Long-term Hemodialysis Catheters Research Articles

Long-Term Tunneled Hemodialysis Catheters: Achieving Efficiency Through Tip Position Optimization

This retrospective study assesses the influence of tunneled hemodialysis catheter tip location and lateralization on catheter-related complications, including dysfunction and catheter-related bloodstream infection. Using data from 162 patients who underwent catheter placement between January 2017 and December 2020, postoperative chest X-rays and clinical records were reviewed. Outcomes were assessed based on catheter removal duration and complication incidence. Out of 177 catheter placements, 56 (32%) patients experienced complications during an average 530-day follow-up. Catheters placed in the superior vena cava (SVC) exhibited more severe complications with shorter dwell times compared with those in the pericavoatrial junction (pCAJ) or right atrium (RA). Moreover, complication rates were significantly higher (P<0.01) in the SVC (1.91 per 1000 catheter days) compared with the pCAJ (0.54) or RA (0.47). Lateralization (right or left internal jugular vein) did not significantly affect the complication rates (0.60 vs. 0.58; P=0.90). However, in subgroup analysis, a significantly higher complication rate was observed for catheters with tips inserted from the left side into the SVC than for those inserted from the right side (6.6 vs. 1.5; P<0.01). Catheters with tips in the SVC exhibited more severe complications than those in the pCAJ or RA, with left-side insertion of SVC-tipped catheters resulting in significantly higher complication rates compared with right-side insertion. These findings highlight the importance of optimal catheter tip positioning in long-term hemodialysis care to minimize complications and enhance patient outcomes.

Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies.

Central venous stenosis is a significant and frequently encountered problem in managing hemodialysis (HD) patients. Venous hypertension, often accompanied by severe symptoms, undermines the integrity of the hemodialysis access circuit. In central venous stenosis, dialysis through an arteriovenous fistula is usually inefficient, with high recirculation rates and prolonged bleeding after dialysis. Central vein stenosis is a known complication of indwelling intravascular and cardiac devices, such as peripherally inserted central catheters, long-term cuffed hemodialysis catheters, and pacemaker wires. Hence, preventing this challenging condition requires minimization of central venous catheter use. Endovascular interventions are the primary approach for treating central vein stenosis. Percutaneous angioplasty and stent placement may reestablish vascular function in cases of elastic and recurrent lesions. Currently, there is no consensus on the optimal treatment, as existing management approaches have a wide range of patency rates.

Microbiota of long-term indwelling hemodialysis catheters during renal transplantation perioperative period: a cross-sectional metagenomic microbial community analysis

Background Catheter-related infection (CRI) is a major complication in patients undergoing hemodialysis. The lack of high-throughput research on catheter-related microbiota makes it difficult to predict the occurrence of CRI. Thus, this study aimed to delineate the microbial structure and diversity landscape of hemodialysis catheter tips among patients during the perioperative period of kidney transplantation (KTx) and provide insights into predicting the occurrence of CRI. Methods Forty patients at the Department of Transplantation undergoing hemodialysis catheter removal were prospectively included. Samples, including catheter tip, catheter outlet skin swab, catheter blood, peripheral blood, oropharynx swab, and midstream urine, from the separate pre- and post-KTx groups were collected and analyzed using metagenomic next-generation sequencing (mNGS). All the catheter tips and blood samples were cultured conventionally. Results The positive detection rates for bacteria using mNGS and traditional culture were 97.09% (200/206) and 2.65% (3/113), respectively. Low antibiotic-sensitivity biofilms with colonized bacteria were detected at the catheter tip. In asymptomatic patients, no statistically significant difference was observed in the catheter tip microbial composition and diversity between the pre- and post-KTx group. The catheter tip microbial composition and diversity were associated with fasting blood glucose levels. Microorganisms at the catheter tip most likely originated from catheter outlet skin and peripheral blood. Conclusions The long-term colonization microbiota at the catheter tip is in a relatively stable state and is not readily influenced by KTx. It does not act as the source of infection in all CRIs, but could reflect hematogenous infection to some extent.

Comparative effectiveness and safety among different tip-design hemodialysis long-term catheters: A meta-analysis.

