Successful use of indwelling cuffed femoral vein catheters in ambulatory hemodialysis patients

Review and Case Studies of Midthigh Femoral Central Venous Catheter Placement

Background: Bedside vascular access options have been limited to the short peripheral intravenous, midline catheter, peripherally inserted central catheter, and central venous catheter (CVC) insertion sites such as the jugular, subclavian, and femoral vein. Many patients with limited options for upper extremity, subclavicular, supraclavicular, and cervical limitations have traditionally received a femoral CVC in the inguinal region. This insertion site is considered a high risk for infection because of its location in the inguinal region and associated difficulties with maintaining the dressing integrity. An alternative location was selected for the insertion of a femoral vein central venous catheter in the midthigh to reduce the risk of infection.

Methods: After a multiple-year implementation process, midthigh femoral (MTF) insertions were performed on a select group of patients. The case studies that are included in this report outline the indications, procedures, and other pertinent aspects of the MTF placement. Patients at this institution with contraindications to upper extremity and thoracic catheter insertion received a MTF vein CVC in place of a traditional common femoral vein catheter insertion in the inguinal area. All procedural consents include permission for photography of procedure sites.

Results: All but a single patient completed their therapy without complication; 1 intentional dislodgement by a patient was recorded. There were no MTF catheter-related bloodstream infections and 2 confirmed central line associated bloodstream infections (n = 2 of 100) with the second noted as probable contaminated specimen. Outcomes reflected no procedural complications (eg, expanding hematoma or femoral nerve injury or any other femoral artery or vein injuries) and 1 nonocclusive deep vein thrombosis (n = 1 of 100).

Conclusions: The MTF CVC provides an alternative to traditional common femoral vein catheter placement for nonemergent patients with upper extremity and thoracic contraindications to central line placement.

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.

Subcutaneous Implantation of the LifeSite® Hemodialysis Access System in the Femoral Vein

Cannulation of the femoral vein is often necessary to provide immediate vascular access for hemodialysis patients in whom a functional permanent access is not available or in patients who have exhausted other access options. Femoral placement of dialysis catheters is typically short term - days, not months - and is associated with high rates of infection, occlusion, recirculation and intervention as well as a high risk of catheter dislodgment.

A new, fully subcutaneous vascular access device - the LifeSite®, Hemodialysis Access System (Vasca, Inc., Tewksbury, MA) - has demonstrated better safety and efficacy profiles than a standard tunneled dialysis catheter in clinical trails that evaluated placement within the thoracic veins. The case reported here extends the use of the LifeSite® System to femoral placement in a patient with multiple failed arteriovenous accesses and dialysis catheters subsequent to central venous stenosis. The LifeSite® System was successfully implanted in the patient's left femoral vein and has served the patient for 4 months with no infections or complications requiring intervention, delivering flow rates >400–450 ml/minute for high-flux, dual-needle hemodialysis. These initial results suggest that the LifeSite® Hemodialysis Access System represents a new, safe and effective vascular access option in patients with limited access choices due to failed access in the upper extremities, central venous stenosis, or other vascular inadequacies.

Retrograde femoral vein catheter insertion. A new approach for challenging hemodialysis vascular access

INTRODUCTION

Venous catheters provide access for hemodialysis (HD) when patients do not have functioning access device. Obstruction of jugular, femoral or even external iliac vessels further depletes options. Subclavian approach is prohibited. Catheterization of inferior vena cava requires specialized equipment and skills.

PURPOSE

The purpose is to assess a new lifesaving HD vascular access approach for patients with nonfunctioning access device in the ordinary sites. This entails insertion of a retrograde temporary HD catheter in the superficial femoral vein, directing the catheter distally, toward the foot.

MATERIALS AND METHODS

We included six end-stage renal disease (ESRD) patients retrospectively who are on regular renal replacement therapy and need urgent HD with nonfunctioning access device in the ordinary sites.

