Central Venous Dialysis Catheters Research Articles

A Modified Switching Procedure from Temporary to Tunneled Central Venous Dialysis Catheters.

Background: Tunneled central venous catheters are commonly used for dialysis in patients without a functional permanent vascular access. In an emergent setting, a non-tunneled, temporary central venous catheter is often placed for immediate dialysis. The most critical step in the catheter insertion is venipuncture, which is often a major cause for longer intervention times and procedure-related adverse events. To avoid this critical step when placing a more permanent tunneled catheter, an exchange over a previously placed temporary one can be considered. In this paper, we present a modified switching approach with a separate access site. Methods: In this retrospective analysis of a prospective database, we examined whether this modified technique is non-inferior to a de novo application. Therefore, we included all 396 patients who received their first tunneled dialysis catheter at our site from March 2018 to March 2023. Out of these, 143 patients received the modified approach and 253 the standard de novo ultrasound-guided puncture and insertion. Then, the outcomes of the two groups, including adverse events and infections, were compared by nonparametric tests and multivariable logistic regression. Results: In both groups, the implantations were 100% successful. Catheter explantation due to infection according to CDC criteria was necessary in 18 cases, with no difference between the groups (5.0% vs. 4.4% p = 0.80). The infection rate per 100 days was 0.113 vs. 0.106 in the control group, with a comparable spectrum of bacteria. A total of 12 catheters (3 vs. 9) had to be removed due to a periinterventional complication. An early-onset infection was the reason in two cases (1.3%) in the study group and five in the control group (1.9%). A total misplacement of the catheter occurred in two cases only in the control group. After adjustment for potential confounders via multivariable logistic regression there was not a significant difference in the complication rate (adjusted odds ratio, aOR = 0.53, 95% CI = 0.14-2.03, p = 0.351) but an estimated decreased risk overall based on the average treatment effect of -1.7% in favor of the study group. Conclusions: The present study shows that a catheter exchange leads to no more infections than a de novo placement; hence, it is a feasible method. Moreover, misplacements and control chest X-rays to exclude pneumothorax after venipuncture were completely avoided by exchanging. This approach yields a much lower infection rate than previous reports: 1.3% compared to 2.7% in all existing aggregated studies. The presented approach seems to be superior to existing switching methods. Overall, an exchange can also help to preserve veins for future access, since the same jugular vein is used.

Optimal volume for the draw-and-return methods to enhance activated partial thromboplastin time ratio accuracy in hemodialysis patients with central venous catheters

BackgroundSignificant errors of activated partial thromboplastin time (aPTT) ratio were frequently observed in blood sampling from central venous dialysis catheter (CVC) of hemodialysis (HD) patients. Following the draw-and-return methods, initial blood withdrawal from the catheter before sampling can reduce the error, but the optimal withdrawal volume remains undetermined. AimThe objective of this study is to determine the optimal blood withdrawal volume for the draw-and-return methods to improve aPTT ratio accuracy in hemodialysis patients with CVC. MethodsA prospective study was conducted in patients receiving HD via CVC. Four blood samples were collected from each patient, involving a peripheral venipuncture and three draw-and-return samples (10 ml, 20 ml and 25 ml groups). The aPTT ratio of a peripheral sample was used as a reference to determine the aPTT ratio accuracy for each draw-and-return group. Subsequently, the agreement was illustrated using modified Bland-Altman plot. ResultsA total of 1,000 samples were obtained from 250 patients. The patients had a mean age of 59.6 ± 15.4 years, with 17.2% using citrate as the CVC's locking agent. The adjusted accuracies of the aPTT ratio varied significantly among the three withdrawal volumes (p-value <0.001). The 25 ml group demonstrated the highest accuracy (43.2%; 95%CI, 38.0–48.4), followed by the 20 ml group (30.0%; 95%CI, 24.9–35.2), and the 10 ml group (18.0%; 95%CI, 12.8–23.2). Additionally, using citrate as a locking agent provided more than 80.0% aPTT ratio accuracy, whereas heparin demonstrated inferior accuracy even in the 25 ml withdrawal group. ConclusionThe optimal blood withdraw volume for the draw-and-return methods concluded at 20 ml for citrate locked-CVC and 25 ml for heparin which significantly improved aPTT ratio accuracies. Applying citrate as a locking agent provides clear benefits for aPTT ratio monitoring, while peripheral venipuncture is recommended in cases of heparin-locked CVC.

