Successful use of central venous catheter as permanent hemodialysis access: 84-month follow-Up in lucania

An Improvised Cost-Effective Repair Technique for Management of Broken Luer Connections of Tunneled Dialysis Catheter and Salvage Existing Catheter

Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.

Central Venous Catheters in Hemodialysis: An Actual Conundrum without Solutions

Vascular access maintenance is a major problem for adequate care of End Stage Renal Disease. An ideal access delivers an adequate flow rate for the HD prescription, remains usable for an indefinitely long period of time, and has a low complication rate. The native arteriovenous fistula (AVF) remains the best access, but this option may be impraticable in many conditions. This paper describes why to use CVC, where CVC can be positioned and how CVC infections can be prevented. Also today, vascular access in hemodialysis remains the conundrum without solution, but it is often necessary and remains the only possible venous access in a particular category of patients.

Unusual Long-Term Complication of Permanent Central venous Catheter for Hemodialysis. Review of the Literature on Mechanical Complications

The ideal dialysis access ensures adequate blood flow for dialysis, has a long life, and is associated with a low complication rate. Although no current type of access fulfills all these criteria, the native arteriovenous fistula (AVF) is close to doing so. Unfortunately, various kinds of vascular access (VA) are becoming more and more necessary to enable hemodialysis (HD). The central venous catheter (CVC), which is associated with higher morbidity and mortality, could be the only viable option to maintain permanent VA. We report an unusual complication in a patient, a 74-year-old female, who had been undergoing HD via a CVC for 14 yrs. A polyurethane CVC with a double lumen was inserted into the right internal jugular vein because an AVF was not feasible, and a polytetrafluoroethylene (PTFE) prosthesis was obstructed. In 2003, the CVC was removed due to stenosis and occlusion of the superior vena cava. A new CVC, also made of polyurethane and with a double lumen, was inserted into the left femoral vein. In January 2005, the patient reported a small rupture of about 3–4 mm located under the cuff of the CVC. For this reason, the left femoral vein had to be used, replacing the Optiflow one with a 40-cm long Tesio CVC, and the second catheter was inserted into the right femoral artery by conventional surgery. After 10 months, the patient returned once more, after the CVC in the left femoral vein had been removed because of malfunction and that the attempts to cannulate the same vein again had failed. Currently, two 70-cm long Tesio catheters implanted in the right femoral vein (whose tips almost reach the diaphragm) are used for dialysis sessions. The number of CVC implants has progressively increased amongst HD patients who are elderly, diabetic or who have been on long-term HD. The patient described in this case report is currently using a 70-cm long double Tesio catheter (single Tesio CVC in SPI silicon) placed in the right femoral vein. She has resumed therapy with dicumarol anticoagulants, maintaining INR within the 2.5–3.5 range. In conclusion, both the increase in the use of venous catheters for HD and in the survival of dialysis patients contribute towards the observation of rare complications associated with CVC use.

Incidence of catheter-related complications in patients with central venous or hemodialysis catheters: a health care claims database analysis

Background

Central venous catheter (CVC) and hemodialysis (HD) catheter usage are associated with complications that occur during catheter insertion, dwell period, and removal. This study aims to identify and describe the incidence rates of catheter-related complications in a large patient population in a United States-based health care claims database after CVC or HD catheter placement.

Methods

Patients in the i3 InVision DataMart^® health care claims database with at least 1 CVC or HD catheter insertion claim were categorized into CVC or HD cohorts using diagnostic and procedural codes from the US Renal Data System, American College of Surgeons, and American Medical Association’s Physician Performance Measures. Catheter-related complications were identified using published diagnostic and procedural codes. Incidence rates (IRs)/1000 catheter-days were calculated for complications including catheter-related bloodstream infections (CRBSIs), thrombosis, embolism, intracranial hemorrhage (ICH), major bleeding (MB), and mechanical catheter–related complications (MCRCs).