The aim of this meta-analysis is to compare effectiveness and safety among different tip-design long-term hemodialysis (HD) catheters. PubMed, Embase, and Cochrane Library databases were searched until 8 December 2021 to identify randomized controlled trials (RCTs) and cohort studies comparing step-tip, split-tip, or symmetrical-tip design catheters in patients undergoing HD will be included. The Cochrane Risk of Bias tool and the Newcastle-Ottawa Scale were used to evaluate the quality of RCTs and cohort studies. Data extracted from the articles were integrated to determine mean effective blood pump velocity (Qb), blood recirculation rates, secondary patency, catheter-related infection, catheter-related blood stream infection (CRBSI), thrombosis rates, and all-cause mortality for the three tip-designs. We performed meta-analysis on dichotomous outcomes using a random-effects model to evaluate risk ratios (RRs) and 95% confidence intervals (Cls). The effect sizes of continuous outcomes were reported as the mean difference (MD). Sensitivity and subgroup analyses were also performed. The study was registered in the PROSPERO (CRD42021297069). Six RCTs and 11 cohort studies of 2617 individuals were included in our meta-analysis, of which 1088 individuals inserted split-tip catheters, 897 individuals inserted step-tip catheters and 650 received symmetrical-tip design catheters. Sym-tip performed better in mean Qb (MD = 43.85, 95% Cl = 18.13-69.56, p = 0.0008) than step-tip. Split-tip had better outcomes vs step-tip in blood recirculation (RR = 3.44, 95% Cl = 2.49-4.39, p < 0.00001). Sym-tip had significantly better outcomes compared with step-tip (RR = 0.28, 95%Cl = 0.09-0.81, Z = 2.34, p = 0.02) and split-tip (RR = 0.19, 95% Cl = 0.09-0.43, p < 0.0001) in thrombotic events. No significant difference was found in secondary patency, infection rates, CRBSI, and all-cause mortality among the three tip-designs. The sym-tip of tunneled cuffed catheters performed better mean Qb, lower thrombotic events, and lower blood recirculation when blood line reversed, which may have an advantage over other two catheter-tips.

CMS ESRD quality incentive program has not improved patient dialysis vascular access.

Over 468,000 patients in the United States use hemodialysis to manage End Stage Renal Disease (ESRD). The purpose of this study was to determine whether the dialysis access Clinical Performance Measures (CPMs) of Centers for Medicare & Medicaid Services (CMS) ESRD Quality Incentive Program (QIP) have increased arteriovenous fistula (AVF) rates and decreased long-term tunneled hemodialysis catheter (TDC) rates among hemodialysis patients in United States. Retrospective observational study: evaluated reported AVF and long-term TDC rates of 4804 dialysis facilities which reported dialysis access data as part of the ESRD QIP from Payment Year (PY) 2014-2020. Facilities were also sorted by specific additional criteria to examine disparities in dialysis access. Mean AVF rates of included facilities increased from 63.7% in PY 2014 to 67.2% in PY 2016 (p < 0.05), did not change in PY 2017 (p > 0.05), and declined significantly in PY 2018-2020 to 64.1% in PY 2020, near AVF rates at the inception of program. Long-term TDC rates decreased from 10.4% in PY 2014 to 9.88% in PY 2015 (p < 0.05), then increased in PY 2015-PY 2020 to rates higher than at the inception of program, at 11.8% in PY 2020 (p < 0.05). Facilities serving majority Black ZIP Code Tabulation Areas (ZCTAs) or ZCTAs with median income <$45,000 achieved significantly lower AVF rates (p < 0.05) with no significant difference in long-term TDC rates (p > 0.05). AVF rates correlated positively and long-term TDC rates correlated negatively with star rating of facilities (p < 0.05). As one of the first financial QIPs in healthcare, the ESRD QIP has not achieved the stated goals of the CMS to increase AVF access rates above 68% and reduce long-term TDC clinical rates below 10%. Systemic disparities in race, geographic region, economic status, healthcare access, and education of providers and patients prevent successful attainment of goal metrics.

Sudden Coma and Quadriplegia in a Hemodialysis Patient.

