact analysis. J Vasc Access 2016; 17:220-8. [PMID: 27032450 DOI: 10.5301/jva.5000519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Early cannulation arteriovenous grafts (ecAVGs) are advocated as an alternative to tunnelled central venous catheters (TCVCs). A real-time observational "virtual study" and budget impact model was performed to evaluate a strategy of ecAVG as a replacement to TCVC as a bridge to definitive access creation. METHODOLOGY Data on complications and access-related bed days was collected prospectively for all TCVCs inserted over a six-month period (n = 101). The feasibility and acceptability of an alternative strategy (ecAVGs) was also evaluated. A budget impact model comparing the two strategies was performed. Autologous access in the form of native fistula was the goal wherever possible. RESULTS We found 34.7% (n = 35) of TCVCs developed significant complications (including 17 culture-proven bacteraemia and one death from line sepsis). Patients spent an average of 11.9 days/patient/year in hospital as a result of access-related complications. The wait for TCVC insertion delayed discharge in 35 patients (median: 6 days). The ecAVGs were a practical and acceptable alternative to TCVCs in over 80% of patients. Over a 6-month period, total treatment costs per patient wereGBP5882 in the TCVC strategy and GBP4954 in the ecAVG strategy, delivering potential savings ofGBP927 per patient. The ecAVGs had higher procedure and re-intervention costs (GBP3014 vs. GBP1836); however, these were offset by significant reductions in septicaemia treatment costs (GBP1322 vs. GBP2176) and in-patient waiting time bed costs (GBP619 vs. GBP1870). CONCLUSIONS Adopting ecAVGs as an alternative to TCVCs in patients requiring immediate access for haemodialysis may provide better individual patient care and deliver cost savings to the hospital.
Collapse
|
11
|
Garcarek J, Gołębiowski T, Letachowicz K, Kusztal M, Szymczak M, Madziarska K, Jakuszko K, Zmonarski S, Guziński M, Weyde W, Klinger M. Balloon Dilatation for Removal of an Irretrievable Permanent Hemodialysis Catheter: The Safest Approach. Artif Organs 2015; 40:E84-8. [DOI: 10.1111/aor.12643] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jerzy Garcarek
- Department of Radiology; Wroclaw Medical University; Wroclaw Poland
| | - Tomasz Gołębiowski
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Krzysztof Letachowicz
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Mariusz Kusztal
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Maciej Szymczak
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Katarzyna Madziarska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Katarzyna Jakuszko
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Sławomir Zmonarski
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Maciej Guziński
- Department of Radiology; Wroclaw Medical University; Wroclaw Poland
| | - Wacław Weyde
- Department of Faculty of Dentistry; Wroclaw Medical University; Wroclaw Poland
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| |
Collapse
|
12
|
Aitken E, Jeans E, Aitken M, Kingsmore D. A randomized controlled trial of interrupted versus continuous suturing techniques for radiocephalic fistulas. J Vasc Surg 2015; 62:1575-82. [DOI: 10.1016/j.jvs.2015.07.083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 07/23/2015] [Indexed: 10/22/2022]
|
13
|
Al Shakarchi J, Houston J, Jones R, Inston N. A Review on the Hemodialysis Reliable Outflow (HeRO) Graft for Haemodialysis Vascular Access. Eur J Vasc Endovasc Surg 2015; 50:108-13. [DOI: 10.1016/j.ejvs.2015.03.059] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/30/2015] [Indexed: 11/28/2022]
|
14
|
Abstract
National UK audits show that 73% of patients start renal replacement therapy (RRT) with haemodialysis (HD). However, 59% of those start HD on non-permanent access in the form of a tunnelled line (TL) or a non-tunnelled line (NTL), 40% on an arteriovenous fistula (AVF) and 1% on an arteriovenous graft (AVG). After 3 months, the number of patients dialysing on AVF was only 41%. Late referrals, within 90 days of starting dialysis to the renal service, occur in one-fifth of all incident HD patients. Referral to a surgeon was an important determinant of mode of access at first dialysis. However, referral to a surgeon occurred in 67% of patients who were known to the nephrologist for over a year and in 46% of patients who were known to nephrology less than a year but more than 90 days. Best practice tariffs of the National Health Service (NHS) payment by results program have set a target of 75% of prevalent HD occurring via an AVF or AVG in 2011/2012, rising to 85% in 2013/2014. We suggest that this target is best achieved by increasing timely referral to a surgeon for creation of access before HD is needed.
