Effect of insertion site on tunnelled haemodialysis catheter outcomes: an observational study of 967 catheters

BACKGROUND

The right internal jugular vein is the preferred approach to tunnelled haemodialysis catheter placement. However, the effect of the insertion site on long-term catheter outcomes remains uncertain.

AIMS

We aimed to analyse a large cohort of tunnelled haemodialysis catheter placements to compare short-term and long-term results according to central venous catheter location.

METHODS

A retrospective cohort study was performed on consecutive tunnelled catheter insertions at two centres over 7 years. The primary outcome was catheter survival, compared according to the central vein site. We used the Kaplan-Meier curve method and Cox proportional hazards modelling to determine the effect of the catheterisation route on primary patency, adjusted for clinical risk factors for catheter failure.

RESULTS

There were 967 tunnelled dialysis catheter placements in 620 patients. The median survival for right internal jugular vein catheters was 569 days. There were no differences in rates of catheter failure between right internal jugular, left internal jugular (adjusted hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.52-1.21), external jugular (HR, 0.79; CI, 0.33-3.13), subclavian (HR, 0.67; CI, 0.58-2.44) and femoral vein (HR, 1.20; CI, 0.36-1.33) catheters following multivariable analysis. There were no major differences in functionality or complications between the groups.

CONCLUSIONS

This study identified no statistically significant relationship between tunnelled haemodialysis catheter insertion site and catheter survival. The contemporary approach to dialysis vascular access should be tailored to specific patient circumstances.

A novel extra-catheter guide wire technique for in situ exchange of dysfunctional tunnelled central venous hemodialysis catheter

BACKGROUND

Tunneled central venous catheters (tCVC) exchange may be difficult in some situations. We retrospectively report our preliminary experience of a novel extra-catheter guide wire technique for exchange of dysfunctional tCVC.

MATERIALS AND METHODS

Retrospectively analyze the demographics, treatment details and outcomes data of 39 patients received tCVC exchange from January 2018 to January 2019. According to whether guide wire could pass through the catheter lumen, patients were divided into in-catheter group and extra-catheter group. The technical successful rate, peri-operative complications, 1-month and 6-month catheter flow rate was recorded and compared between the 2 groups.

RESULTS

The final study population consists of 39 patients, including 16 in-catheter group and 23 extra-catheter group. The technical successful rate was 100% in both groups. All patients achieved restoration of line patency and completed at least 1 hemodialysis section. The 1-month (267.69 ± 20.12 vs. 274.13 ± 17.69, p = 0.604) and 6-month (255.81 ± 12.93 vs. 256.97 ± 11.20, p = 0.403) catheter flow rate was comparable between the 2 groups.

CONCLUSION

The novel extra-catheter guide wire technique was helpful for in situ exchange of dysfunctional tunneled central venous hemodialysis catheters, especially when the guide wire could not pass through the catheter lumen.

Non-cuffed central venous catheter for unplanned and urgent start haemodialysis in chronic kidney disease: A multi-centre experience from India

BACKGROUND

Central Venous Catheter (CVC) is indispensable to unplanned and urgent start haemodialysis in chronic kidney disease (CKD). While cuffed CVC is preferred to non-cuffed CVC for urgent start haemodialysis, patient's clinical condition might warrant immediate insertion of non-cuffed CVC. In the resource poor setting, non-cuffed CVCs might have to be retained longer than guideline recommended limit of 2 weeks. In this multi-centre retrospective observational study, the real-world survival of non-cuffed CVC was assessed among CKD patients who initiated dialysis urgently.

METHODS

CVC survival was assessed by Kaplan-Meier survival estimate. Predictors of premature CVC loss were assessed using multi-level multi-variate Cox frailty model wherein, each centre was provided with a random intercept to account for within-centre correlation of practice patterns.

RESULTS

Among 433 non-cuffed CVCs, there were 393 removals out of which 80% were elective and 20% were premature. The median CVC survival was 37 days (95% CI: 35-41). The rate of premature CVC removal was 4.5/1000 CVC-days (95% CI: 3.6-5.6). Mechanical complications followed by central line associated blood stream infection (CLABSI) were the most common reasons for premature removal. Rate of CLABSI was 1.7/1000 CVC-days (95% CI: 1.2-2.5). Diabetic CKD significantly increased the hazard of premature CVC removal (HR 1.91, 95% CI: 1.01-3.63, p = 0.04) while right internal-jugular location decreased the hazard (HR 0.22, 95% CI: 0.13-0.38, p < 0.001).

CONCLUSION

Prolonged retention of non-cuffed CVC (median 37 days) is common in resource-poor setting. It is worrisome and calls for pre-emptive access creation.

The impact of anatomical variables on haemodialysis tunnelled catheter replacement without fluoroscopy

AIM

Tunnelled haemodialysis (HD) catheters can be used instantly, but there are several anatomical variables that could impact it survival. This study aimed to examine the impact of different novel anatomic variables, with catheter replacement.

METHODS

In a single-centre a prospective cohort in chronic kidney disease G5 patients were conducted. The primary outcome was to determine the factors associated with catheter replacement during the first 6-month of follow-up. All procedures were performed without fluoroscopy. Three anatomic regions for catheter tip position were established: considered as superior vena cava (SVC), cavo-atrial junction (CAJ) and mid-to deep atrium (MDA). Many other anatomical variables were measured. Catheter-related bloodstream infection was also included.

