Central Venous Dialysis Catheters Research Articles

Presence of retained calcified fibrin sheath after central venous catheter removal: A systematic literature review.

Central venous catheters (CVC) are used in many clinical settings for a variety of indications. We performed a systematic literature review concerning case reports of retained calcified fibrin sheaths after dialysis CVC removal. The aim of our study was to systematize the knowledge regarding clinical management of this phenomenon, placing special emphasis on diagnostic radiological features in different imaging modalities, including chest radiography, echocardiography, computed tomography, and magnetic resonance imaging. We discuss the most common risk factors associated with this CVC complication. In our review, we found eight cases of hemodialysis patients. The most common risk factors associated with calcified fibrin sheath formation in the analyzed cases were pro-thrombotic and pro-calcification factors related to patient comorbidities, and prolonged catheter dwell time. Differentiating between a calcified fibrin sheath (present in about 6% of patients with long-term indwelling CVC as diagnosed by computed tomography) and a retained catheter tip can be challenging. The initial diagnosis based on imaging methods was incorrect in most of the analyzed cases. This suggests that some cases of retained fibrin sheaths may remain undetected or misinterpreted. This is important in patients with known pro-thrombotic and pro-calcification risk factors and prolonged catheter dwell time. Therefore, implementation of preventive strategies, familiarity with radiological findings of this phenomenon, comparison with previous imaging studies, and an overall comprehensive assessment with clinical data is imperative.

Improving practice in accessing haemodialysis central venous catheters.

In children, haemodialysis is used as a form of renal replacement therapy and is typically delivered via a central venous catheter (CVC). It is necessary to access the CVC for dialysis and blood sampling regularly, and safe line practice is essential to minimise complications associated with CVCs, including infection. The authors had concerns about the rate of CVC infection in their children's haemodialysis unit, which prompted a practice review. A questionnaire was emailed to all other children's haemodialysis units in the UK, which identified variations in practice and training. The authors subsequently modified their unit's CVC access guidelines and blood sampling technique, and developed a new competency-based 'haemodialysis CVC access only' training programme for nursing staff. A willingness to review practice in the unit, supported by comparison and communication with other units, assisted in implementing this change in practice.

Outcomes after endovascular mechanical thrombectomy in occluded vascular access used for dialysis purposes.

PurposeEndovascular mechanical thrombectomy using the AngioJet™ system can be considered to reestablish patency in occluded vascular access. The aim of this study was to review our results for endovascular mechanical thrombectomy using the AngioJet™ system in patients with arteriovenous fistulae (AVF) and arteriovenous grafts (AVG).MethodsData collected in a database of patients requiring hemodialysis for renal failure were analyzed. Patients who underwent endovascular mechanical thrombectomy procedures with the AngioJet™ system for occlusion of vascular access were included. Clinical and technical success rates and patency rates were calculated. Multivariate analysis was used to identify factors of influence.ResultsA total of 92 AngioJet™ procedures in 60 patients with thrombosed vascular access were reviewed during a mean follow‐up period of 21.5 months in patients with an AVF and 11.9 months in patients with an AVG. Technical and clinical success was achieved in 92.6% of AVF cases and 92.0 and 90.8% of AVG cases with an AVG, respectively. Significantly higher primary and primary‐assisted patency rates were observed in the AVF group. Multivariate regression analysis indicated that left‐sided vascular access and female sex were independent predictors for failure regarding primary patency in AVG patients. Immunosuppressive drugs and older age were negative predictors for secondary patency in AVG patients.ConclusionsThe AngioJet™ system can be deemed an effective technique to reestablish patency in occluded vascular access with minimal use of central venous catheters for dialysis. Good technical and clinical success rates were achieved with acceptable patency rates, especially in AVF patients.

Multicenter Outbreak of Gram-Negative Bloodstream Infections in Hemodialysis Patients

Contaminated water and other fluids are increasingly recognized to be associated with health care-associated infections. Weinvestigated an outbreak of Gram-negative bloodstream infections at 3 outpatient hemodialysis facilities. Matched case-control investigations. Patients who received hemodialysis at Facility A, B, or C from July 2015 to November2016. Infection control practices, sources ofwater, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates. Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C. Exposures in cases and controls were compared using matched univariate conditional logistic regression. 58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n=21) and Pseudomonas aeruginosa (n=12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wallboxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers' hands to contaminate central venous catheters with contaminated fluid from the wall boxes. Limited patient isolates for testing, on-site investigation occurred after peak of infections. This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment.