Results

Thirty percent of the CVC cohort and 54% of the HD cohort had catheter placements lasting <90 days. Catheter-related complications occurred most often during the first 90 days of catheter placement. IRs were highest for CRBSIs in both cohorts (4.0 [95% CI, 3.7-4.3] and 5.1 [95% CI, 4.7-5.6], respectively). Other IRs in CVC and HD cohorts, respectively, were thrombosis, 1.3 and 0.8; MCRCs, 0.6 and 0.7; embolism, 0.4 and 0.5; MB, 0.1 and 0.3; and ICH, 0.1 in both cohorts. Patients with cancer at baseline had significantly higher IRs for CRBSIs and thrombosis than non-cancer patients. CVC or HD catheter–related complications were most frequently seen in patients 16 years or younger.

Conclusions

The risk of catheter-related complications is highest during the first 90 days of catheter placement in patients with CVCs and HD catheters and in younger patients (≤16 years of age) with HD catheters. Data provided in this study can be applied toward improving patient care.

Repair of Damaged Connectors of Tunneled Cuffed Catheters with a Two-Piece Adaptor for Peritoneal Dialysis

Purpose

Although catheter use exposes the patient to several complications, tunneled cuffed catheters are widely applied for temporary or long-term vascular access. The aim of the study was to establish the rate of tunneled dialysis catheter damage and report our experience with breakage repair.

Methods

All 363 cuffed tunneled hemodialysis catheters inserted into 309 patients from May 2000 to December 2008 were followed up. When connector damage was encountered, repair with a two-piece adaptor for peritoneal dialysis was attempted.

Results

Mechanical breakage occurred in 33 (9.1%) of catheters with an incidence of 0.36/1000 catheter-days. The most frequent was connector damage, found in 25 cases (67.6%). Catheter repair using a peritoneal dialysis Luer adaptor was performed with good early and long-term outcome.

Conclusions

Tunneled catheter breakage is a relatively rare complication. Catheter repair using the adaptor for peritoneal dialysis is easy to perform, safe, and cost-effective.

Factors affecting long-term survival of tunnelled haemodialysis catheters--a prospective audit of 812 tunnelled catheters

BACKGROUND

In 2001, in the US, 23% of haemodialysis patients were dialysing through tunnelled venous catheters (TVCs), and in the UK (2006) there were 28% of prevalent patients using catheters. It is unlikely that numbers will significantly decrease. We present the results of a prospective audit of the survival of 812 TVCs placed in 492 patients at our institution over a 6-year period (comprising 212 048 patient catheter days or 7068 patient catheter months of follow-up). Four different designs of catheter were studied: Split-Cath III (Medcomp), HemoSplit (Bard), Tesio twin catheter (Medcomp) and Permcath (Quinton).

METHODS

We used Kaplan-Meier survival analysis with log-rank test, to compare the effect of different parameters on catheter survival. The relative importance of significant parameters was determined by Cox regression analysis.

RESULTS

We have shown a significant catheter survival advantage of first catheters over second and subsequent insertions, of right internal jugular site over left internal jugular and thereafter over femoral site, and of non-diabetic over diabetic patients. Patient age, sex and operator (physician in ward-based procedure room under ultrasound control or surgeon in operating theatre under fluoroscopic assistance) did not significantly affect survival. The Permcath design demonstrated inferior survival in all but first catheter insertions in catheter-naïve patients. The HemoSplit and Tesio twin catheter designs demonstrated best survival overall. By Cox proportional hazard modelling the design and the position of the TVC seemed to be the most significant independent survival factors.

CONCLUSIONS

Clinicians need accurate data regarding catheter survival, mode of insertion and design, to inform practice.

Septicemia, access and cardiovascular disease in dialysis patients: the USRDS Wave 2 study

BACKGROUND

Microinflammation is linked to cardiovascular disease, and is highly prevalent in dialysis patients. It is logical to postulate that septicemia, a common macroinflammatory occurrence in dialysis patients, contributes to their large burden of cardiovascular disease.

METHODS

The Dialysis Morbidity and Mortality Wave 2 was a randomly selected prospective cohort of incident dialysis patients. Admission claims data were used to define and calculate rates of septicemia or bacteremia and cardiovascular events in those with Medicare as the primary payer. Utilizing Cox proportional hazard models we determined the association between baseline access and the development of bacteremia or sepsis, and also the association between bacteremia or sepsis episodes and subsequent cardiovascular events.

