Evaluation of Catheter Infection Rates in Converted Dialysis Catheters versus de Novo Placement in the Setting of Chlorhexidine Use

A Modified Switching Procedure from Temporary to Tunneled Central Venous Dialysis Catheters

Background: Tunneled central venous catheters are commonly used for dialysis in patients without a functional permanent vascular access. In an emergent setting, a non-tunneled, temporary central venous catheter is often placed for immediate dialysis. The most critical step in the catheter insertion is venipuncture, which is often a major cause for longer intervention times and procedure-related adverse events. To avoid this critical step when placing a more permanent tunneled catheter, an exchange over a previously placed temporary one can be considered. In this paper, we present a modified switching approach with a separate access site. Methods: In this retrospective analysis of a prospective database, we examined whether this modified technique is non-inferior to a de novo application. Therefore, we included all 396 patients who received their first tunneled dialysis catheter at our site from March 2018 to March 2023. Out of these, 143 patients received the modified approach and 253 the standard de novo ultrasound-guided puncture and insertion. Then, the outcomes of the two groups, including adverse events and infections, were compared by nonparametric tests and multivariable logistic regression. Results: In both groups, the implantations were 100% successful. Catheter explantation due to infection according to CDC criteria was necessary in 18 cases, with no difference between the groups (5.0% vs. 4.4% p = 0.80). The infection rate per 100 days was 0.113 vs. 0.106 in the control group, with a comparable spectrum of bacteria. A total of 12 catheters (3 vs. 9) had to be removed due to a periinterventional complication. An early-onset infection was the reason in two cases (1.3%) in the study group and five in the control group (1.9%). A total misplacement of the catheter occurred in two cases only in the control group. After adjustment for potential confounders via multivariable logistic regression there was not a significant difference in the complication rate (adjusted odds ratio, aOR = 0.53, 95% CI = 0.14-2.03, p = 0.351) but an estimated decreased risk overall based on the average treatment effect of -1.7% in favor of the study group. Conclusions: The present study shows that a catheter exchange leads to no more infections than a de novo placement; hence, it is a feasible method. Moreover, misplacements and control chest X-rays to exclude pneumothorax after venipuncture were completely avoided by exchanging. This approach yields a much lower infection rate than previous reports: 1.3% compared to 2.7% in all existing aggregated studies. The presented approach seems to be superior to existing switching methods. Overall, an exchange can also help to preserve veins for future access, since the same jugular vein is used.

Central Venous Catheters for Hemodialysis-the Myth and the Evidence

Hemodialysis-central venous catheter (HD-CVC) insertion is a most often performed procedure, with approximately 80% of patients with end-stage kidney disease in the United States initiating kidney replacement therapy through a HD-CVC. Certain adverse events arising from HD-CVC placement, including catheter-related bloodstream infections (CR-BSIs), thrombosis, and central vein stenosis, can complicate the clinical course of patients and lead to considerable financial impact on the health care system. Medical professionals with different training backgrounds are responsible for performing this procedure, and therefore, comprehensive operator guidelines are crucial to improve the success rate of HD-CVC insertion and prevent complications. In this review article, we not only discuss the basic principles behind the use of HD-CVCs but also address frequently asked questions and myths regarding catheter asepsis, length selection, tip positioning, and flow rate assessment.

Maturation of arteriovenous fistulas in patients with ventricular assist devices

OBJECTIVE

Postoperative renal dysfunction necessitating hemodialysis after implantation of ventricular assist devices presents a challenge with respect to establishment of hemodialysis access. Lack of pulsatile flow has led to concerns that arteriovenous fistulas will not mature. This study aims to evaluate arteriovenous fistula as a method of hemodialysis.

METHODS

Consecutive patients who underwent implantation of a ventricular assist device between 1988 and 2016 with a subsequent need for hemodialysis were identified. Retrospective data were collected for patients requiring hemodialysis through an arteriovenous fistula or arteriovenous graft. Access flow rates and duration of patency are reported.

RESULTS

Sixty-four patients were identified (10 required long-term hemodialysis, 5 via arteriovenous fistula, 1 via arteriovenous graft). All six patients receiving long-term hemodialysis access were on continuous-flow ventricular assist devices. Brachiocephalic arteriovenous fistulas were performed in all arteriovenous fistula patients, and the average preoperative vein diameter was 4.1 ± 0.9 mm. On 30-day follow-up, the average flow rate was 1262 ± 643 mL/min (880-2220). In arteriovenous fistula patients, one died at 30 days, one arteriovenous fistula required ligation for steal syndrome at 5 months, and one was abandoned after 10.7 months for low flow. Of remaining fistulas, one was converted to an arteriovenous graft at 1.7 years for malfunction (with 5.3 month patency), and one remains open at 4.0 years.

CONCLUSION

Arteriovenous fistulas should be considered in selected patients with ventricular assist devices as a means of long-term hemodialysis access to avoid use of catheters. Maturation and usage of primary arteriovenous fistulas is possible despite lack of pulsatile flow.

Exchange over the guidewire from non-tunneled to tunneled hemodialysis catheters can be performed without patency loss

PURPOSE

The exchange from a non-tunneled hemodialysis catheter to a tunneled one over a guidewire using a previous venotomy has been reported to be safe. However, some concerns that it may increase infection risk prevent its clinical application. This approach seems particularly useful for acute kidney injury patients requiring initial renal replacement therapy, in whom we frequently worry about the choice of non-tunneled versus tunneled catheters.

MATERIALS AND METHODS

From March 2012 to February 2016, 88 cases to receive the over-the-guidewire exchange method from a non-tunneled to a tunneled catheter and 521 cases to receive de novo tunneled catheter placement from the hemodialysis vascular access cohort were compared retrospectively.

RESULTS

The immediate complication, later catheter dysfunction requiring replacement, and infection rates were comparable between the two groups. Newly placed tunneled catheter survival in the over-the-guidewire exchange group was comparable with survival in the de novo tunneled catheter group (p = 0.24). In addition, when we compared the same two methods among only intensive care unit patients; they remained similar (p = 0.19).

CONCLUSION

An exchange with the over-the-guidewire method from a non-tunneled to a tunneled catheter was comparable to a de novo catheter placement technique. Therefore, this method should be viewed more favorably and should especially be considered for acute kidney injury patients.

Treatment of Tunneled Dialysis Catheter Malfunction: Revision versus Exchange

Introduction

Exchange procedures involve tunneled dialysis catheter (TDC) removal and exchange over a wire, using the same exit site and venotomy site. Diagnostic imaging or intervention was generally not performed in exchange procedures. Revision procedures involve placement of new TDC using the previous venotomy site and a new tunnel and exit site. The majority of revisions usually include diagnostic imaging and intervention in the central circulation if needed.

Methods

A retrospective single review of 70 patients who underwent 97 TDC replacements from 2010 to early 2012 because of catheter malfunction was evaluated for either infection or malfunction within 30 days of the procedure.

Results

There were 41 exchanges and 56 revisions out of the 97 procedures performed. There were eight infections (documented by positive blood culture) in the exchanges (19.5%) and one in the revision group (1.8%). The need for an additional procedure due to malfunction was 10 in the exchange (24.4%) and 10 (17.8%) in the revision group.

Conclusions

Revision is a clearly superior procedure with regard to infection and more data need to be gathered as to whether it will decrease repeat procedures.