A 90-year-old man with a 5-year history of ESKD presented with sudden coma and quadriplegia. It turned out that the patient had cut his long-term hemodialysis catheter, and the lumens were exposed directly to air. A 1-minute epileptic myoclonus occurred 7 hours later, and occasional tremors followed. Brain computer tomography showed multiple air emboli in the bilateral brain hemispheres, especially in the right basal ganglia and vessels over the bilateral cerebral surface. Clusters of bubbles were also seen in the superior sagittal sinus (Figure 1). There were emboli in the right internal jugular vein, right brachiocephalic vein, and superior vena cava. Neurologic examination revealed limbs spasticity and diffuse areflexia, yet brainstem reflex was preserved. Hypoxic ischemic encephalopathy was diagnosed. Acute myocardial infraction occurred 1 day later. …

MON-132 PERCUTANEOUS TRANSHEPATIC TUNNELLED CATHETER FOR HAEMODIALYSIS: A SINGLE CENTRE EXPERIENCE

Obtaining vascular access for dialysis can be challenging in long-term haemodialysis patients who have exhausted all traditional access sites as a result of multiple catheter placements. Transhepatic dialysis catheter insertion is potentially life-saving for those with access failure. This study aims at evaluating the functionality and safety of transhepatic venous catheters in haemodialysis patients. Eight patients (3 male and 5 female, aged 59+/-17 years ) had transhepatic tunnelled dialysis catheters inserted in our haemodialysis unit in the past 3 years. The insertion method, type of catheter use, functional duration of catheters, maximum blood flow rate achieved, catheter complications and reasons for catheter removal were evaluated retrospectively. A total of eleven transhepatic catheters were placed in eight patients between January 2016 and November 2018. All the patients were on long term dialysis, with a mean dialysis vintage of 160 months. Most patients started with peritoneal dialysis, and switched to haemodialysis after peritoneal failure. The average heamodialysis duration was 85 months (range 14-144 months). Nine catheters were placed successfully (9/11, 82% technical success). Catheter insertion failed due to development of subphenic haematoma in 1 patient and the negotiation of the catheter into the proper venous position was unsuccessful in the other. One catheter was placed under general anaesthesia while the rest were done under local anaesthesia. RetrO® Long-Term Hemodialysis Catheter (BARD Access Systems) was used in 10 out of 11 of the procedures, and Permcath™ (Medtronic) was used in 1 case. Seven of the 9 functional catheters were placed in the portal vein while the remaining 2 were placed in the hepatic vein. The functional duration of transhepatic catheters ranges from 32 to 551 days, with a mean of 298 days. Of the 9 catheters, 2 were still in use at the end of the study (2/9, 22.2%). One patient died with a functional catheter. Six of the catheters were removed(6/9, 66.6%) . Arteriovenous fistular was created in 1 patient, while 3 catheters were removed due to catheter thrombosis (3/9, 33.3%). Two patients were noted to have catheter dislodgement into the pleural cavity (2/9, 22.2%), both presented with shock and haemothorax. Poor blood flow was the most common complication during the use of transhepatic catheters. Catheter revision was required in 2 cases. The maximum blood flow rate achieved for each catheter ranged from 150ml/minute to 250ml/minute, with a mean rate of 186ml/minute. The maximum blood flow rate was below 200ml/minute in 4 of the catheters (4/9,44.4%). Bleeding at the catheter site necessitating hospital admission occurred in 3 cases (3/9, 33.3%), catheter exit site infection occurred in 2 (2/9, 22.2%), but there were no catheter related sepsis. For patients who have exhausted access options for dialysis, transhepatic catheter placement is an alternative with potentially good long-term functionality. However, limitations in blood flow rate, and the high thrombosis rate with the need for high level of maintenance to preserve patency should be noted. Furthermore, physicians need to be cautious about potentially life-threatening complications such as catheter dislodgement.

Insertion of long-term tunneled cuffed hemodialysis catheters via the external jugular vein by using a simple, safe and reliable surgical technique.

