Laterality of Tunneled Dialysis Catheter Does Not Affect Patency of Subsequent Arteriovenous Access but Has Increased Rates of Reintervention and Swelling

Abstract

The goal for reliable hemodialysis is establishing permanent vascular access, typically arteriovenous fistulae (AVF) or grafts (AVG) in the upper extremity. However, most patients have a tunneled catheter placed at first to initiate dialysis, usually in an upper extremity central vein. The primary aim of this study is to assess whether the laterality of the dialysis catheter affects the patency of the eventual vascular access. Prior studies have had small sample sizes, been limited to single centers, and looked primarily at AVF maturation and not at patency and important secondary outcomes. The Vascular Quality Initiative data registry was queried retrospectively from August 2011 through May 2019. Subjects were at least 18 years old, required hemodialysis, underwent a vascular access procedure in the upper extremity, and did or did not receive a tunneled catheter in an internal jugular or subclavian vein prior to the vascular access procedure. Subjects with the catheter and AVF/AVG in the same arm were part of the ipsilateral group, and those with the catheter and vascular access in opposite arms were in the contralateral group. We analyzed our data to compare secondary patency between the two groups. Secondary outcomes were rates of upper extremity swelling on the side of the vascular access and reintervention (endovascular or open) for the AVF/AVG. During the study period, 42,921 vascular access procedures were performed with prior tunneled catheter placement: 35,447 (83%) were contralateral, and 7,474 (17%) were ipsilateral. The mean age for all patients was 61.89 ± 14.51 years, and 56.05% (24,057) were male. A Cox regression model showed no association between the loss of secondary patency and laterality group (P = .77). The average time from procedure to occlusion was 308 ± 257.8 days in the contralateral group and 342 ± 312.9 days in the ipsilateral group. In terms of secondary outcomes, a Cox regression model using hazard ratios (HR) showed the ipsilateral group had a 26% higher reintervention rate (HR, 1.26; 95% confidence interval, 1.19-1.34; P < .0001). The ipsilateral group had a 38% higher rate of swelling (HR, 1.38; 95% confidence interval, 1.18-1.62; P < .0001). Both were statistically significant. There is no difference in secondary patency between ipsilateral and contralateral procedures. However, swelling and reintervention rates were higher in the ipsilateral group. The side of the body a dialysis catheter is placed may not affect patency, but one may choose to place the catheter and vascular access on opposite sides to avoid swelling and reintervention.