This document discusses vascular access for hemodialysis patients. It notes that adequate vascular access is important for dialysis efficiency and patient outcomes. Catheters should only be used short-term for acute dialysis or in hospitalized patients, while permanent access like arteriovenous fistulas are preferred. The document provides guidelines on catheter placement, maintenance, complications, and infection risks. It emphasizes that catheters are located in the heart and proper placement and care is important to minimize risks.

1. Dr. Hamed Ezzat El-Eraky
Nephrology Specialist – MIH
CME Director Of Dakahlia Medical Syndicate

3.  Without an adequate vascular access, HD efficiency
is reduced, which results in increased morbidity
and mortality
 Dialysis access is most common vascular surgery
procedure
 Access-related problems are responsible for 50% of
the hospitalizations of HD patients

4.  Short-term catheters should be used for acute dialysis and
for a limited duration in hospitalized patients.
 Non cuffed femoral catheters should be used in bed-bound
patients only.
 Long-term catheters should be used in conjunction with a
plan for permanent access. Catheters capable of rapid flow
rates are preferred.
 Catheter choice should be based on local experience, goals
for use, and cost.
 Long-term catheters should not be placed on the same side
as a maturing AV access, if possible (RT sided for RT handed).

5.  Patients with advanced CKD disease stage
4 CKD (GFR <30), or based on progression
of renal disease) who have elected
hemodialysis as their choice of renal
replacement therapy should be referred
to an access surgeon in order to evaluate
and plan construction of AV access
 If a prosthetic access is to be constructed,
this should be delayed until just before
the need for dialysis.

6.  Able to deliver high flow (>400 ml/min)
reliably
 Easy to insert and remove
 Comfortable and acceptable by patient
 Durable
 Free of infection
 Does not cause venous thrombosis or stenosis
 Free of fibrin sheath
 Inexpensive

9.  Universally applicable
 Multiple access sites
 No maturation time can be used
immediately
 No direct hemodynamic effects on the
circulation
 Allows time for maturation of native AVF
 Thrombotic complications simple to
correct

10.  The shortest long term patency rates of all
permanent access procedures
 Lower blood flow rates obligating longer
dialysis times
 External device
 Morbidity
 Insertion complications
 Thrombosis
 Infection
 > 3 months -morbidity excessive
 Risk of central vein stenosis or occlusion
 •Limits chronic access options

11.  These catheters are suitable for
immediate use and should not be
inserted before needed .
 The subclavian insertion site should not
be used in a patient who may need
permanent vascular access .

13.  2nd left internal jugular
-Higher incidence of flow problems
-Higher risk of stenosis
 3rd inferior vena cava
-Femoral –best alternative
-Translumbar
 Subclavian
-High risk of stenosis
-Acceptable only if no further arm access
planned

14.  Chest x-ray is mandatory after subclavian
and internal jugular insertion prior to
catheter use to confirm catheter tip position
 Femoral catheters should be at least 19-cm
long to minimize recirculation.
 Noncuffed femoral catheters should not be
left in place longer than 5 days and should be
left in place only in bed-bound patients.

17.  Place in right internal jugular
 Use ultrasound for cannulation
 Use fluroscopy for placement
 Place tip well within atrium

18.  The primary determinants of catheter blood flow
(1) are catheter (inner) size dimensions
(2) Tip placement

19.  Blind placement of a relatively stiff device
through the right internal jugular vein has
created the necessity of using a short
catheter to avoid atrial perforation.
 The tip of these catheters comes to be
located in the proximal part of superior
vena cava, and this tip location in
smaller blood vessels does not allow for
as great a blood flow as catheters
located in the distal superior vena cava
and the right atrium

20.  NKF-DOQI guidelines recommend placement
of a catheter with the tip adjusted to the
level of the caval atrial junction or into the
right atrium to ensure optimal blood flow.
 For untunneled catheters, the catheter
length and diameter should be adjusted to
the size of the patient.

21. In general, in patients with a body
surface area of 1.5 to 2.0 m2
-A 12-15 cm catheter should be
selected for the jugular vein in the low
right position and
-A 15-19 cm catheter for the left
jugular vein.
-A 14 to 17 cm catheter should be
used for the right subclavian vein and
A17 to 22 cm catheter for the left
subclavian vein.

22.  Subclavian catheters are more comfortable for
the patient and provide reliable blood flow if
placed in the right atrial cavity( SVC ostum)
 It was shown that in the US 46% of all temporary
catheters used in patients starting hemodialysis
treatment were inserted into the subclavian
vein.(may be lower infection)
(against DOQI guidelines)

24. Recirculation:
With the use of catheters, recirculation
is dependent upon two factors:
 the location of the catheter tip
 the status of the patient's central
circulation.

26.  Early – malposition
 Late - thrombosis

28.  Local infection
- Exit site infection
- Tunnel infection
 Systemic infection
- Catheter related bacteremia( CRB )

29.  Frequent – 20 to 30%
- Septic arthritis
- Endocarditis
- Epidural abscess
- Death – 6 to 18%

35.  Nonfunctional non cuffed catheters can be
exchanged over a guide wire as long as the
exit site and tunnel are not infected.
 Exit site, tunnel tract, or systemic
infections should prompt the removal of non
cuffed catheters.

36.  The Problem is that
we forget that these
catheters are in the
heart exactly like our
patients who think
that these catheter
are in the neck or
chest .

37.  After decades of success in dialysis research
and treatment, prompt availability of a well-
functioning vascular access for dialysis
remains a disturbing problem.
(Ravani P et al. Am J Kidney Dis 2002; 40:1264-76)