This document provides information on hemodialysis catheters. It begins by describing the characteristics of an ideal catheter and then discusses permacath catheters, which are tunnelled central venous catheters often used for hemodialysis. The document outlines the advantages and disadvantages of catheters compared to arteriovenous fistulas. It also discusses various complications associated with catheters including thrombosis, fibrin sheath formation, infection, and vascular thrombosis. The document provides details on preventing, diagnosing, and treating these complications.

1. Dr. Sameh Attia Ali
Vascular and Transplant surgeon
MBBCh,MSc, MRCS (A),
Egyptian board of vascular surgery

2. INTRODUCTION
• Permacath (or permcath)
are a type of tunnelled
central venous catheter. It
is a split catheter - this
means that the two
lumens have unequal
lengths with one opening
a few centimetres distal to
the other giving a
staggered or step tip
appearance. It is often
used for hemodialysis.
1. Funaki B. Central venous access: a primer for
the diagnostic radiologist. AJR Am J
Roentgenol. 2002;179 (2): 309-18.

3. Characteristics of an Ideal Catheter
• Easy to insert and remove
• Inexpensive
• Free of infection
• Free of fibrin sheath (“invisible to body”)
• Does not cause venous thrombosis or stenosis
• Delivers high flow (>400ml/min) reliably
• Durable
• Comfortable and acceptable to the patient
Scott O. Trerotola, MD. Hemodialysis Catheter Placement and
Management1. Radiology 2000; 215:651–658

4. Advantage of the Catheters
 Universal Application.
 No maturation time.
 No skin puncture.
 Short term Hemodynamic consequence.
 Lower initial cost.
 Provide time for fistula maturation.
National kidney Foundation KDOQI

5. Catheters Disadvantages
 Associated with higher mortality risk than fistula.
 Thrombosis.
 Infection.
 Central venous thrombosis.
 Discomfort.
 Cosmetic.
 Shorter expected using time.
 Lower Qb.
National kidney Foundation. KDOQI

6. Catheter Location

7. Catheter location
 Rt IJ.
 Lt IJ.
 Subclavian, not preferred due to the venous stenosis.
 Femoral.
 Translumber.
Ultrasound should be used in the placement of the
catheters.
Fluoroscopy is needed for cuffed tunneled catheters.
National Kidney foundation KDOQI

8. Cuffed tunnelled catheter position
 Fluoroscopy guidance.
 Tips at junction of SVC with Rt. Atrium.
 Fixed suturing.
 Patient body habitus and position.
 Catheter migration.
Granata A, Figuera M, Basile A: Why doesn’t this hemodialysis catheter
work? Am J Kidney Dis 51: xlii–xliv, 2008.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology.ASN. 361-
375. 2009.

9. Tip of the Cuffed tunneled catheter

10. Length/French of Cuffed Catheters
Length:
 Rt IJC: 24, 28 cm
 Lt IJC: 28, 32 cm
 Rt femoral CATH: 36, 42 or 55 cm
 Lt femoral CATH: 55 cm
There are many variations according to patient size and CATH
availability.
French:
 • Rt IJV CATH (24 cm), French 14 or more
 • Other approaches at least 15 French

11. Complications

12. Early and immediate complications
 Arterial puncture.
 Venous perforation.
 Bleeding & hematoma.
 Pneumothorax.
 Hemothorax & Hemomediastinum.
 Air embolism.
 Arrhythmia and cardiac arrest.
 Cardiac chamber perforation.
 Pericardial Tamponade.
 Injury to adjacent structures: Nerves, Trachea,..etc.
Schwab SJ, Beathard G: The hemodialysis catheter conundrum: Hate living with them, but can’t live without
them. Kidney Int 56: 1–17, 1999.
Walsh SB, Ekbal N, Brookes J, Cunningham J: Tinnitus after hemodialysis catheter placement. Kidney Int 74: 688,
2008.
Muthuswamy P, Alausa M, Reilly M: The effusion that would not go away. N Engl J Med 345: 756–759, 2001.

13. Late Complications
 Thrombosis.
 Fibrin sheath formation.
 Infection.
 Vascular thrombosis and stricture.
 AV fistula.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-
375. 2009.

