PC134. Tunneled Catheter Placement for Hemodialysis Should Be Paired With Evaluation for Arteriovenous Fistula or Graft Creation

Abstract

Permanent dialysis access with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is the first choice for hemodialysis whenever possible. In patients who do not have a matured AVF or AVG, large-bore tunneled catheters (TCs) are placed to provide bridging access. Whereas TCs provide convenient access for hemodialysis, they are at risk for development of central line-associated bloodstream infections and can cause central vein stenoses. Ideally, TCs are used as a bridge to AVF or AVG creation for minimization of total catheter days. A multispecialty Vascular Access Service Team (VAST) was implemented to evaluate patients for permanent hemodialysis access at the time of TC placement. The objective of this study was to evaluate the efficacy of VAST in the context of identifying patients for AVG or AVF creation. The VAST provides a multidisciplinary centralized consultation service to evaluate and to implement appropriate vascular access. All inpatient TC consultations for dialysis are reviewed by nephrologists, who evaluate patients for causes of kidney failure and possibility of renal recovery. Patients who are not expected to have meaningful renal recovery are referred to the vascular surgery team for permanent dialysis access creation with a preference for distal radiocephalic AVF. A retrospective review was performed of a prospectively maintained database of patients undergoing TC placement at a large academic medical center. From January 2018 to December 2018, a total of 213 TCs were placed. The indications for TC placement included acute tubular necrosis, acute kidney injury due to hepatorenal syndrome, tubulointerstitial nephritis, chronic kidney disease due to uncontrolled hypertension, renal cell carcinoma, glomerulonephritis, polycystic kidney disease, and failed kidney transplants. The average number of days from consultation to TC placement was 1.7 business days; 43% of the patients (n = 90) undergoing TCs were expected to have renal recovery and cessation of hemodialysis. Of the remaining patients, 19% refused the procedure, 7% had contraindications to access creation, and 20% had existing AVFs or AVGs awaiting maturation; 65 patients (54%) agreed to AVF or AVG creation. Seven patients were able to have permanent access creation simultaneously with the time of TC placement. Median wait time was 8 business days, with 40% of procedures occurring within 3 business days. Around a third of patients undergoing TC placements did not have expected renal recovery and benefited from early evaluation for permanent dialysis access creation. A centralized vascular access team facilitates expedited evaluation for permanent dialysis access and may reduce the total catheter days per patient and catheter-related complications.