RESULTS

Successful insertion of six retrograde femoral vein catheters in the superficial femoral vein. The mean catheter days were 2.5±0.5 days with one patient having 26 catheter days. The mean blood pump speed was 230.0±44.7 mL/min. Urea reduction ratio and Kt/V at 3 hours HD session were 47% and 1.5, respectively, which increased with increasing session duration. The ultrafiltration volume was 2-3 L/session which increased up to 6 L/session in case of using slow low-efficiency dialysis. No major complications were observed during insertion or the postinsertion period except thigh pain in one patient and exit site infection in the case of long duration.

CONCLUSIONS

This is a newly applied lifesaving HD vascular access approach for selected ESRD patients with no available HD vascular access at the ordinary sites with accepted HD adequacy. It needs more evaluation and more studies.

Using Tunneled Femoral Vein Catheters for “Urgent Start” Dialysis Patients: A Preliminary Report

Background

Multiple benefits of arteriovenous fistulas (AVF) and arteriovenous grafts (AVGs) exist over catheters. As part of a strategy to preserve thoracic venous sites and reduce internal jugular (IJ) vein catheter use, we inserted tunneled femoral vein catheters in incident “urgent start” dialysis patients while facilitating a more appropriate definitive dialysis access.

Methods

“Urgent start” dialysis patients between January 15, 2013 and January 15, 2014 who required chronic dialysis, and did not have prior modality and vascular access plans, had tunneled femoral vein catheters inserted. We determined the femoral vein catheter associated infections rates, thrombosis, and subsequent dialysis access. Eligible patients were surveyed on their femoral vein catheter experience.

Results

Twenty-two femoral vein catheters were inserted without complications. Subsequently, one catheter required intraluminal thrombolytic locking, while all other catheters maintained blood flow greater than 300 ml/min. There were no catheter-related infections (exit site infection or bacteremia). Six patients continued to use their tunneled catheter at report end, one transitioned to peritoneal dialysis, thirteen to an arteriovenous graft, and two to a fistula. One patient received a tunneled IJ vein catheter. Of the patients who completed the vascular access survey, all indicated satisfaction with their access and that they had minimal complaints of bruising, bleeding, or swelling at their access sites. Pain/discomfort at the exit site was the primary complaint, but they did not find it interfered with activities of daily living.

Conclusions

Femoral vein tunneled catheters appear to be a safe, well tolerated, and effective temporary access in urgent start dialysis patients while they await more appropriate long-term access.

Utilização da veia ilíaca externa recanalizada para implante de cateter de longa permanência para hemodiálise

O uso de cateteres venosos cervicais para hemodiálise leva freqüentemente à oclusão dessas veias. Como alternativa, os acessos venosos femorais são válidos, porém o seu uso também está associado à oclusão dessas veias e a um maior índice de infecção. Vias alternativas são cada vez mais utilizadas na impossibilidade dos acessos previamente mencionados. Descrevemos neste relato de caso uma alternativa para o implante de cateter de longa permanência para hemodiálise usando a veia ilíaca externa recanalizada. Comentamos os detalhes da técnica utilizada, suas vantagens e desvantagens.

Tunnelled Catheters for the Haemodialysis Patient

Haemodialysis depends upon the establishment of a durable means of vascular access. Although the creation of a successful arterio-venous Fistulae (AVF) is the ideal, this is not always possible or practical. Tunnelled catheters play an important role as an interim/bridge technique for emergency access or while an AVF matures, but may be associated with significant morbidity. The aim of this review is to highlight recent evidence based developments in tunnelled catheters, including methods of placement, complications and possible management strategies.

Ultrasound imaging findings of femoral veins in patients with renal failure and its impact on vascular access

BACKGROUND

Patients requiring dialysis due to acute or chronic renal failure frequently require temporary vascular access. Femoral vein catheterization is the easiest method for obtaining temporary vascular access in haemodialysis patients. The aim of this study was to utilize ultrasound imaging to describe femoral vein structures and to examine anatomical variations in uraemic patients.

METHODS

We evaluated 114 (70 males, 44 females) renal failure patients. Femoral arteries were localized manually inferior to the femoral ligament, and ultrasonographic examination was performed from this location. Images of the vessels and demographic data of patients were recorded and analysed. Femoral veins were classified according to their diameter, patency and palpation status of the neighbouring femoral artery.