Current practice in dialysis central venous catheter management: Multi-disciplinary renal team perspectives.

To explore the current practices related to the insertion, management and removal of dialysis central venous catheters (CVCs) used in patients with chronic kidney disease requiring haemodialysis. This qualitative descriptive study involved semi-structured interviews with surgeons, interventional radiologists, renal physicians, dialysis nurses, renal access nurses and renal researchers involved in the care of patients with chronic kidney disease requiring haemodialysis. Data were collected from staff at eight hospitals in six states and territories of Australia. Thirty-eight face-to-face interviews were conducted. A modified five-step qualitative content analysis approach was used to analyse the data. Improved visualization technology and its use by interventional radiologists has steered insertions to specialist teams in specialist locations. This is thought to have decreased risk and improved patient outcomes. Nurses were identified as the professional group responsible for maintaining catheter access integrity, preventing access failure and reducing access-related complications. While best practice was considered important, justifications for variations in practice related to local patient and environment challenges were identified. The interdisciplinary team is central in the insertion, maintenance, removal and education of patients regarding dialysis CVCs. Clinicians temper research-based decision-making about central dialysis access catheter management with knowledge of individual, environmental and patient factors. Strategies to ensure guidelines are appropriately translated for use in a wide variety of settings are necessary for patient safety.

Endovascular removal of a hemodialysis catheter stuck in central vein

The number of patients with end-stage kidney disease requiring hemodialysis has been growing. The use of permanent central venous dialysis catheters has been increasing. Catheters in the central veins may adhere strongly to the vessel wall, so their removal may lead to difficulties. A recently published endovascular method (so-called Hong technique) turns the catheter removal to an easy and fast outpatient method and avoids sternotomy. We successfully removed a catheter inserted into the left subclavian vein 6 years ago which was impossible to extract by the usual techniques. Based on our experience, we recommend the routine use of the Hong technique. Orv Hetil. 2019, 160(11): 435-437.

Low Concentration Trisodium Citrate as a Non-inferior Locking Agent for Non-tunneled Dialysis Catheters in the Asian Setting.

Introduction:Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population.Methods:In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done.Results:The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock.Conclusions:The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.

Haemodialysis vascular access function in dialysis patients at the Kenyatta National Hospital

Background: The number of patients requiring renal replacement therapy (RRT) worldwide has been on the rise. Vascular access is the lifeline for these patients when haemodialysis (HD) is the treatment of choice. Access-related morbidity is a leading cause of hospitalization so that the function and patency of access are essential for the optimal management of patients. There is a need to recognize when a vascular access is dysfunctional because intervention must maintain function as well as preserve future vascular access sites. Methods: This was a cross-sectional study that evaluated the haemodialysis vascular access function in patients undergoing chronic haemodialysis at the Kenyatta National Hospital, Nairobi, Kenya. Peak access blood flow rates, urea reduction ratio (URR) and Kt/V were analysed in 150 patients.Results: The temporary (non-tunnelled) central venous dialysis catheters had poor function, with only 48% achieving a mean blood flow rate > 300 mL/min. The comparable rate for arteriovenous fistulae (AVF) was 88% and for tunnelled dialysis catheters 82%. One-quarter of the patients had a URR < 65%. Higher mean blood flow rates were associated with higher URR (P = 0.004) and Kt/V (P = 0.009) values. AVF stenosis was present in 12.5% and thrombosis in 3% of patients. Aneurysms were the commonest AVF complication (47%) but were not haemodynamically significant. Conclusions: Tunnelled haemodialysis catheters offered adequate blood flows and achieved adequate delivered dialysis, comparable to arteriovenous fistulae. Non-tunnelled catheters delivered poor blood flow rates and dialysis dose. Greater blood flow rates were associated with a higher delivered dialysis dose. There is a need for routine surveillance and affordable interventional procedures to prevent loss of vascular access.