A technique to retrieve an internalised embedded central venous catheter

BackgroundCentral venous catheters may become embedded due to the formation of adhesions between the indwelling catheter and the vein wall.Case presentationA 49-year-old patient with bacteraemia was referred for retrieval of an embedded internalised central venous dialysis catheter. Recently the catheter had been surgically ligated at the venotomy site internalising the intravascular catheter component, which precluded antegrade ballooning through the catheter hub.Seldinger technique was used to access the catheter lumen within the left internal jugular vein and through and through access was established across the catheter. Retrograde endoluminal balloon dilation was performed to disrupt adhesions and free the catheter. The catheter was snared over the wire and removed from the right femoral vein.ConclusionThis case report outlines an effective, minimally invasive retrieval method in a rare case of an embedded internalised central venous catheter.Graphical

Multiple Cold Abscesses of a Chest Wall with Ribs Destruction in a Hemodialysis Patient

Cold abscess of the chest wall is an uncommon disease that is mainly caused by tuberculous infection. Staphylococcal cold abscesses of the chest wall are extremely rare and usually clinically occult, frequently leading to a delay in diagnosis and consequently severe infectious complications. We report an 88-year-old woman with end-stage renal disease, who presented with an exit site infection of a cuffed tunneled dialysis catheter caused by methicillin-resistant Staphylococcus aureus (MRSA). Despite the removal of the catheter and administration of antibiotics, she developed refractory MRSA bacteremia. Computed tomography (CT) of the chest revealed septic thrombophlebitis with metastatic cold abscesses of the chest wall and ribs destruction. Although CT-guided drainage and vancomycin therapy eliminated MRSA bacteremia, the chest wall abscesses did not resolve. Patients fitted with a central venous dialysis catheter are at risk of septic thrombophlebitis with metastatic cold abscesses of the chest wall that are resistant to antibiotic therapy. Early identification is based on serial blood cultures and prompt CT scans. Surgical management coupled with antibiotic therapy can eradicate the source of infection and improve patients’ outcomes.

Evaluation of Central Venous Catheter for Dialysis Associated with Bloodstream Infections.

Objective: Hemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are a major complication of long-/short-term catheter. Material and Methods: Patients with HD CRBSIs were identified, and their blood was taken and sent to clinical pathology for culture and sensitivity testing. The inclusion criteria were adults with end-stage renal disease who required urgent HD access in the presence of a central venous catheter (CVC) infection. Results: The most common isolates among the patients with CRBSIs were gram-positive microorganisms (57.5%) and gram-negative organisms (42.5%). Overall, in our entire study, Staphylococcus aureus was the most common pathogen isolated, accounting for 30%, followed by Pseudomonas aeruginosa (20%), coagulase-negative staphylococci (CoNS) (12.5%), Klebsiella spp. and Acinetobacter (10%), Staphylococcus epidermidis (7.5%), and methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Staphylococcus hominis, and Enterococcus faecalis (2.5%). The commonest bacterial in femoral was S. aureus, and for subclavian was Pseudomonas aeruginosa. All S. aureus were sensitive to aminoglycosides and quinolones. P. aeruginosa was sensitive to the third generation of cephalosporins, especially cefoperazone and carbapenem. Conclusion: Nontunneled CVCs used for more than 2 weeks could increase the risk of CRBSIs. Procalcitonin and erythrocyte sedimentation rate could predict the CRBSIs in this study. This study also revealed that the gram-positive bacteria were primadonna in dialysis of CRBSIs, and most of them were sensitive to aminoglycosides.

Removal of stuck tunnelled dialysis line requiring cardiopulmonary bypass and venous repair.