14. HD catheter Thrombosis

15. HD Catheter Thrombosis
 within or outside of the lumen.
 Prevention with Catheter Lock:
 Heparin 1000-10000/ml.
 Affect aPTT and cause HIT ( Thrombocytopenia).
 Bleeding.
 Allergic reaction.
Warkentin TE, Levine MN, Hirsh J, Horsewood P, Roberts RS, Gent M, Kelton JG:
Heparininduced thrombocytopenia in patients treated with low-molecular-weight
heparin or unfractionated heparin. N Engl J Med 332: 1330–1336, 1995.
Karaaslan H, Peyronnet P, Benevent D, Lagarde C, Rince M, Leroux- Robert C: Risk
of heparin lock-related bleeding when using indwelling venous catheter in
haemodialysis. Nephrol Dial Transplant 16: 2072–2074, 2001.

16. Citrate as Anticoagulation
 Trisodium Citrate: 4%.
 As effective as Heparin.
 Hypocalcemia.
 Lower catheter related bacteremia.
Weijmer MC, van den Dorpel MA, Van de Ven PJ, ter Wee PM, van Geelen JA,
Groeneveld JO, van Jaarsveld BC, Koopmans MG, le Poole CY, Schrander-Van der
Meer AM, Siegert CE, Stas KJ, CITRATE Study Group: Randomized clinical trial
comparison of trisodium citrate 30% and heparin as catheter-locking solution in
hemodialysis patients. J Am Soc Nephrol 16: 2769–2777, 2005.
Moran JE, Ash SR, ASDIN Clinical Practice Committee: Locking solutions for
hemodialysis catheters: Heparin and citrate—A position paper by ASDIN. Semin
Dial 21: 490–492, 2008.

17. Systemic Anticoagulation use for preventing
Thrombosis
 105 patient
 RCT.
 Warfarin versus Placebo.
 No difference in thrombosis free survival.
Mokrzycki MH, Jean-Jerome K, Rush H, Zdunek MP, Rosenberg SO: A randomized
trial of minidose warfarin for the prevention of late malfunction in tunneled, cuffed
hemodialysis catheters. Kidney Int 59: 1935–1942, 2001

18. Systemic Anticoagulation use for preventing
Thrombosis
Comparing ASA, Warfarin and placebo:
120 days Cather patency:
 91 % with ASA.
 73 % with Warfarin.
 29% with placebo.
Bennett WM: Should dialysis patients ever receive warfarin and for
what reasons? Clin J Am Soc Nephrol 1: 1357–1359, 2006.

19. Management of Catheter
Thrombosis Forceful Flushing.
 Urokinase or tPA.
Clase CM, Crowther MA, Ingram AJ, Cina` CS: Thrombolysis for restoration of
patency to haemodialysis central venous catheters: A systematic review. J Thromb
Thrombolysis 11: 127, 2001.
Shavit L, Lifschitz M, Plaksin J, Grenader T, Slotk I: Urokinase for restoration of
patency of occluded permanent central venous access in haemodialysis patients:
A new protocol. Nephrol Dial Transplant 22: 666–667, 2007.
 Mechanical disruption with brush.
Cox K, Vesely TM, Windus DW, Pilgram TK: The utility of brushing dysfunctional
hemodialysis catheters. J Vasc Interv Radiol 11: 979–983, 2000.

20. Other sites of Thrombosis
 Central Venous.
 Atrial.
 Treatment:
 Removal of catheter.
 Anticoagulation.
 Surgical intervention.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology,
ASN. 361-375. 2009

21. Fibrin Sheath

22. Fibrin Sheath
 Outer side.
 Cover the pores.
 Compose of
Thrombus with fibrin, Endothelial cells, Smooth muscle cells and collagen.
Treatment:
 Thrombolysis.
 Wires and balloons.
O’Farrell L, Griffith JW, Lang CM: Histologic development of the sheath that forms around longterm
implanted central venous catheters. J Parenter Enteral Nutr 20: 156–158, 1996.
Forauer AR, Theoharis C: Histologic changes in the human vein wall adjacent to indwelling central
venous catheters. J Vasc Interv Radiol 14: 1163–1168, 2003.
Savader SJ, Haikal LC, Ehrman KO, Porter DJ, Oteham AC: Hemodialysis catheter-associated fibrin
sheaths: Treatment with a low-dose rt-PA infusion. J Vasc Interv Radiol 11: 1131–1136, 2000.

23. Hemodialysis Catheter-related
infection

24. Hemodialysis catheter infection
 Second cause of mortality.
 First cause of Morbidity.
 Bacterial flora migration.
 Exoluminal and Endoluminal growth.
 Increased catheter loss, bacteremia, hospitalization.
Ishani A, Collins AJ, Herzog CA, Foley RN: Septicemia, access and
cardiovascular disease in dialysis patients: The USRDSWave 2 study.
Kidney Int 68: 311–318, 2005.