Superior Vena Cava Obstruction - A Rare Cause of Recurrent Esophageal Variceal Bleeding: Case Report

The most common cause of esophageal varices is portal hypertension. ‘Downhill’ esophageal varices are in the proximal esophagus as a consequence of superior vena cava (SVC) obstruction and are considered to be among the rare causes of gastrointestinal bleeding. We present a rare case of recurrent upper gastrointestinal bleeding from chronic SVC thrombosis in a patient with end stage renal disease on hemodialysis. A 55-year-old female on hemodialysis, presented with abdominal pain and vomiting of a large quantity of bright red blood. She remembers a similar episode of vomiting blood in the past. She gives a history of hemodialysis vascular access in her neck six years ago, that was later removed after a clot formation. She has no history of liver disease. On examination, there are no clinical signs of chronic liver disease. Prominent veins of the anterior chest are noted. Laboratory showed a hemoglobin of 12.9g/dl with a platelet count of 206,000/μL. Liver enzymes and liver synthetic function were normal. The patient was admitted. An urgent esophagogastroscopy revealed esophageal varices with no red wale signs in the proximal esophagus. Abdominal ultrasound showed a normal liver. Computed tomography (CT) of the chest showed a stenosis of the superior vena cava at the right atrial junction with prominent venous collaterals of the right internal mammary and azygous veins. Other venous collateral were noted in the posterior left and anterior chest. The patient was managed conservatively. Vascular surgery consult for bypass surgery was requested. She was discharged in a stable condition. The majority of SVC obstructions are due to mediastinal compression from malignancy: thymoma, lymphoma or lung cancer Superior vena cava stenosis from central venous dialysis catheters is rare.Venography, (CT) angiography and Magnetic Resonance Venography (MRV) allow confirmation of SVC obstruction. Currently there is a limited data on management of downhill varices. Options include surgical bypass or percutaneous angioplasty and stent placement. Upper GI endoscopy can be done to control variceal bleed. Gastroenterologists must be attentive to the clinical history in patients with history of central catheter placement, especially in the absence of chronic liver disease. There are no standard guidelines to manage acute bleeding associated with ‘downhill’ varices. We suggest prompt diagnosis, and multidisciplinary management for successful outcomes.1938_A Figure 1. Markedly engorged neck veins (arrows)1938_B Figure 2. — Esophagoscopy showing moderate size mid esophageal varices (arrows)1938_C Figure 3. CT chest with contrast showing significant narrowing of the superior venacava at the right atrial junction (white arrow).

Prevalence of Central Vein Stenosis in Patients Referred for Vein Mapping.

Central vein stenosis is considered to be common in patients on hemodialysis but its exact prevalence is not known. In this study, we report the prevalence of central vein stenosis in patients with CKD referred for vein mapping. We conducted a retrospective study of adult patients who had bilateral upper extremity venographic vein mapping from September 1, 2011 to December 31, 2015. Patients with and without stenosis were compared for differences in clinical or demographic characteristics. Multiple logistic regression was used to identify independent associations between patient characteristics and central vein stenosis. There were 525 patients who underwent venographic vein mapping during the study period, 27% of whom were referred before initiation of hemodialysis. The mean age (±SD) and body mass index were 59 (±15) years and 28 (±7), respectively. Women accounted for 45% of patients; 82% were black. The prevalence of central vein stenosis was 10% (95% confidence interval [95% CI], 8% to 13%) for the whole group, and 13% (95% CI, 10% to 17%) among patients with tunneled central venous dialysis catheters. Current use of tunneled hemodialysis catheters (odds ratio [OR], 14.5; 95% CI, 3.25 to 65.1), presence of cardiac rhythm devices (OR, 5.07; 95% CI, 1.82 to 14.11), previous history of fistula or graft (OR, 3.28; 95% CI, 1.58 to 6.7), and history of previous kidney transplant (OR, 18; 95% CI, 4.7 to 68.8) were independently associated with central vein stenosis. In this population, the prevalence of central vein stenosis was 10% and was clustered among those with tunneled hemodialysis catheters, cardiac rhythm device, and previous history of dialysis access or transplant.

Urgent: Stop Preventable Infections Now.