Tunnelled central venous dialysis catheters can usually be removed easily. However, their removal can become rarely complicated requiring more invasive techniques. We report a case in which cardiopulmonary bypass and repair of great veins was required for safe removal. A 38-year-old female with end-stage renal failure and a 3-year-old Hickman line inserted into her right internal jugular vein was referred to our cardiac surgical unit following failed attempts of line removal by local vascular surgical team using open vascular surgical techniques. As a result, an MDT decision was made that it was safer to proceed to a cardiothoracic surgical approach rather than other techniques. Investigations showed significant calcification surrounding the line which was adherent to the venous wall. Removal of the retained catheter required median sternotomy and the use of cardiopulmonary bypass as the great veins had to be opened to free the line and allow complete removal. The line was successfully removed with its encircling calcified sheath, and the veins were closed primarily without needing a patch repair. The integrity of the great veins was maintained to meet the on-going need this young patient has for central venous access. The patient made an uneventful recovery. When other measures fail, sternotomy and cardiopulmonary bypass provide a safe option for complete removal of stuck central venous catheters with low risk to the patient.

Improving assessment and escalation of threatened haemodialysis access: results of a nursing-led program

BackgroundOptimal vascular access is critical to successful haemodialysis. Acute thrombosis of haemodialysis access often leads to unplanned hospital admissions and interventions to restore patency.Western Health is a large health service in Victoria, Australia. During the period February 2019 to January 2020, the rate of arteriovenous fistula (AVF) and arteriovenous graft (AVG) at Western Health satellite dialysis units was 0.33 episodes per 1000 patient-days, higher than the reported rate in the literature of 0.24 events per 1000 patient-days, and was associated with a cumulative total of 139 days of inpatient stay (2.2 per 1000 patient-days).MethodsThe above results prompted creation of an education and escalation pathway for threatened haemodialysis access, based upon clinical markers of vascular access stenosis or imminent thrombosis assessed by nursing staff in satellite haemodialysis centres.In the period February 2020 to January 2021, the education and escalation pathway was implemented. We assessed referrals via the pathway, rates of AVF/AVG thrombosis and associated hospital length of stay in the following 12-month period (February 2021 to January 2022).ResultsFollowing introduction of the pathway, rates of AVF/AVG thrombosis declined to 0.15 per 1000 patient-days (p = 0.02), associated with a decline in attributable cumulative inpatient stay to 55 days (0.69 per 1000 patient-days).ConclusionsOur program demonstrates that the majority of thrombosed vascular access can be predicted and potentially averted with vigilant and well-practiced routine clinical assessment by trained nursing staff. Our nursing-led education and escalation program successfully identified vascular access at risk of imminent thrombosis, reduced rates of acute thrombosis and associated healthcare costs.Despite these improvements, there are still disparities in outcomes for patients with thrombosed vascular access, with regards to length of stay and requirement for insertion of a temporary central venous catheter (CVC) for urgent dialysis whilst awaiting intervention, and these are areas for further investigation and improvement.

Feasibility Analysis of Ultrasound-Guided Placement of Tunneled Hemodialysis Catheters

Radiographic fluoroscopy is the current standard for placement of tunneled central venous catheters (CVCs) for hemodialysis. Radiographic fluoroscopy requires structural and personnel infrastructure and exposes the patient to ionizing radiation. Here, we investigate the feasibility of solely ultrasound-guided placement of tunneled central venous dialysis catheters (USCVCs). We evaluated prospectively collected single-center data regarding safety and catheter function of 134 consecutive patients who underwent USCVC implantation between 2020 and 2021. We used the inset guidewire to visualize the position of the catheter tip. In the case of inadequate visibility by ultrasound, we used intracardiac electrocardiography (ECG) recording or agitated saline. A total of 1844 catheter days were assessed. The optimal CVC position was defined as being within the upper right atrium (URA) and middle to deep right atrium. Of the 134 USCVCs, 87% were placed on the right side. The primary success rate for optimal tip position and catheter function was 98%. Of the USCVCs, 97% were placed solely by ultrasound. Regarding positioning, 6% were in the vena cava superior zone, 70% in the URA and 24% in the middle to deep right atrium, resulting in a rate of 94% with optimal positioning. Effective blood flow averaged 292 ± 39 ml/min. There were no immediate procedure-associated complications. Placement of CVC for hemodialysis solely by ultrasound is an effective alternative to fluoroscopy-assisted placement.