Collapse
|
15
|
Is there an association between central vein stenosis and line infection in patients with tunnelled central venous catheters (TCVCs)? J Vasc Access 2015; 16 Suppl 9:S42-7. [PMID: 25751550 DOI: 10.5301/jva.5000335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2014] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Central vein stenosis (CVS) and line infection are well-recognized complications of tunnelled central venous catheters (TCVCs) in patients on haemodialysis. The aim of this study was to evaluate any relationship between CVS and line infection. METHODS Analysis of 500 consecutive patients undergoing TCVC insertion was undertaken. Data were collected on patient demographics, details of line insertion and duration, culture-proven bacteraemia and presence of symptomatic CVS. Logistic regression analysis was used to determine risk factors for CVS and bacteraemia. RESULTS Mean patient age was 59.0 years (range: 17-93). Mean number of catheter days was 961.1 ± 57.6 per TCVC; 39.4% of TCVCs were associated with culture-proven bacteraemia and 23.6% developed symptomatic CVS. Bacteraemia and CVS were inevitable complications of all TCVCs. The time to symptomatic CVS was longer in patients with bacteraemia than without (1230.91 ± 101.29 vs. 677.49 ± 61.59 days, p<0.001). Patients who had early infection within 90 days of TCVC insertion were less likely to develop CVS (5.9% vs. 22.8%, p<0.001). There was no difference in the bacteraemia rate per 1,000 catheter days between patients with and without CVS (2.62 ± 1.41 vs. 2.35 ± 0.51; p = 0.98). Number of line days (odds ratio (OR) 1.02, p = 0.003), age (OR 1.04, p = 0.04) and culture-proven line infection (OR 0.59, p = 0.014) were all independently associated with CVS. CONCLUSIONS Our results suggest that early line infection may be protective against CVS. Alternatively, there may be two distinct predisposition states for CVS and line infection. Further studies are needed to confirm our association and investigate causation.
Collapse
|
16
|
Aitken E, Geddes C, Thomson P, Kasthuri R, Chandramohan M, Berry C, Kingsmore D. Immediate access arteriovenous grafts versus tunnelled central venous catheters: study protocol for a randomised controlled trial. Trials 2015; 16:42. [PMID: 25885054 PMCID: PMC4343055 DOI: 10.1186/s13063-015-0556-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 01/07/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Autologous arteriovenous fistulae (AVF) are the optimal form of vascular access for haemodialysis. AVFs typically require 6 to 8 weeks to "mature" from the time of surgery before they can be cannulated. Patients with end-stage renal disease needing urgent vascular access therefore traditionally require insertion of a tunnelled central venous catheter (TCVC). TCVCs are associated with high infection rates and central venous stenosis. Early cannulation synthetic arteriovenous grafts (ecAVG) provide a novel alternative to TCVCs, permitting rapid access to the bloodstream and immediate needling for haemodialysis. Published rates of infection in small series are low. The aim of this study is to compare whether TCVC ± AVF or ecAVG ± AVF provide a better strategy for managing patients requiring immediate vascular access for haemodialysis. METHODS/DESIGN This is a prospective randomised controlled trial comparing the strategy of TCVC ± AVF to ecAVG ± AVF. Patients requiring urgent vascular access will receive a study information sheet and written consent will be obtained. Patients will be randomised to receive either: (i) TCVC (and native AVF if this is anatomically possible) or (ii) ecAVG (± AVF). 118 patients will be recruited. The primary outcome is systemic bacteraemia at 6 months. Secondary outcomes include culture-proven bacteraemia rates at 1 year and 2 years; primary and secondary patency rates at 3, 6, 12 and 24 months; stenoses; re-intervention rates; re-admission rate; mortality and quality of life. Additionally, treatment delays, impact on service provision and cost-effectiveness will be evaluated. DISCUSSION This is the first randomised controlled trial comparing TCVC to ecAVG for patients requiring urgent vascular access for haemodialysis. The complications of TCVC are considered an unfortunate necessity in patients requiring urgent haemodialysis who do not have autologous vascular access. If this study demonstrates that ecAVGs provide a safe and practical alternative to TCVC, this could instigate a paradigm shift in nephrology thinking and access planning. TRIAL REGISTRATION This study has been approved by the West of Scotland Research Ethics Committee 4 (reference no. 13/WS/0087, 28 August 2013) and is registered with the International Standard Randomised Controlled Trial Number Register (reference no. ISRCTN80588541 , 27 May 2014).