25. Cuffed Tunneled Cath. Duration
Catheter survival will depend on:
 1. Design.
 2. Site of insertion.
 3. Rt. IJ > Lt IJ> Femoral.
 4. Non Dm.
Fry AC, Stratton J, Farrington K, Mahna K, Selvakumar S, Thompson T,
Warwicker P: Factors affecting longterm survival of tunneled
haemodialysis catheters: A prospective audit of 812 tunneled catheters.
Nephrol Dial Transplant 23: 275–281, 2008

26. Types of HD catheter infection
 Localized exit site infection.
 Tunnel infection.
 Systemic infection.
 Last access cuffed tunnelled infected catheter.

27. Signs and symptoms of Haemodialysis Catheter
related infection
 Immunosuppressed patients.
 Inflammatory signs:
redness, hotness, pain, swelling, discharge.
 Fever during Hemodialysis.
The catheter is the cause of fever unless proven
otherwise.
 Redness over the exit site.
 Discharge from the exit site.

28. Investigations for catheter infection
 CBC.
 Blood Culture peripheral and from catheter.
 Catheter tip Cx.
 Exit site discharge.
 Others: Urine, Sputum, Drains..etc.

29. Exit site infection
 Erythema, discharge and tenderness.
 Management:
 Obtain Cx.
 Could be treated with Local and oral AB.
 Rarely required removing the catheter.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375.
2009.

30. Catheter Tunnel infection
 Inflammatory signs over the tunnel.
 Purulent discharge.
 Management:
 IV AB.
 Exchange of the catheter.
 Different site.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375.
2009.

31. Catheter related Bacteremia
 Cuffed rate 1.6-5.5/1000 d.
 Non cuffed 3.8-6.6/1000 d.
 High mortality and morbidity.
 Related with Catheter tip colonization.
 Higher risks:
 Immunosuppressed patients.
 S. Alb < 3.5 g/dl.
 Organisms; G+, less common G- bacilli.
Beathard GA, Urbanes A: Infection associated with tunneled hemodialysis
catheters. Semin dial 21: 528–538, 2008.

32. Catheter related Bacteremia
 Clinical picture:
 Fever with chills.
 May be only during HD.
 No other focus.
 Sepsis.
 Dx: Blood Cx > 15CFU. (From peripheral and catheter).
 Treatment: AB for 2-3 wks. with exchange of the catheter.

33. Catheter Salvage in poor access
 30% AB treatment could clear infection.
 80% AB with exchange over guide wire.
Tanriover B, Carlton D, Saddekni S, Hamrick K, Oser R, Westfall AO, AllonM:Bacteremia
associated with tunneled dialysis catheters: Comparison of two treatmentstrategies.
Kidney Int 57: 2151–2155, 2000.
Exchange:
 72 hours post AB.
 No need for negative blood Cx.
National Kidney Foundation: KDOQI clinical practice guidelines and clinical
practice recommendations for

34. Bacterial Biofilm
 Spread for Skin exit site.
 Reduced with:
 Mupirocin.
 Polysporin.
 Medicated Honey.
Johnson DW, MacGinley R, Kay TD, Hawley CM, Campbell SB, Isbel NM, Hollett P: A randomized controlled trial of
topical exit site mupirocin application in patients with tunnelled, cuffed haemodialysis catheters. Nephrol Dial Transplant
17: 1802–1807, 2002.
Johnson DW, Van Eps C, Mudge DW, Wiggins KJ, Armstrong K, Hawley CM, Campbell SB, Isbel NM, Nimmo GR, Gibbs H:
Randomized, controlled trial of topical exit-site application of honey (Medihoney) versus mupirocin for the prevention of
catheter-associated infections in hemodialysis patients. J Am Soc Nephrol 16: 1456–1462, 2005.
29. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW, Conly J: Hemodialysis infection prevention with polysporin
ointment. J Am Soc Nephrol 13: 169–179, 2003

35. Antibiotic Lock
 Is indicated in reinfection with same organism.
 In limited catheter sites.
 Catheter Salvage is acceptable.
Onder AM, Chandar J, Simon N, Diaz R, Nwobi O, Abitbol CL, Zilleruelo G:
Comparison of tissue plasminogen activator–antibiotic locks with heparin–
antibiotic locks in children with catheter-related bacteraemia. Nephrol Dial
Transplant 23: 2604–2610, 2008.
Rijnders BJ, Van Wijngaerden E, Vandecasteele SJ, Stas M, Peetermans WE:
Treatment of longterm intravascular catheter-related bacteremia with
antibiotic.

