Inserting tunnelled hemodialysis cathetersusing elective guidewire exchange from
nontunnelled catheters: Is there a greaterrisk of infection when compared with
new-site replacement?
Jonathan CASEY, Jonathan DAVIES, Amanda BALSHAW-GREER, Nichola TAYLOR,
Alexander V. CROWE, Peter MCCLELLAND
Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, Wirral, Merseyside, UK
AbstractThe objective is to evaluate bacteremia outcomes and survival rates when using guidewire exchange
to place tunnelled hemodialysis catheter (THDC) compared with a new-site replacement. Retrospec-
tively, all patients were identified who received a THDC between January 1, 2000 and January 1,
2007. Any THDC having received antibiotic line locks or tunnel-to-tunnel exchange were excluded.
This left 408 THDC placed in 329 patients: 46 guidewire exchange, 362 new-site replacement.
Bacteremia rate from the new-site insertion group was 3.0 per 1000 catheter days, the guidewire
exchange group demonstrated a rate of 2.8 per 1000 catheter days. Local infection rates did not
differ between the groups at 1.2 per 1000 catheters days. The actuarial catheter survival rates using
Kaplan-Meier survival analysis demonstrated no difference between the 2 groups. The placing of
tunnelled cuffed hemodialysis catheters to replace temporary catheters using a guidewire exchange
did not contribute to further episodes of sepsis and has the advantage of preserving venous access
and minimizing invasive procedures for the patient.
Key words: Catheter, hemodialysis, bacteremia, tunnelled
INTRODUCTION
Tunnelled hemodialysis catheters (THDC) are becomingincreasingly commonplace when seeking access for
hemodialysis treatment. Their importance to the dialysis
patient cannot be overstated. Insertion, use, and care may
have an influence on the patient’s morbidity and mortality
particularly with respect to flow inadequacies and infec-
tion.1 Placement technique and management of further
complications are a prerequisite for an individual or
department seeking to place these lines. Temporary
uncuffed catheters are commonly used when immediate
hemodialysis access is required in an acute situation or
when primary access has failed. However, the longer
these lines are left in place, the higher the rate of infec-
tion.2 The National Kidney Foundation Kidney DiseaseOutcomes Quality Initiative3 (K/DOQI) guidelines rec-
ommend that internal jugular catheters should not be left
in place longer than 3 weeks. The K/DOQI guidelines also
indicate that the use of guidewire exchange is
a promising future therapy when dealing with infected
lines. It has the advantage of preserving the venous access
site and is only 1 procedure as opposed to 2, i.e., removal
and subsequent reinsertion. Robinson et al.4 furthercomments that using new-site insertion may compromise
future long-term upper extremity access and can lead to
Correspondence to: J. Casey, Department of Nephrology,Wirral University Teaching Hospital NHS Foundation, Ward31 (Nephrology), Upton, Wirral, Merseyside CH49 5PE, UK.E-mail: [email protected]
Hemodialysis International 2008; 12:52–54
r 2008 The Authors. Journal compilation r 2008 International Society for Hemodialysis52
central venous stenosis. This study asks whether replac-ing a noncuffed temporary line for a cuffed THDC using
guidewire exchange increases catheter associated bacter-
emia rates when compared with new-site insertion.
MATERIALS AND METHODS
A record of all cuffed and noncuffed lines placed within a
3-centered renal unit is recorded on a single SPSS (Sta-
tistical Package for the Social Sciences) package for rou-tine audit scrutiny. Retrospective data retrieval from
January 1, 2000 to January 1, 2007 revealed a total of
464 cuffed lines placed of which 418 were new-site and
56 THDC placed using guidewire exchange from a non-
cuffed catheter. The phenomenon of antibiotic lock to
combat bacteremia and salvage catheters has recently
gained popularity with reported success.5,6 To ensure va-
lidity those catheters that had received such a ‘‘line lock’’in both groups were excluded from the study, along with
tunnel-to-tunnel exchange, thus leaving 362 new-site in-
sertion and 46 guidewire exchange catheters for inclusion
(total 408). Any evidence of an exit site infection pre-
cluded the noncuffed catheter from guidewire exchange,
the noncuffed catheter was removed and a THDC
placed as a new-site insertion. Tunnelled hemodialysis
catheter-related infection was prospectively evaluated forguidewire exchange and new-site insertion and analyzed
relative to time to first infection and bacteremia rate per
1000 catheter days.