In 2009, the US Renal Data System (USRDS) presented trends in rates of hospitalization for cardiovascular disease and infection in the first year of dialysis, 1991–2006 ([1][1]), highlighting a marked rise in infection-related hospitalizations and a need for providers and policymakers to address

Central Venous Line and Dialysis Catheter Position Affects Drug Clearance during Continuous Renal Replacement Therapy in an Animal Model.

In intensive care, drugs are commonly administered through central venous catheters (CVC). These catheters and central venous dialysis catheters (CVDC) are often placed in the same vessel for practical reasons. The aim of this experimental study was to investigate if the position of CVC and CVDC influences the elimination of infused drugs, during continuous renal replacement therapy (CRRT). In a randomized, cross-over model, anesthetized piglets received both a CVC and a CVDC in a jugular vein. Another CVDC was placed in a femoral vein for comparison. After baseline measurements, CRRT was performed in either of the CVDC, each CRRT-period separated by another baseline period. Hypotension was induced by peripherally given sodium nitroprusside. In the CVC, both gentamicin and noradrenaline were administered. Noradrenaline was titrated to reach a target blood pressure. When CRRT was performed using the CVDC in the same vessel as the drugs were infused, the plasma concentration of gentamicin was reduced compared with when the infusion and CVDC were in different vessels (5.66 [standard deviation (SD) ± 1.23] vs. 7.76 [SD ± 2.30] mg/l [p = 0.02]). The noradrenaline infusion rate needed to reach the target blood pressure was more than doubled (0.32 [SD ± 0.16] vs. 0.15 [SD ± 0.08] µg/kg/min [p = 0.006]). This experimental study indicates that the removal of drugs is increased if infusion is in close vicinity of the CVDC, during CRRT.

Placement of Central Venous Dialysis Catheters without X-Ray: Safety and Feasibility

Objective: After a placement of central venous catheters chest x-ray is the standard procedure to exclude malpositions and pneumothoraces. In this study we combined ultrasonographic techniques to obviate the routine use of x-ray. Setting: Dialysis Center of the Department of Nephrology, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany. Patients: 298 consecutive adult patients undergoing central venous catheter placement for hemodialysis. Interventions: None Measurements and Main Results: 298 consecutive patients received a central venous catheter for dialysis by using chest ultrasound to localize the target vessel, guide the puncture, confirm the tip position using agitated saline as a contrast media and to rule out pneumothoraces. The ultrasound results were proven by a chest x-ray after the first dialysis session. During the two years observation period, two catheter malpositions were readily observed with ultrasound and directly corrected in the operation room. Ultrasound of the chest revealed four pneumothoraces, three of them could be confirmed by chest x-ray. Conclusion: The prospective data presented illustrate that the combination of bedside ultrasonographic techniques is not inferior to x-ray. Our method is less time consuming, without radiation exposure and less costly than chest x-ray investigation after central venous catheter placement. As the localization of the tip is based on agitated saline as a contrast media, it adds no infrastructural demands. It is now our well founded believe that the study does challenge the mandatory use of a post insertion x-ray.

Downhill Run, Uphill Battle: An Interesting Case of Downhill Esophageal Varices

Introduction: Downhill esophageal varices are a rare cause of upper gastrointestinal bleeding, and are distinct from varices seen in portal hypertension in etiology, clinical behavior and management. Case Report: A 60-year-old African American male with chronic anemia, end-stage renal disease on hemodialysis, and recurrent arteriovenous shunt occlusions presented with three days of melena. He was on a daily low dose aspirin, but denied non-steroidal anti-inflammatory or anti-coagulant use. He was hemodynamically stable upon arrival. On examination, he had mild conjunctival pallor, an arteriovenous fistula in his right groin, and melena in his rectal vault, but no features of chronic liver disease. Laboratory evaluation was normal except for hemoglobin 6.3 g/dL (down from 9.7 g/dL two weeks prior) and creatinine 5.4 mg/dL. Computed tomography of the abdomen from one year prior showed no evidence of chronic liver disease. Upper gastrointestinal endoscopy was notable for non-bleeding varices confined to the proximal esophagus; one varix had a red wale mark and old blood was noted in the esophagus (Fig 1). Therapy was not performed in the absence of active bleeding. A venogram revealed total occlusion of the superior vena cava with collateral drainage through the azygos system (Fig 2). A previously placed central venous dialysis catheter was thought to be the nidus of thrombosis. Venoplasty and stenting was attempted, but not successful.Figure 1Figure 2Discussion: Proximal or “downhill” esophageal varices are a rare complication of benign or malignant superior vena cava (SVC) obstruction. They differ from distal or “uphill” varices that are secondary to portal hypertension, and the varices derive their name from the direction of blood flow. The extent of downhill varices depends upon the level and duration of SVC occlusion. Literature suggests downhill varices have a lower risk of hemorrhage (8%) compared to uphill varices (33%) due to lower pressure gradients, smaller caliber and sub-mucosal nature of the vessels, and decreased exposure to erosive gastroesophageal reflux. Definitive therapy addresses the underlying cause of the vascular obstruction. Endoscopic treatment of active variceal bleeding is a temporizing measure, with band ligation felt to be safer than sclerotherapy.