RESULTS

The 2358 (59%) patients with Medicare as primary payer were older and more likely to have heart failure than those with other payers, but had similar comorbidity-adjusted mortality hazards. Rates of first septicemia, bacteremia, or either condition, were 7.0, 5.9 and 10.4 events per 100-patient years, respectively. Cox regression identified initial dialysis access as the main antecedent of septicemia or bacteremia. Hazards ratios for hemodialysis with permanent catheters, temporary catheters, and grafts were 1.95 (95% CI 1.47-2.57), 1.76 (95% CI 1.29-2.41), and 1.05 (95% CI 0.82-1.35), respectively, while that for peritoneal dialysis was 0.96 (95% CI 0.75-1.23) (reference arteriovenous fistula). After adjustment for baseline factors, septicemia or bacteremia, as a time-dependent covariate, was associated with subsequent death [hazards ratio (HR) 2.33, 95% CI 1.38-2.28], myocardial infarction (HR 1.78, 95% CI 1.38-2.28), heart failure (HR 1.64, 95% CI 1.39-1.95), peripheral vascular disease (HR 1.64, 95% CI 1.34-2.0), and stroke (HR 2.04, 95% CI 1.27-3.28).

CONCLUSION

Septicemia appears to be an important, potentially preventable, cardiovascular risk factor in dialysis patients.

Unusual complication of central venous catheter in hemodialysis

A case of a partial rupture of a cuffed central venous catheter (CVC) implanted in the femoral vein with the purpose of being used for chronic hemodialysis is described in a 74-year-old female patient. Of relevance is that the CVC described was from the same manufacturer as the previous one that had lasted 12 years.

Survival and Complications of Indwelling Venous Catheters for Permanent Use in Hemodialysis Patients

BACKGROUND

The risk factors influencing the survival of indwelling central vein catheters and their potential complications have not been assessed in depth and on a large scale.

METHODS

We investigated the general characteristics of 245 single lumen cuffed tunneled catheters and analyzed their survival by Kaplan-Meier and Cox regression analysis. Risk factors for bacteremia and thrombosis were assessed by logistic regression analysis.

RESULTS

The incidence of exit-site infection, tunnel infection, bacteremia and thrombotic events was 0.35, 0.25, 1.71, and 1.94/1000 catheter days, respectively. The mean survival time per catheter was 276 days. After censoring for non catheter-related events leading to the removal of the catheter (n = 245 with 120 catheters censored and 125 events), the mean survival time of the catheter appeared to be 615 +/- 67 days (95% CI of 483-747) and the median survival time 310 +/- 50 days (95% CI of 212-408). The localization of the catheter into the right internal jugular vein results in significantly better survival as compared with other insertion sites both in Kaplan-Meier (mean survival of 650 days compared to a mean survival of 519 days, P value < 0.009) and in Cox regression analysis (relative risk of 0.537, P value < 0.001). Localization of the catheter into the right internal jugular vein seemed to increase the risk for bacteremia (relative risk of 1.798, P value of 0.063). The use of anticoagulant agents was not protective for thrombosis, although this might be due to lack of power (relative risk of 0.626, P value of 0.141).

CONCLUSION

We provide evidence of a mean survival in long-term hemodialysis catheter close to 2 years with an acceptable complication rate. If a long-term hemodialysis catheter is required, it is best placed in the right internal jugular vein.

Hemodialysis central venous catheter tip fracture with embolization into the pulmonary artery

We describe the first reported case of spontaneous hemodialysis catheter fracture and embolization. We also include a summary of similar cases not previously reported in the literature that appear in the Food and Drug Administration records as medical equipment malfunctions. Our patient presented with a cough and was initially treated for presumptive pneumonia. A chest radiograph indicated that the tip of the catheter had fractured and migrated into a distal branch of the pulmonary artery. The catheter was replaced, but the tip could not be retrieved because of its peripheral location. Possible causes and consequences of this underreported complication are discussed.