36. Types of Antibiotic Lock
 Cefazolin, Cephotaxim, Vancomycin, Tobramycin,
Gentamyin.
 Concentration: 5mg/ml.
 mixed with Citrate, EDTA, Heparin, rtPA.
Systemic AB with Antibiotic lock more effective for
 G. Neg.
 Less effective for Staph. Epidermidis.
 Worst for Staph aureus.
Maya ID, Carlton D, Estrada E, Allon M: Treatment of dialysis catheter-related
Staphylococcus aureus bacteremia with antibiotic lock: A quality improvement
report. Am J Kidney Dis 50: 289–295,2007

37. Hemodialysis Catheter infection
complications
 Osteomylitis.
 Endocarditis.
 Septic arthritis.
 Spinal epidural abscess.

38. Catheter Dysfunction
 Early:
 Late:

39. Catheter Dysfunction signs
 Qb < 300ml/min.
 Art. Pressure <-250.
 Ven. Pressure > 250.
 URR < 65, Kt/V < 1.2.
 Unable to aspirate blood freely (Late sign).
 Frequent pressure alarms.

40. Causes for Catheter Dysfunction
 Mechanical.
 Kink.
 Misplaced suture.
 Catheter Migration.
 Drug Precipitation.
 Patient Position.
 Catheter integrity.
 Holes.
 Cracks.
 Fibrin Sheath.
NKF KDOQI

41. Catheter Dysfunction
 Progress to complete non functional.
 Better salvaged early.
 17-33% leads to removal.
 30-40% leads to catheter thrombosis.
 Increased Morbidity and mortality.
 Higher cost.

42. Managing catheter dysfunction
 Reposition.
 Thrombolytic:
 1. Intralunminal.
 2. Intradialytic Lock.
 3. Intracatheter thrombolytic infusion.
 Exchange with sheath disruption.

43. Central Venous occlusion
 41% of Catheter patient.
 25% of dysfunction AVF is related to previous subclavian cath.
 Risk increase with:
1. Multiple insertions.
2. Longer catheter time.
3. Non Cuffed cath. > 21days.
4. Lt IJ and Subclavian.
Macrae JM, Ahmed A, Johnson N, Levin A, Kiaii M: Central vein stenosis: A common problem in patients
on hemodialysis. ASAIO J 51: 77–81, 2005
Oguzkurt L, Tercan F, Torun D, Yildirim T, Zumrutdal A, Kizilkilic O: Impact of short-term hemodialysis
catheters on the central veins: A catheter venographic study. Eur J Radiol 52: 293–299, 2004

44. Central Venous occlusion

45. Central Venous occlusion
Causes:
 Endothelial injury.
 Movement with respiration and pulsation.
 Vibration & turbulence flow.
Agarwal AK, Patel BM, Haddad NJ: Central vein stenosis: A
nephrologist’s perspective. Semin Dial 20: 53–62, 2007.

46. Central Venous occlusion
Clinical picture:
 Swelling of the arm.
 Higher venous pressures.
 Bleeding.
 Access Thrombosis.
 Loss of access.
 SVC Syndrome.
 Increased collaterals.

47. Central Venous occlusion Treatment
 Medical treatment.
 Angioplasty.
 Stent.
Bakken A, Protack C, Saad W, Lee D,Waldman D, Davies M: Long-term
outcomesof primary angioplasty and primary stenting of central venous stenosis
in hemodialysis patients. J Vasc Surg 45: 776–783, 2007.
Maya ID, Saddekni S, Allon M: Treatment of refractory central vein stenosis in
hemodialysis patients with stents. Semin Dial 20: 78–82, 2007

48. Catheter replacement
 Sever infection.
 Staph Aureus, Pseudomonas, Fungal Cx.
 Replace after 72 hours of AB treatment.
precautions:
 maintain negative Cx is recommended before
replacement?
 Different insertion location is recommended.
 Avoid cuffed tunneled catheter with infection focus.
 AB selection depends on antibiogram.

49. Fistula First
 KDOQI.
 www.fistula first.org.
 Medicare/Medicade:
 www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp.

50. Thank you