Dialysis Central Venous Catheter–Associated Sepsis: Complimentary Role of Local Susceptibility Pattern

Introduction: Effective treatment of central venous catheters infections could be very challenging, and may require catheter removal. Reinsertion could worsen the economic burden on patient, particularly those paying out of pocket.&#x0D; Methods: Management was anchored on dialysis-based nitrogenous waste, antigen and cytokines clearance, in addition to antibiotic treatment that was based on sensitivity results and, local microbial susceptibility pattern, to minimize cost.&#x0D; Results: He was febrile (38.40C), had a non-tunnelled jugular vein catheter with a dirty, wet dressing with a greenish tinge. He had tachycardia (110/min), fine crepitaions in the lung bases and ascites. Blood and central line samples grew Pseudomonas aeuriginosa sensitive to Imipenem ++ (both), Vancomycin + (blood) and Ciprofloxacin + (central line). He had 4 haemodialysis sessions through the infected catheter, a dose of Vancomycin but none of Imipenem (on account of cost). He had a full course of intravenous Ciprofloxacin and Ceftazidime which was introduced on the basis of local microbial susceptibility pattern as it had been very effective in managing infective conditions in our CKD patients (either in mono or in combination therapy), particularly in patients unable to afford culture and sensitivity test . He had a good clinical and, microbiological recovery as a repeat culture after seven days of antibiotics treatment showed no growth. The catheter was retained for use in further dialysis sessions.&#x0D; Conclusion: Treatment of infected non-tunnelled dialysis catheters could be very challenging particularly in resource poor settings. The use of low cost antibiotics with positive local microbial susceptibility pattern could be very beneficial, additive and effective in treatment and in minimizing complications.

#4687 CORRELATION OF FRAILTY SELF-ASSESSMENT WITH MEASURED FRAILTY USING THE FRIED CRITERIA IN PATIENTS ON DIALYSIS

Abstract Background and Aims Frailty describes a complex syndrome of reduced resistance to stress factors as a consequence of age-related degeneration in various organ systems and is associated with poor clinical outcomes [1]. The European Renal Best Practice Guideline on the management of older patients with CKD recommends a regular assessment of functional status with the intention to identify those who would benefit from a more in-depth geriatric assessment and rehabilitation program [2]. Different frailty screening tools have been evaluated in CKD patients whereas the optimal tool for routine clinical application is not defined. The aim of this study was to evaluate an instrument that can be easily implemented in clinical practice and that can simplify the identification of vulnerable patients on dialysis. Method This cross-sectional, multicenter, prospective study included 123 adult patients on hemodialysis. Frailty status was assessed based on modified Fried criteria: self-reported exhaustion, weakness, slow walking speed, low physical activity level and unintentional weight loss [1]. Patients were categorized as frail meeting 3 of the 5 criteria. Patients were also asked to self-assess their frailty status on a 5-point visual analogue scale (VAS). Patients were considered robust selecting “1”, pre-frail “2 and 3”, and frail “4 and 5”. For data-analysis pre-frail and robust patients both using self-assessment and Fried criteria were categorized as “non-frail”. Correlation between Fried-criteria and self-assessment was measured using a contingency table and rank correlation (spearman´s coefficient). Results The median age was 68 years, 71% were male and 40% were considered frail using the Fried criteria (Table 1). One patient was on intermittent peritoneal dialysis, all other patients received hemodialysis. There was no difference in frailty status assessed by Fried-criteria according to age, sex, body mass index (BMI) or dialysis vintage. Patients receiving dialysis using a central venous dialysis catheter were more likely to be frail than patients with an arterio-venous fistula or graft. Patients who assessed themselves as frail on the basis of the VAS were significantly more likely to be assigned to this group when measured according to the Fried-criteria. The same applies to the non-frail group (Table 2). The specificity of the VAS was 95%, the sensitivity 39%. This means agreement with the Fried-criteria for patients who considered themselves as non-frail was very high, whereas patients frequently misjudged themselves as frail although they were assigned to the non-frail group when measured according to Fried. Spearman's correlation showed a positive correlation coefficient (0.419) and a significant correlation (2-sided, p &amp;lt; 0.001) between patient self-assessment using the VAS and the Fried-criteria. Conclusion Frailty is very common among patients on dialysis and occurs independent of age. The self-assessment by VAS simplifies frailty-screening in patients on dialysis by identifying more robust patients who do not need a time-consuming further evaluation.