RESULTS

Between January 2019 and January 2020 a total of 75 patients with tunnelled catheter insertion were analysed. Catheter replacement at 6-month occur in 10 (13.3%) patients. By multivariate analysis, the incorrect catheter tip position (SVC) (OR 1.23, 95% CI 1.07-1.42, p <.004), the presence of extrasystoles during the procedure (OR 0.88, 95% CI 0.78-0.98, p = .03), incorrect catheter tug (OR 1.31, 95% CI 1.10-1.55, p = .003), incorrect catheter top position (kinking; OR 1.40, 95% CI 1.04-1.88, p = .02) and catheter-related bloodstream infection (OR 2.60, 95% CI 2.09-3.25, p <.001) were the only variables associated with catheter replacement at 6-month follow-up.

CONCLUSION

The risk of catheter replacement at 6-month follow-up could be attenuated by avoiding incorrect catheter tug and top position, and by placing the vascular catheter tip in the CAJ and MDA.

Long-term IV access in paediatrics - why, what, where, who and how

Establishment of long-term central venous access imposes the risk of procedural adverse events (air embolism, pneumothorax, accidental arterial cannulation of the great vessels, tricuspid valve damage and cardiac tamponade) as well as the risk of increased morbidity and mortality due to catheter related blood stream infections, vessel stenosis, deep vein thrombosis and the often high risk anaesthetic management of syndromic children. This narrative review aims to provide a historical and clinical background for the development and use of CVADs (central venous access devices), origin and management of the most common complications (catheter related thrombosis, infections and persistent withdrawal occlusion) and present the reader with an update on the "why, what, where, who and how" in paediatric long-term central venous access. Finally, we will present the reader with a clinical method for applying a retrograde inserted tunnelled and cuffed catheter using the left brachiocephalic vein access.

Contemporary management and outcomes of infective tunnelled haemodialysis catheter-related right atrial thrombi: a case series and literature review

INTRODUCTION

Infective haemodialysis catheter-related right atrial thrombus (CRAT) is a complication of tunnelled catheter use. Management recommendations are based mainly on published case series prior to 2011. We report our institution's recent experience in managing infective haemodialysis CRAT and correlate treatment with outcomes.

METHODS

We conducted a retrospective analysis of haemodialysis CRAT cases diagnosed on transthoracic echocardiography between 1 January 2011 and 31 December 2017. Clinical outcomes, including mortality at 180 days post diagnosis and thrombus resolution, were traced from electronic medical records.

RESULTS

There were 14 cases identified. The median age was 59 (range 47-88) years and 11 (78.6%) were male. Sepsis was the most common reason for hospitalisation (71.4%). Blood cultures identified Staphylococcus aureus in seven cases, of which two were methicillin-resistant. Three had coagulase-negative Staphylococcus. All cases received antibiotics with infectious disease physician input. Seven were treated with catheter removal alone, of which three died within 180 days. Both cases treated with catheter removal plus anticoagulation survived at 180 days. Of the two cases who had anticoagulation without catheter removal, one died within 180 days and the other did not have thrombus resolution. Three underwent surgical thrombus removal, of which two died postoperatively and the last required repeated operations and prolonged hospitalisation. Mortality at 180 days post diagnosis was 42.9%.

CONCLUSION

Catheter removal and anticoagulation are modestly effective. Surgery is associated with poor outcomes. Despite contemporary management, infective haemodialysis CRAT still results in high mortality. Prospective studies are needed to identify the optimal management.

A retrospective study of tunnelled haemodialysis central line-associated bloodstream infections

Infection is a serious complication of tunnelled haemodialysis catheters. We aimed to describe the epidemiology of tunnelled haemodialysis central line-associated bloodstream infections (CLABSI) in an Australian centre. We performed a retrospective audit of tunnelled haemodialysis CLABSI from June 2010 to June 2014. From 674 catheter insertions, 70 CLABSI occurred in 55 patients at a rate of 0.95 infections per 1000 catheter days. Aboriginal and Torres Strait Islanders (ATSI) compared to non-ATSI had a higher rate of CLABSI (1.70 vs 0.58 CLABSI per 1000 catheter days, p < 0.001). Staphylococcus aureus (n = 22, 31.4%), coagulase negative Staphylococci (n = 14, 17.5%), and Gram negative bacilli (n = 28, 35.0%) were the predominant causative organisms. Two patients who died both had Staphylococcus aureus infection. In conclusion, our infection rate and microbiology are similar to prior reports. Morbidity and mortality are associated with Staphylococcus aureus as the causative organism.

Low dose heparin lock (1000 U/mL) maintains tunnelled hemodialysis catheter patency when compared with high dose heparin (5000 U/mL): A randomised controlled trial

Introduction Heparin is commonly used after hemodialysis treatments as a locking solution to prevent catheter thrombosis. The comparative efficacy and safety of different heparin concentrations to maintain catheter patency has been previously reported in retrospective studies. We conducted a prospective, randomised, controlled study of 1000 U/mL heparin (low dose) versus 5000 U/mL heparin (high dose) locking solution to maintain patency of tunnelled catheters. Methods One hundred patients receiving chronic, unit-based hemodialysis with newly placed tunnelled hemodialysis catheters (less than 1 week) were randomly assigned to either a low dose (n = 48) or high dose heparin (n=52). The primary intention-to-treat analysis examined time to malfunction in both groups over a 90 day period. A secondary analysis compared baseline patient characteristics in relation to catheter malfunction. Findings Overall rate of catheter patency loss was 32% of catheters by 90 days. There was no significant difference in time to malfunction of catheters locked with low dose or high dose heparin (P = 0.5770). Time to catheter malfunction was not associated with diabetic, hypertensive or smoking status. There was no difference in mean delivered blood flow rate, venous and arterial pressure, and dialysis adequacy between low dose and high dose groups. No patient suffered a hemorrhagic complication requiring hospitalisation during the study period. Discussion Low dose heparin is adequate to maintain tunnelled hemodialysis catheter patency when compared with high dose heparin. The study also suggests that there is no relationship between catheter malfunction and diabetic, hypertensive or smoking status.