Transparent Film Intravenous Line Dressing Incorporating a Chlorhexidine Gluconate Gel Pad: A Clinical Staff Evaluation

BackgroundChlorhexidine gluconate (CHG) has been shown to reduce the microbial load at intravascular (IV) catheter insertion sites and the risk of catheter-related infections. The Centers for Disease Control and Prevention and the UK National Institute for Health and Care Excellence subsequently recommended CHG-containing IV dressings for specific clinical indications. AimTo evaluate clinical staff perceptions of a standard transparent IV dressing in comparison to a transparent IV dressing incorporating a 2% (w/w) CHG gel pad when used at the insertion site of short-term central venous catheters and vascular access catheters for dialysis in adult critical care patients. MethodsFollowing a 9-month trial period during which a CHG dressing was introduced to critical care patients at a university hospital, the staff perception of this dressing in comparison to a standard transparent IV dressing was evaluated by a questionnaire. The number of dressing changes required and skin condition under the dressing was also determined in a proportion of patients. ResultsThe majority of the clinical staff (70 out of 81 respondents) considered the performance of the IV dressing containing a CHG gel pad better or much better than the standard dressing, and 77 out of 78 of the respondents recommended continuing its use. Both types of dressing performed well when applied to the insertion site of IV catheters in the internal jugular, subclavian, or femoral vein. ConclusionsStaff satisfaction with the IV dressing incorporating a CHG gel pad was rated good, and the dressing performed well in a diverse group of critical care patients.

Maintenance of blood flow rate on dialysis with self-centering CentrosFLO catheter: A multicenter prospective study.

Introduction Chronic central venous catheters (CVC) for dialysis lose patency and deliver lower blood flow over time, often due to fibrous sheathing that covers the lumen tips. The CentrosFLO central venous catheter has a shape that directs the arterial and venous tips away from the walls of the vena cava and right atrium, making sheathing of the tips less likely. Methods A prospective, multicenter, single arm, non-controlled, observational study was conducted at eight sites in the United States. All consenting dialysis patients receiving CentrosFLO catheters through the right or left internal jugular veins were accepted in the study, as long as the catheter was expected to be used for 45 days and was not an over-the-wire replacement for a previous CVC. Data were automatically collected on initial and average dialysis blood flow rate and initial arterial and venous pressures, for up to 26 weeks of dialysis therapy. Findings 75 patients were enrolled. Kaplan-Meier analysis indicated that 87% of patients maintained blood flow rate over 300 mL/min throughout 26 weeks of follow-up. There was no decline in average dialysis blood flow rate and no significant change in hydraulic resistance of the arterial or venous lumens of the catheters during the study. Discussion The CentrosFLO catheter demonstrates long term patency with good flow rates on dialysis, which, by comparison with previous studies, shows a clinically significant improvement in blood flow rate vs. other catheters. Stable hydraulic resistance of the catheter lumens showed no evidence of tip encroachment by fibrous sheaths.

Creating arteriovenous fistulas using surgeon-performed ultrasound.