#4216 FEASIBILITY ANALYSIS OF AN ULTRASOUND-GUIDED PLACEMENT OF TUNNELED HEMODIALYSIS CATHETERS

Abstract Background and Aims Radiographic fluoroscopy (RAD) is the current standard for placement of tunneled central venous catheters (CVC) for hemodialysis. RAD requires structural and personnel infrastructure and exposes the patient to ionizing radiation. Here, we investigate the feasibility of solely ultrasound-guided placement of tunneled central venous dialysis catheters. Method We evaluated prospectively collected single center data of 134 consecutive patients who underwent CVC implantation between 2020 and 2021 regarding feasibility, safety, and catheter function. We used the inset guidewire to visualize the position of the catheter tip. In the case of inadequate visibility by ultrasound, we additionally used intracardiac ECG recording or agitated saline. A total of 1844 catheter days were assessed. As a historical control, we analyzed the position of 50 CVCs placed by RAD. Optimal CVC position was defined to be in between the cavoatrial junction (CAJ) and the right atrium (RA), according to the guidelines. Results The catheters were placed on the right side in 117 (87%) cases. The primary success rate for optimal position and function was 97,7% (n = 131). Placement solely by ultrasound was possible in 130 (97%) cases. There were no immediate procedure-associated complications related to the new technique. Effective blood flow averaged 292 +/- 39 ml/min. Of all ultrasound-placed catheters, 6% were in the vena cava superior (RAD 24%), 70% in the CAJ (RAD 60%), and 24% in the RA (RAD 16%), resulting in a rate of 94% with optimal position. Conclusion Placement of CVCs for hemodialysis solely by ultrasound is an effective and safe alternative to fluoroscopy-assisted placement.

In an endotoxaemic model, antibiotic clearance can be affected by different central venous catheter positions, during renal replacement therapy

BackgroundIn intensive care, different central venous catheters (CVC) are often used for infusion of drugs. If a patient is treated with continuous renal replacement therapy (CRRT) a second catheter, a central venous dialysis catheter (CVDC), is needed. Placing the catheters close together might pose a risk that a drug infused in a CVC could be directly aspirated into a CRRT machine and cleared from the blood without giving the effect intended. The purpose of this study was to elucidate if drug clearance is affected by different catheter placement, during CRRT. In this endotoxaemic animal model, an infusion of antibiotics was administered in a CVC placed in the external jugular vein (EJV). Antibiotic clearance was compared, whether CRRT was through a CVDC placed in the same EJV, or in a femoral vein (FV). To reach a target mean arterial pressure (MAP), noradrenaline was infused through the CVC and the dose was compared between the CDVDs.ResultsThe main finding in this study was that clearance of antibiotics was higher when both catheter tips were in the EJV, close together, compared to in different vessels, during CRRT. The clearance of gentamicin was 21.0 ± 7.3 vs 15.5 ± 4.2 mL/min (p 0.006) and vancomycin 19.3 ± 4.9 vs 15.8 ± 7.1 mL/min (p 0.021). The noradrenaline dose to maintain a target MAP also showed greater variance with both catheters in the EJV, compared to when catheters were placed in different vessels.ConclusionThe results in this study indicate that close placement of central venous catheter tips could lead to unreliable drug concentration, due to direct aspiration, during CRRT.

Hemodialysis through persistent left superior vena cava. Should it be used?

Background To describe a case of hemodialysis done through persistent left superior vena cava, identified incidentally after a left jugular central venous dialysis catheter insertion, and to discuss its feasibility. Case Summary Single case: A 66-year-old woman was admitted to the ICU with a diagnosis of septic shock, severe pneumonia, and acute renal failure. Hemodialysis was required for acute renal insufficiency. Persistent left superior vena cava (PLSVC) was detected on Chest x-ray after a left jugular central venous dialysis catheter placement. Hemodialysis was uneventful. Using a permanent dialysis catheter placed later through the PLSVC was less efficient. Although no complications were seen during hemodialysis, it was technically difficult (with high pressure in access and low blood flow rate). Conclusion Hemodialysis through PLSVC should remain an exceptional and short-term therapeutic alternative in dialysis patients.

