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Microsoft PowerPoint - CVC toolkit Titleslide 1

  1. 1. Tunneled Hemodialysis Catheters: Placement and complications Arif Asif, M.D M.D. Director, Interventional Nephrology Associate Professor of Medicine University of Miami, FL
  2. 2. Tunneled Hemodialysis Catheters: Placement and Complications
  3. 3. Despite the highest risk of mortality, a significant number of chronic hemodialysis patients continue to receive dialysis using a tunneled hemodialysis catheters. 21% Chronic caths
  4. 4. 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
  5. 5. Problems Thrombosis, infection, stenosis The access does not last as long as a fistula or a graft Lower blood flow rates
  6. 6. 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.
  7. 7. Optimal Catheter design • Use largest diameter available • Use shortest length compatible with proper placement
  8. 8. 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.
  9. 9. A micropuncture needle could be used to enter the internal jugular vein. Courtesy of Tony Samaha
  10. 10. Local anesthesia is infiltrated and a tunnel created for the catheter Courtesy of Tony Samaha
  11. 11. Catheter insertion can be accomplished with or without a peel-away sheath. Courtesy of Tony Samaha
  12. 12. Optimal site • Right internal jugular vein
  13. 13. Other Sites • Femoral • Left internal jugular • Trans-lumbar (IVC) • Subclavian • High risk for stenosis • Acceptable only if no further arm access planned
  14. 14. Cannulation of the Vein • Ultrasound guided cannulation should be mandatory
  15. 15. Location of Internal Jugular Slide form Gerald Beathard
  16. 16. Slide form Gerald Beathard
  17. 17. Tip Position • Fluoroscopy is mandatory for tip position
  18. 18. Placement without fluoroscopy Slide form Gerald Beathard
  19. 19. Optimum Catheter Tip Position:
  20. 20. Optimal tunneled HD catheter • Place in right internal jugular • Use ultrasound for cannulation • Use fluoroscopy for placement • Place tip well within atrium
  21. 21. Complicating Issues
  22. 22. 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.
  23. 23. Impact of blood flow on Dialysis Dose Dose Decay Progression Patient health; QOL Kt /V M or ⇒ ta M l it or y bi d ity ;Q & O L Increasing BFR 300 mL/min Decreasing BFR QB 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.
  24. 24. 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.
  25. 25. 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. Prabhu 1997; Atkinson 1990; Paulsen 1993; Crowther 2000 2. Twardowski 1998; Dowling 2000; Spry 2001; Eyrich 2002
  26. 26. 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, 2001 Adapted from Beathard G., Seminars in Dial 14:441-45, 2001
  27. 27. Fibroepithelial Sheath • Fibroepithelial sheath is major problem • Catheter exchange is solution • tPA is of short term value only Photo Courtesy: G. Beathard
  28. 28. Treatment of Fibrin Sheath • Sheath mostly associated with venous stenosis • Treatment of stenosis will obliterate sheath
  29. 29. Fibroepithelial Sheath: Pre and post treatment Left IJ catheter Sheath Right atrium
  30. 30. Catheters can cause central venous stenosis
  31. 31. BRCHPH SVC BRCHPH SVC Complete occlusion of superior vena cava Right Atrium
  32. 32. Balloon angioplasty can be successful in selected cases
  33. 33. Post angioplasty SVC BRCHPH BRCHPH SVC RA
  34. 34. Pre-angioplasty of central venous occlusion Post-angioplasty of central venous occlusion
  35. 35. Catheter can be accidentally dislodged
  36. 36. In some cases of a new catheter could be inserted through the same exit site after sterile preparation Asif et al: Seminars in Dialysis 2007 Funaki et al: JVIR 1998
  37. 37. Wire insertion
  38. 38. Imager over the wire
  39. 39. Angiography is then performed to confirm central veins and the atrium
  40. 40. A new catheter is then fed onto the Wire and into the atrium
  41. 41. New tunnel creation is usually performed for the following conditions • Badly placed catheter with a kink • Infected exit site
  42. 42. Kink Infected exit site
  43. 43. Site of new tunnel drawn
  44. 44. New tunnel created under Local anethesia
  45. 45. Wire insertion through the new tunnel
  46. 46. Catheter insertion through the new tunnel
  47. 47. Kink New Tunnel Kink
  48. 48. Catheter can cause exit site infection, endocarditis and discitis Image from Tony Samaha
  49. 49. 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