Collapse
Affiliation(s)
- Emma Aitken
- Department of Renal Surgery, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
- School of Medical, Veterinary and Life Science, University of Glasgow, University Avenue, Glasgow, G12 8TA, UK.
| | - Colin Geddes
- Department of Nephrology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Pete Thomson
- Department of Nephrology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Ram Kasthuri
- Department of Radiology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Mohan Chandramohan
- Department of Radiology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| | - Colin Berry
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, University Avenue, Glasgow, G12 8TA, UK.
| | - David Kingsmore
- Department of Renal Surgery, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
| |
Collapse
|
17
|
Bilateral Central Vein Stenosis: Options for Dialysis Access and Renal Replacement Therapy when all upper Extremity Access Possibilities have been Lost. J Vasc Access 2014; 15:466-73. [DOI: 10.5301/jva.5000268] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 11/20/2022] Open
Abstract
Purpose Patients with bilateral central vein stenosis present a unique challenge: treatment options are limited, largely unproven and associated with reputedly poor outcomes. Our aim was to compare patency rates of different access and renal replacement treatment (RRT) modalities in patients with bilateral central vein stenosis/occlusion. Material and methods Data on all patients presenting to a tertiary referral vascular access centre with end-stage vascular access (defined by bilateral central vein stenosis/occlusion with loss of upper limb access) over a 5-year period were included. 3, 6 and 12-month patencies of translumbar catheters (TLs), tunnelled femoral catheters (Fem), native long saphenous vein loops (SV), prosthetic mid-thigh loop grafts (ThGr), peritoneal dialysis (PD), and expedited donation after cardiac death (DCD) cadaveric renal transplants (Tx) via local allocation policies were compared using log-rank test. Kaplan–Meier survival analysis was used to estimate long-term access survival. Results One hundred forty-six vascular access modalities were attempted in 62 patients (62 Fem, 25 TL, 15 SV, 25 ThGr, 8 PD, 11 Tx). Median follow-up was 876±57 days. Three, 6 and 12-month primary-assisted patencies for each modality were as follows: Fem: 75.4%, 60% and 28%; TL: 88%, 65% and 50%; SV: 87.5%, 60% and 44.6%; ThGr: 64%, 38% and 23.5%; PD: 62.5%, 62.5% and 50%; Tx: 72.7%, 72.7% and 72.7%. SV had better secondary patency at 900 days (76.9%) than ThGr (49.2%) or Fem (35.8%) (p<0.01). No patients died as a result of loss of access. Conclusion Patients with bilateral central vein stenosis often require more than one vascular access modality to achieve a “personal access solution.” Native long saphenous vein loops provided the best long-term patency. Expedited renal transplantation with priority local allocation of DCD organs to patients with precarious vascular access provides a potential solution to this difficult problem.
Collapse
|