Venous thoracic outlet syndrome and hemodialysis.

Central venous stenotic disease is reported in 7%-40% of patients needing a central venous catheter for dialysis and in 19%-41% of hemodialysis patients who have had a prior central venous catheter. Half of these patients will be asymptomatic. Venous Thoracic Outlet syndrome in hemodialysis (hdTOS) is part of this spectrum of disease. The extrinsic mechanical compression of the subclavian vein at the costoclavicular triangle between the clavicle and 1st rib results in an area of external compression with a predisposition to intrinsic mural disease in the vein. The enhanced flow induced by the presence of a distal arteriovenous access in all patients exacerbates the subclavian vein's response to ongoing extrinsic and intrinsic injury. Repeated endovascular interventions during the maintenance of vascular access accelerates chronic untreatable occlusion of the subclavian vein in the long term. Similar to patients with central venous stenosis, patients with hdTOS can present immediately after access formation with ipsilateral edema or longitudinally with episodes of access dysfunction. hdTOS can be treated in an escalating manner with arteriovenous access flow reduction to <1,500 ml/min, endovascular management, surgical decompression by first rib resection in healthy patients and medial clavicle resection in less healthy patients followed by secondary venous interventions, or finally, a venous bypass. hdTOS represents a complex and evolving therapeutic conundrum for the dialysis community, and additional clinical investigations to establish robust algorithms are required.

Accidental removal of dialysis central venous catheter inserted for blood purification therapy: a single-center study.

Dialysis central venous catheters (DCs) are used for various blood purification therapies. Accidental removal of a DC is a potentially life-threatening event. However, the risk factors associated with accidental removal have rarely been discussed in the literature. We performed a 5year retrospective, single-center, cohort study of patients who were admitted to the ward other than intensive care units and were inserted DCs. We compared patient characteristics between patients who used DCs with and without a history of accidental removal. There were 17 cases of accidental removal (3.5%) out of 489 DC insertions during the observation period. There was no significant difference between patients with and without accidental removal in terms of age, sex, reason for DC insertion, catheter type, or insertion site. The presence of dementia was 35 and 11% (p = 0.006), and that of delirium was 88 and 13% (p < 0.0001) in those with and without accidental removal, respectively. The median days from insertion to accidental removal were 5 (range 0-21) days, and removal occurred mainly at night (71%). One patient with accidental removal developed hemorrhagic shock, but there no deaths occurred due to accidental removal. The present findings suggest that to prevent accidental removal, sufficient attention should be paid to delirium that occurs after admission as well to pre-existing dementia at the time of admission. As accidental removal occurs most commonly early after insertion and at night, special attention should be paid during these periods.

Scheduled screening of patency of permanent central venous dialysis catheters

Background: The number of hemodialysis patients is being increased year by year throughout the world, due to the increase in the life expectancy of the population, as well as the increase in incidences of hypertension and diabetes among them, but also due to the fact that many of the patients with heart and renal failure are now being dialyzed. Hemodialysis requires vascular access. But diabetics, hypertensives, as well as the elderly patients, usually have no vessels (arteries and veins) capable enough to give a satisfactory blood flow via a fistula, so the catheter is the only choice. Objective-Design: A well-functioning catheter is a prerequisite for the quality of the clearance provided. In the present study, control of the catheter patency was performed in a monthly basis. If the blood supply remained high (at least &gt;300 ml/min) the catheter was considered to function satisfactorily. Participants-Results: The study examined the patency of permanent dialysis catheters in 34 patients (19F, 15M). The catheter survival was found to be good in all cases (100%) with a blood supply of at least &gt;300 ml/min for 17 months. Furthermore, 75% of the catheters had a good blood supply for 20 months, while 6 catheters survived with good function for 25 months and continue to operate satisfactorily even now. Conclusion: The study found out that the method of controlling the patency of permanent dialysis catheters was easy and efficient for the timely detection of those that were malfunctioning and that the results from their use were satisfactory, compared to those of other researchers in the literature.

Complex central venous catheter for dialysis: interventional radiology experience in insertion and management of their complications.

