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Successful use of cuffed central venous hemodialysis catheters inserted percutaneously
R D Swartz1, J M Messana, C J Boyer
1Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0364.
Insights
Central venous catheters are crucial for hemodialysis access when permanent options aren't feasible. Catheter failure rates were 36%, split between malfunction and infection, with subclavian vein placement showing higher mechanical failure risks.
Area of Science:
- Nephrology
- Vascular Surgery
- Infectious Diseases
Background:
- End-stage renal disease necessitates hemodialysis access.
- Permanent access (fistulae, grafts) is preferred, but central venous catheters (CVCs) are vital when permanent access is not immediately feasible.
- CVCs provide temporary or bridge hemodialysis access.
Purpose of the Study:
- To report the prospective experience with CVC placement for hemodialysis access.
- To evaluate early complications, catheter function, survival rates, and failure modes.
- To compare outcomes based on placement technique and vein selection.
Main Methods:
- Prospective study of 118 CVCs over 3.5 years.
- Catheters placed via percutaneous (79%) or operative (21%) techniques.
- Placement in subclavian (65%), internal jugular (31%), or femoral (4%) veins.
Main Results:
- Early complications were infrequent.
- Catheter function averaged 3 months; actuarial survival for percutaneous CVCs was ~60% at 6 months and ~30% at 12 months.
- Catheter failure occurred in 36% of cases, equally split between malfunction (e.g., thrombosis, kinking) and infection with septicemia. Internal jugular placement showed less mechanical failure than subclavian. Infection rate was ~1 per patient-year, with Staphylococcus aureus being common.
Conclusions:
- CVCs are a necessary option for hemodialysis access.
- Catheter failure due to malfunction or infection remains a significant concern.
- Internal jugular vein placement may offer advantages in reducing mechanical complications compared to subclavian vein placement.
Abstract:
Although endogenous fistulae and grafts are preferred for permanent hemodialysis access, central venous catheters are often required for varying intervals when creating permanent access is not feasible. The prospective experience with 118 catheters in over a 3.5-yr period is reported; 93 (79%) were placed by percutaneous techniques, and 25 (21%) were placed by operative techniques. Seventy seven catheters (65%) were placed in the subclavian vein, 36 (31%) were placed in the internal jugular vein (usually right side), and 5 (4%) were placed in the femoral vein. Early postplacement complications were infrequent. Catheter function at last local follow-up ranged from several days to nearly 2 yr, averaging approximately 3 mo, even though many patients returned to their referring centers with a functioning catheter after only a short follow-up. Actuarial survival for percutaneously placed catheters was approximately 60% at 6 mo and 30% at 12 mo. Catheter failure occurred in 36% of cases, equally divided between malfunction (thrombosis refractory to fibrinolysis, extrusion, kinking, or related event) and infection with septicemia requiring removal. Such failure was not more frequent after percutaneous placement than after operative placement. Failure due to mechanical malfunction, but not that due to infection, tended to be less frequent among catheters placed in the internal jugular vein than among catheters placed in the subclavian vein. Finally, infection with septicemia involved 22% of all catheters and occurred at an average cumulated rate of approximately one infection per patient-year. Coagulase-positive staphylococcus was the most common organism isolated.(ABSTRACT TRUNCATED AT 250 WORDS)