Tunneled Hemodialysis

Catheters:

Placement and complications

Arif Asif, M.DDirector, Interventional Nephrology

Associate Professor of Medicine

University of Miami, FL

Tunneled Hemodialysis

Catheters:

Placement and complications

Asif, M.D.Director, Interventional Nephrology

Associate Professor of Medicine

University of Miami, FL

Tunneled Hemodialysis Catheters: Placement and Complications

21% Chronic caths

Despite the highest risk of mortality, a significant number of chronic hemodialysis patients continue to receive dialysis

using a tunneled hemodialysis catheters.

While there are many disadvantages, there are some advantages of tunneled hemodialysis catheters

• Relative simple insertion procedure• Can be insert into multiple sites even in

patients with exhausted upper and lower extremity veins

• Compared to an arteriovenous fistula or a graft, no maturation time or prolonged healing period is not required

• Some of the complications could be handled relatively easily

Problems

Thrombosis, infection, stenosis

The access does not last as long as a fistula or a graft

Lower blood flow rates

Catheter design• Diameter is major factor

– 19 % diameter increase - flow increases 2X– 50 % diameter increase - flow increases 5X– Increasing from 2.0mm to 2.1mm increases flow

21%

• Catheter length is less important– l9% increase in diameter will compensate for doubling of length

Slide from Gerald Beathard, M.D.

Optimal Catheter design

• Use largest diameter available

• Use shortest length compatible with proper placement

Tunneled Catheter Placement:While anatomical landmarks are important to identify internal jugular

vein, ultrasound should be strongly considered to identify the vein and reduce complications. In fact, ultrasound is considered mandatory by

many leaders in catheter insertion.

Courtesy of Tony Samaha, M.D.

Courtesy of Tony Samaha

A micropuncture needle could be used to enter the internal jugular vein.

Courtesy of Tony Samaha

Local anesthesia is infiltrated and a tunnel created for the catheter

Courtesy of Tony Samaha

Catheter insertion can be accomplished with or without a peel-away sheath.

Optimal site

• Right internal jugular vein

Other Sites• Femoral • Left internal jugular• Trans-lumbar (IVC)• Subclavian

• High risk for stenosis • Acceptable only if no further arm access

planned

Cannulation of the Vein• Ultrasound guided cannulation should be

mandatory

Location of Internal Jugular

Slide form Gerald Beathard

Slide form Gerald Beathard

Tip Position

• Fluoroscopy is mandatory for tip position

Placement without fluoroscopy

Slide form Gerald Beathard

Optimum Catheter Tip Position:

Optimal tunneled HD catheter• Place in right internal

jugular• Use ultrasound for

cannulation• Use fluoroscopy for

placement• Place tip well within

atrium

Complicating Issues

Catheter Dysfunction

• Thrombosis and sheath formation are the most common cause of catheter dysfunction and access loss1,2

– Occurs in 30% to 40% of patients undergoing hemodialysis3,4

1. Blankestijn. In Hemodialysis Vascular Access: Practice and Problems. 2001; 2. NKF. Am J Kidney Dis. 2001;37(suppl 1); 3. Little. Am J Kidney Dis. 2002; 4. Moss. Am J Kidney Dis. 1988; 5. Feldman. J Am Soc Nephrol. 1996; 6. Feldman. Kidney Int. 1993.

Impact of blood flow on Dialysis Dose

Held et al. Kidney Int. 1996;50:550-556; Hakim et al. Am J Kidney Dis. 1994;23:661-669; Owen. JAMA. 1998;280:1764-1768.

Patie

nt h

ealth

; QO

L

300 mL/minQB

Increasing BFRIncreasing BFR Decreasing BFRDecreasing BFR

Kt/V ⇒

Morbidity &

Mortality ; QOLDose Decay Progression

Inadequate Dialysis Dosing Increases HD Treatment Time and Costs

• Every 0.1 in Kt/V is independently associated with– 11% more hospitalizations

– 12% more hospital days

– $940 increase in Medicare inpatient expenditures

United States Renal Data System, 2003; Sehgal et al. Am J Kidney Dis. 2001;37(6):1223-1231.

Thrombolytics have been used to treat catheter thrombosis

• High level of safety and efficacy– Efficacious as lytic to restore flow1

– Efficacious to maintain blood flow2

• Lower incidence of complications

• Cost-effective

1.1. PrabhuPrabhu 1997; Atkinson 1990; Paulsen 1993; 1997; Atkinson 1990; Paulsen 1993; CrowtherCrowther 200020002.2. Twardowski 1998; Dowling 2000; Spry 2001; Twardowski 1998; Dowling 2000; Spry 2001; EyrichEyrich 20022002

rTPA protocol for intraluminal thrombus

• 2mg tPA mixed with NS to total volume of catheter lumen

• Fill lumens with mixture to “fill volume”and wait 15min

• Inject 0.3ml of saline to move active enzyme toward the tip of catheter every 5 min X 3

• Aspirate from catheter• If aspirates easily, do forceful flush• If cannot aspirate easily, may repeat

procedure• If still unsuccessful, probably dealing

with fibroepithelial sheth

Adapted from Beathard G., Seminars in Dial 14:441-45, 2001Adapted from Beathard G., Seminars in Dial 14:441-45, 2001

Fibroepithelial Sheath

• Fibroepithelial sheath is major problem

• Catheter exchange is solution

• tPA is of short term value only Photo Courtesy: G. Beathard

Treatment of Fibrin Sheath

• Sheath mostly associated with venous stenosis

• Treatment of stenosis will obliterate sheath

Fibroepithelial Sheath:Pre and post treatment

Sheath

Left IJ catheter

Right atrium

Catheters can cause central venous stenosis

SVC

Right Atrium

BRCHPH

BRCHPH

SVCComplete occlusion of superior vena cava

Balloon angioplasty can be successful in selected cases

SVC

RA

BRCHPH

BRCHPH

SVC

Post angioplasty

Pre-angioplasty of central venous occlusion

Post-angioplasty of central venous occlusion

Catheter can be accidentally dislodged

In some cases of a new catheter could be inserted through the same exit site after

sterile preparation

Asif et al: Seminars in Dialysis 2007Funaki et al: JVIR 1998

Wire insertion

Imager over the wire

Angiography is then performed to confirm central veins and the atrium

A new catheter is then fed onto theWire and into the atrium

New tunnel creation is usually performed for the following

conditions• Badly placed catheter with a kink• Infected exit site

Kink

Infected exit site

Site of new tunnel drawn

New tunnel created underLocal anethesia

Wire insertion throughthe new tunnel

Catheter insertionthrough the new tunnel

Kink New Tunnel

Kink

Catheter can cause exit site infection, endocarditis and discitis

Image from Tony Samaha

Conclusions• At present tunneled dialysis catheters play a major

role in providing dialysis therapy• Right internal jugular vein continues to be the

preferred site• Ultrasound and fluoroscopy are mandatory• Thrombosis, stenosis and infection remain the most

important problems associated with catheters• Due to these problems, catheter continue to be

associated with the highest risk of mortality compared to fistulae and grafts in hemodialysis patients