CVCs are defined 'complex' when they are inserted through non-conventional accesses or positioned in non-usual sites or substituted by IR endovascular procedures. We report our experience in using diagnostic and interventional radiology techniques for complex CVC insertion and management; we recommend some precautions and techniques that could lead to long-term availability of central venous access and to avoid non-conventional sites CVC insertion. We retrospectively evaluated 617 patients, between January 2010 and December 2019, (mean age 71 ± 13; male 448/617), treated in our department for insertion of tunnelled CVC for haemodialysis. Among 617 patients, 241 cases (39%) are considered 'complex' because they required either a PTA with or without stenting to restore/maintain venous access or had an unusual positioning site or required unconventional access. A direct correlation between CT angiography and PTA (r = 0.95; p-value <0.001) and an inverse correlation between CT angiography and unconventional 'rescue' access (r = -0.92; p-value <0.001) were found. Precise pre-operative planning of treatment in a multidisciplinary setting and diagnostic and interventional radiology procedures knowledge allows reducing complex catheterisms in haemodialysis patient.

The Ash Split Cath(TM): The best inventions are simple

Dual-lumen "acute" central venous catheters (CVC) for dialysis were developed in the 1970s and tunneled "chronic" CVC in the 1980s. Fibrous sheathing of these catheters diminished the patency after weeks to months of use. Double catheters like Canaud/Tesio worked better and longer than single body catheters but were tedious to place. I decided that the optimal CVC design would be a single body that split into two tips within the vena cava. The "Ash Split Cath(TM) " was developed in cooperation with a company focused on dialysis access catheters, and quickly became widely used around the world. However, the patent did not prevent other companies from marketing split-tip catheters. A disagreement on the terms of a royalty agreement further weakened the relationship between the marketing company and our R&D company.

Ultrasonographic evaluation of deep vein thrombosis related to the central catheter in hemodialytic patients

BackgroundPoint of care ultrasound (PoCUS) is a useful tool for the early diagnosis of thrombosis related to the central venous catheter for dialysis (TR-CVCd). However, the application of PoCUS is still not common as a bedside imaging examination and TR-CVCd remains often underdiagnosed in the routine practice. The aim of this study was to investigate if a compression technique for the diagnosis of TR-CVCd blindly performed by PoCUS experts and medical students is accurate when compared to a Doppler study.MethodsTwo medical students without prior knowledge in PoCUS received a short theoretical–practical training to evaluate TR-CVCd of the internal jugular vein by means of the ultrasound compression technique. After the training phase, patients with central venous catheter for dialysis (CVCd) were evaluated by the students in a private hemodialysis clinic. The results were compared to those obtained on the same population by doctors with solid experience in PoCUS, using both the compression technique and the color Doppler.ResultsEighty-one patients were eligible for the study and the prevalence of TR-CVCd diagnosed by Doppler was 28.4%. The compression technique performed by the students and by experts presented, respectively, a sensitivity of 59.2% (CI 51.6–66.8) vs 100% and a specificity of 89.6% (CI 84.9–94.3) vs 94.8% (CI 91.4–98.2).ConclusionThe compression technique in the hands of PoCUS experts demonstrated high accuracy in the diagnosis of TR-CVCd and should represent a standard in the routine examination of dialytic patients. The training of PoCUS inexperienced students for the diagnosis of TR-CVCd is feasible but did not lead to a sufficient level of sensitivity.

Endovascular Management of a Subclavian Arterial Injury During Central Venous Catheter Placement for Hemodialysis.

Subclavian artery injuries after central venous catheter placement constitute a rare but potentially fatal complication. The surgical repair of a subclavian artery trauma is a real challenge, associated with a high rate of morbidity and mortality. The role of endovascular treatment for vascular trauma, including injury to the subclavian artery, continues to evolve. In this manuscript, we report the case of an urgent endovascular repair by a covered stent graft of a subclavian artery perforation following the placement of a central venous catheter for dialysis in a 52-year-old patient, having a chronic kidney failure stage 5, with multiple comorbidities. The present case suggests that attention needs to be paid to preventing iatrogenic arterial cannulation during central vein catheterization to avoid potentially devastating complications. Endovascular treatment using a covered stent should be attempted as a first-line therapeutic option.