Bacteremia (for the purposes of this study) was diag-
nosed by positive blood cultures from either lumen of the
THDC and if possible, from a peripheral vein. Blood was
drawn on suspicion of a THDC systemic infection, i.e.,
pyrexia, rigors, elevated C-reactive protein, and raisedWCC. If cultures were negative, even with associated raised
markers, this did not qualify as a bacteremic episode.
Routine practice for new-site placement involves
THDC insertion under ultrasound guidance by an expe-
rienced operator using strict aseptic technique (Tesio
catheter-medComp, Harleysville, PA, U.S.A.). The cathe-
ter exit site for all lines was inspected at each dialysis
session and cleaned with a 10% alcoholic povidine-iodinesolution after each dialysis. Intradialytic anticoagulation
is standardized: 5000 U unfractionated heparin per mL to
the length of the THDC lumens.
RESULTS
The new-site insertion accounted for 88.7% (362) of the
total THDC placed leaving 11.3% (46) in the guidewire
exchange group. Technical success for guidewire ex-
change was 100%. Age distribution across the whole
group was: youngest=20 years old; oldest=94 years
old; mean age=56 years old. Gender distribution across
the whole cohort was 269 male (65.9%) and 139 female(34.1%). Within groups: guidewire exchange=30 male,
16 female; new-site=239 male, 123 female. Diabetic
patients accounted for 25.5% (104) of the total. Surpris-
ingly, only 8 from 46 of the guidewire exchange group
were diabetic (11%). The bacteremia rate of the THDC
for both groups was analyzed as per 1000 catheter days
and total catheter survival using Kaplan-Meier survival
analysis (Figure 1).Systemic infection rates from the new-site insertion
group was 3.0 per 1000 catheter days; the guidewire ex-
change group demonstrated a rate of 2.8 per 1000 cath-
eter days. Local infection rates did not differ between the
groups at 1.2 per 1000 catheters days. The time to first
infection in the guidewire exchange group demonstrated
a mean of 72 days and median of 64 days, and in the
new-site replacement group, a mean of 124 days but amedian of 66 days.
Limitations
This is a retrospective study and there is a clear numerical
difference between groups with a smaller number of
catheters exchanged over guidewire. It would have been
useful to include as a separate group those THDC receiv-
ing antibiotic line locks to avoid bias; unfortunately, this
data was not available.
60483624120
time (months)
1.0
0.8
0.6
0.4
0.2
0.0
Cu
m c
ath
eter
su
rviv
al %
-Guidewire exchange (no.46)
-New-site insertions (no.358)
Figure 1 Kaplan-Meier survival curve comparing electiveguidewire exchange with new-site tunnelled hemodialysiscatheter insertions.
New-site replacement or guidewire exchange?
Hemodialysis International 2008; 12:52–54 53
DISCUSSION
While it is difficult to estimate, Combe et al.7,8 suggest
that between 20% and 60% of new end-stage renal dis-
ease patients start hemodialysis with a temporary cathe-
ter, and approximately 23% of patients receive long-term
treatment via a THDC. Thus, it is reasonable to postulatethat many patients are converted from temporary un-
cuffed catheters to THDCs.
Many studies have commented on the successful out-
come of guidewire exchange in combating catheter-asso-
ciated bacteremia for noncuffed catheters.4,9,10 However,
scant evidence exists for elective guidewire exchange
from temporary uncuffed catheters to THDC and their
relationship to bacteremia rates when compared with anew-site insertion. There are advantages to placing a line
in the same access site such as avoiding multiple vein
occlusions, and by using guidewire exchange you are
preserving other veins for future use. Another advantage
pointed out by Gersch11 is that the patient only under-
goes 1 invasive procedure instead of 2 or more proce-
dures with the removal and delayed reinsertion strategy.
This study demonstrated similar rates of bacteremia be-tween guidewire exchanged THDC and THDC placed to a
new site. With similar survival rates for the newly inserted
catheter observed, the use of this strategy does not seem
to increase the incidence of infectious complications,
although it is interesting to note that the Vascular Access
Society guidelines12 recommend against the use of
guidewire exchange citing the possibility of ‘‘delayed sep-
tic metastasis or endocarditis.’’ Clearly more confirmationis required by prospective controlled trials, and while
all THDC continue to carry a risk of infection, perhaps
more focus should be on early referral to vascular
surgery.
CONCLUSION
Guidewire exchange caused no increase in bacteremia
episodes and provided similar longevity to new-siteplacements. The procedure is safe and easy to perform
and has the advantage of preserving venous access and
minimizing invasive procedures for the patient.
Manuscript received May 2007; revised June 2007.
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Casey et al.
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