An arteriovenous fistulas (AVF) is the preferred vascular access for hemodialysis and is associated with lower mortality, morbidity and cost when compared with grafts and particularly with central venous dialysis catheters. This study reviews a series of new patients where an autogenous access was constructed for each individual utilizing surgeon-performed ultrasound (SP-US). Consecutive new patients referred for a permanent vascular access during an 11-year period were retrospectively reviewed. In addition to physical examination, each patient underwent SP-US evaluation for pre-operative vessel mapping and post-operative evaluation for access maturation. SP-US was also used in the evaluation of access dysfunction in mature AVFs. We identified 1874 patients. Ages were 8-94 years (mean 60 years). Of these, 51% were female and 59% were diabetic; 33% had previous failed access operations. Follow-up was 3-127 months (mean 23 months). An autogenous access was constructed for each individual. No grafts were used. Direct AVFs were constructed in 1240 (66%) patients and 634 (34%) individuals required a transposition or translocation procedure. Primary and cumulative patency rates were 60.0% and 93.0% at 12 months and 47.3% and 90.2% at 24 months, respectively. AVF arterial inflow was most commonly supplied by the proximal radial artery (67%). Creating a functional autogenous vascular access is possible for most patients. No grafts were used in this series of 1874 consecutive new patients. Important elements for success included SP-US evaluation, utilization of the many vascular access options available, establishing radial artery AVF inflow when feasible, and prompt intervention when indicated.

Safety and Complications of Double-Lumen Tunnelled Cuffed Central Venous Dialysis Catheters: Clinical and radiological perspective from a tertiary centre in Oman.

This study aimed to assess the technical success, safety and immediate and delayed complications of double-lumen tunnelled cuffed central venous catheters (TVCs) at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman. This retrospective study took place between January 2012 and October 2013. The clinical records and radiological data of all patients who underwent ultrasound- and fluoroscopy-guided TVC placement at SQUH during the study period were reviewed. Demographic data and information regarding catheter placement, technical success and peri- and post-procedure complications (such as catheter-related infections or thrombosis) were collected. A total of 204 TVCs were placed in 161 patients. Of these, 68 were female (42.2%) and 93 were male (57.8%). The mean age of the patients was 54.4 ± 17.3 years. The most common reason for catheter placement was the initiation of dialysis (63.4%). A total of 203 procedures were technically successful (99.5%). The right internal jugular vein was the most common site of catheter placement (74.9%). Mild haemorrhage which resolved spontaneously occurred in 11 cases (5.4%). No other complications were observed. Subsequent follow-up data was available for 132 catheters (65.0%); of these, thrombosis-related catheter malfunction was observed in 22 cases (16.7%) and catheter-related infection in 29 cases (22.0%). Radiological-guided placement of tunnelled haemodialysis catheters can be performed safely with excellent technical success. The success rate of catheter insertion at SQUH was favourable in comparison with other studies reported in the literature.

Three-Dimensional Imaging of a Central Venous Dialysis Catheter Related Infected Thrombus.

Three-dimensional (3D) echocardiography is becoming widely available and with novel applications. We report an interesting case of a 68-year-old lady with a central venous thrombosis coincident with both a dialysis catheter infection and a recent pacemaker insertion. Two-dimensional transesophageal echocardiography was unable to delineate whether the thrombosis was involved with the pacemaker wire or due to the tunneled catheter infection. The use of 3D echocardiography was able to produce distinct images aiding diagnosis. This circumvented the need for invasive investigations and inappropriate, high-risk removal of the pacing wire. This case highlights the emerging application of 3D echocardiography in routine nephrology practice.

Dialysis central venous catheter types and performance.

The choice of both short-term (nontunneled) and long-term (tunneled) central venous catheters (CVCs) for hemodialysis is a difficult one, due to the large number of available catheters, with very different characteristics and cost.CVC-related complications (in particular infections, thrombosis and inefficient dialysis) can determine ominous consequences and death, with extremely elevated costs due to prolonged hospitalization and expensive procedures. Thus, the correct balance between cost and quality of CVC is required when deciding which kind of CVC should be adopted.In this regard, the design of CVCs has become a very active area of industrial and clinical research, with the ultimate goal of improving the long-term function of the catheter and of reducing complication rates, because even small improvements in the complication or reintervention rates have a positive impact on individual patient care and cost to society. In this article we review the general features of CVCs, including differences between tunneled and nontunneled CVCs, materials and their compatibility with lock solutions, the implications of straight versus precurved design in nontunneled CVCs, lumen and tip features with their clinical implications, catheter coatings and their effect on infection and thrombosis.