Insertion of long-term hemodialysis catheters by interventional radiologists: the trend continues

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Hickmans in unusual places

Radiologists now commonly insert long-term indwelling right atrial catheters. The insertion of these catheters in patients with limited venous access is a challenging clinical problem. Our experience in dealing with patients with limited venous access from a series of 500 Hickman catheter insertions is presented, as are the problems encountered during the insertion of catheters in patients with anomalies of the venous system.

Infectious complications of 393 peripherally implantable venous access devices in HIV-positive and HIV-negative patients

PURPOSE

To compare and investigate the rate of infection in patients with and without human immunodeficiency virus (HIV) who have implantable venous access devices placed by interventional radiologists.

MATERIALS AND METHODS

Three hundred ninety-one patients undergoing radiologically guided placement of peripheral arm ports were grouped according to their HIV serologic status. Findings were prospectively reviewed in 393 peripherally placed arm ports that were implanted in the basilic, cephalic, or brachial vein under fluoroscopic or sonographic guidance over a 4-year span. Infectious complications were categorized according to severity (local or systemic) and time (periprocedural or late).

RESULTS

Three hundred ninety-three ports have been indwelling for a total of 97,256 patient days (range, 1-694; mean duration, 247 days). Among the 30 catheter placements in 29 HIV-positive patients with a total exposure time of 7,242 days, five (one local and four systemic) infections occurred, resulting in a 16.6% overall infection rate, yielding 0.069 infections per 100 catheter days at risk (95% confidence interval [CI], 0.032-0.127). In the remaining 362 HIV-negative patients, 27 (14 local and 13 systemic) infectious complications (7.4%) occurred, translating into 0.030 infections per 100 catheter days (95% CI, 0.021-0.042). The odds ratio of getting an infection from the implantable arm ports in the HIV-positive group was 2.5 times higher than that of the HIV-negative group. The relative risk was similar and was calculated to be 2.3. The P value was .084 (P < .05 required to be considered significant).

CONCLUSIONS

These results suggest a significant difference in the infectious complication rate encountered in HIV-positive patients compared with the general population. However, the HIV-positive peripheral arm port infection rate compares favorably with the surgically placed catheters and ports. Many more arm ports in HIV-positive patients must be evaluated for the data to achieve an acceptable level of statistical significance.

Experience with 100 consecutive central venous access arm ports placed by interventional radiologists

PURPOSE

This study reports the authors' experience with long-term follow-up of 100 consecutive peripherally inserted, subcutaneous arm ports for central venous access.

MATERIALS AND METHODS

One hundred patients with subcutaneous arm ports inserted by interventional radiologists were retrospectively studied. Data were collected from the patients' medical records and from telephone canvassing. Using each insertion period as an observation, the complication rates per 100 catheter days were determined with 95% confidence intervals (CIs).

RESULTS

One hundred subcutaneously implanted ports were placed in 98 patients; three devices (three patients) were lost to follow-up, leaving 97 devices in 95 patients. Total exposure time was 23,842 days (mean, 246 days; range, 2-865 days). Seven infectious and two noninfectious complications occurred with seven (7.2%) devices in six patients (6.3%), yielding 0.038 complications per 100 catheter days at risk (95% CI; 0.011-0.069) and 0.029 infections per 100 catheter days at risk (95% CI; 0.008-0.058). A successful clinical outcome was defined as a functional port at removal, time of death, or at study closure (minimum of 6 months of follow-up), which was not removed because of a complication. This successful outcome was achieved in 91 ports (93.8%). Procedural-related complications, defined as those occurring up to 30 days after insertion, occurred in only one port (thrombophlebitis and catheter tip infection-day 9). All other patients received several months of service from their port. Fifteen devices were placed in 13 patients with HIV for 3,486 days, with a total complication rate of 0.11 per 100 catheter days (95% CI; 0.0-0.28), all of which were infections. Devices in HIV-positive patients were associated with higher total complication (20% vs 4.9%) and infection rates (20% vs 3.7%) than devices in patients without HIV infection. This gives a relative risk 8.17 x (P = .04) greater for infectious complications for devices placed in HIV-infected individuals.

CONCLUSIONS

Subcutaneous arm ports placed by interventional radiologists are effective for central venous access with excellent functionality (93.8% achieved a successful long-term outcome) and a very low procedural complication rate. Although infections were more frequent in HIV-infected individuals, these devices are associated with a very low incidence of both immediate and long-term complications, including infection, for all patients.