RESULTS

Three patients had a history of prior femoral catheterization. In one of these, who had a history of bilateral catheterization, we detected bilateral femoral vein thrombosis. Overall, non-palpable femoral arteries or unsuitable femoral veins were found unilaterally in 16 patients (14.0%) and bilaterally in six patients (5.2%). The depth of femoral arteries (r = 0.54, P<0.001) and femoral veins (r = 0.59, P<0.001) was correlated with body mass index (BMI). Femoral arteries and femoral veins were located significantly deeper in overweight (BMI >25) patients compared with normal weight patients (20.7+/-6.5 vs 14.6+/-5.1 mm, P<0.001 and 26.1+/-6.7 vs 18.9+/-5.5 mm, P<0.001).

CONCLUSIONS

Bilateral anatomical variations of femoral veins were relatively rare. However, ultrasound surveys should be performed in obese patients or when the femoral artery is not palpable.

Direct peripheral venopuncture: another new choice of temporary vascular access

BACKGROUND

Femoral, subclavian, and internal jugular veins access have been widely used for temporary vascular access for hemodialysis, but their use has been associated with a significant complication rate. We report in three selected hemodialysis patients with the procedure of direct peripheral venopuncture as temporary vascular access to reduce complications.

METHODS

We have demonstrated hemodialysis via direct puncture of peripheral veins of the antecubital fossa (cephalic vein in the process of arterial inflow to dialyzer and venous outflow from dialyzer to basilic vein) as temporary vascular access for these patients.

RESULTS

Renal function of case 1 and case 2 progress to normal status after several sessions of dialytic therapy as well as quit hemodialysis, and case 3 successfully shifts to peritoneal dialysis following four sessions of dialytic therapy.

CONCLUSIONS

We recommend this short-term access contribute a important additional new choice in selected patients with acute, reversible renal failure, obstructive uropathy, initiation of peritoneal dialysis, patients on peritoneal dialysis with peritonitis, or under plasmapheresis therapy.

The hemodialysis catheter conundrum: hate living with them, but can't live without them

BACKGROUND

Hemodialysis requires reliable recurrent access to the circulation. On a chronic basis, this has been best provided by the use of arteriovenous fistulae and arteriovenous grafts. In recent years, hemodialysis catheters have come to play an increasingly important role in the delivery of hemodialysis. The use of both temporary as well as cuffed hemodialysis catheters has emerged as a significant boon for both patients and practicing nephrologists. The complications, however, associated with each of these hemodialysis catheters, both in terms of anatomic, thrombotic, and infectious issues, have emerged as a major problem with their continued use. This significant morbidity and complication rate has forced many nephrologists to face a basic conundrum: they have come to hate having to deal with the problems inherent in catheter usage, but the enormous utility of these devices have forced physicians to accept the fact they cannot live without them in their current practice.

METHODS

We used a comprehensive literature review to describe the types, use and dilemmas of hemodialysis catheters.

RESULTS

This article provides a comprehensive review of both the benefits inherent with the use of these hemodialysis catheters while cataloging their complications and offering some possible solutions.

CONCLUSION

Hemodialysis vascular access catheters are essential in the maintenance of hemodialysis vascular access. However, they have a significant infectious, thrombotic, anatomic complication rate that are detailed with proposed problem-solving guidelines.

Central venous catheters for maintenance hemodialysis: a cautionary approach

There is an increasing trend toward the use of indwelling central venous catheters (CVC) for maintenance hemodialysis. Although such devices are necessary in some problematic cases, the general use of CVC is worrisome. Not only may CVC prejudice the ultimate success of future permanent vascular access, but CVC also may be associated with reduced dialysis delivery and with several important complications. This review summarizes recent developments in catheter design, placement techniques, maintenance of the indwelling catheter, and complications of CVC use. Based on cumulated experience, a judicious position is taken that recognizes the place of CVC among the various access options but that favors permanent vascular access whenever feasible.

Acute vascular access: new advances

Dual lumen central venous hemodialysis catheters have become the preferred form of acute of acute vascular access. Although they provide rapid angioaccess, these catheters are associated with a number of serious insertion complications. Furthermore, prolonged use can lead to late complications including infection and central venous stenosis. Recent advances in catheter construction as well as new techniques for line placement should reduce the incidence and severity of catheter-related problems.