Description of our technique for the insertion of long-term tunneled cuffed hemodialysis (HD) catheters via the external jugular vein. From December 1999 to August 2006, 357 long-term tunneled cuffed HD catheters were inserted in 308 patients, who were referred to us from various hospitals and clinics in Greece. About half of them (168, or 47%) were inserted via the external jugular vein. We describe our surgical technique for the insertion of long-term tunneled cuffed HD catheters via the external jugular vein. During our study, there was a gradual increase in using the external jugular vein as a method for the insertion of permanent HD catheters. In all cases, the intraoperative catheter blood flow was measured >300 ml/min. No major complications occurred. Long-term tunneled cuffed HD catheters can be inserted via the external jugular vein by using an easy, simple, safe surgical technique. This procedure provides the possibility of using the internal jugular vein in the future.

A Proposed Simple and Accurate Technique for Optimal Long-Term Hemodialysis Catheter Tip Placement.

We describe a simple ultrasound (US)-guided technique for accurate anatomical right atrium localization prior to permanent hemodialysis catheter insertion. It is used in patients for whom a permanent hemodialysis catheter will be inserted through an internal jugular vein access, in order to have the functional catheter tip located at the mid-level of the right atrium. In this technique, the right atrium is localized on US via left intercostal approach prior to catheter insertion under fluoroscopic guidance.

Diagnosis and treatment of catheter-related bloodstream infection: Clinical guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology and (SEIMC) and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (the Spanish Society of Infectious Diseases and Clinical Microbiology and [SEIMC] and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp., Gram-negative bacilli, and Candida spp.), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications.

Diagnosis and treatment of catheter-related bloodstream infection: Clinical guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology and (SEIMC) and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (the Spanish Society of Infectious Diseases and Clinical Microbiology and [SEIMC] and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp., Gram-negative bacilli, and Candida spp.), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications.

Surface analysis of long-term hemodialysis catheters made of carbothane (poly(carbonate)urethane) before and after implantation in the patients' bodies.

The vascular cannulation is associated with a number of complications. The aim of this work was to study the composition and distribution of the film covering the surfaces of Mahurkar Maxid and Palindrome catheters, which were removed from the body of long-term hemodialysis patients. Moreover, the roughness and contact angle of the catheters were evaluated. Two brand new (as a reference) and thirty used catheters were the subject of the study. Their implantation period lasted from 4 months to a year and the reason for removal was the production of another vascular access or obstruction. Surfaces were analyzed by scanning electron microscope, atomic force microscope and goniometer. The inner surfaces of the used catheters were covered with a film of various complexity which includes a plurality of protein, blood cell counts and the crystals. The closer to the distal part the film becomes more complex and multi-layered. Even the surfaces of brand new catheter were not completely smooth. The only significant difference between analyzed models was the presence of thrombus in the distal part of Mahurkar Maxid catheters, not in the Palindrome. The distal part of the catheters is the place most exposed to obstruction and infection, which may be due to not reaching the anticoagulant agent into this part. Not only the occurrence of side holes affects the formation of thrombus, but also their quantity, geometry and distribution which effect on fluid mechanics. The surface of the catheters needs to improvement to minimize the occurrence of defects and cracks.

Prospective, randomized study of long-term hemodialysis catheter removal versus guidewire exchange to treat catheter-related bloodstream infection

BackgroundLong-term (tunneled cuffed) hemodialysis catheters are frequently used vascular access in renal failure patients. Catheter-related bloodstream infection (CRBSI) is a common complication of long-term hemodialysis catheters, with severe morbidities and high risk of mortality. Management of CRBSI by systemic antibiotics while keeping the catheter in place is not effective. Among the different modalities of CRBSI management are catheter removal (CR) and guidewire exchange (GE) of the catheter. The aim of this study was to compare the clinical outcome of CRBSI treated with two different strategies: GE vs CR with new catheter insertion 3 to 7 days later. MethodsThis prospective randomized study analyzed the outcomes of all cases of long-term hemodialysis CRBSI during a 5-year period. The catheter infection-free survival time was analyzed in the two groups of patients (GE group, 339 patients; CR group, 339 patients). Three weeks of systemic antibiotic therapy was used according to culture in both groups. The catheter infection-free survival was analyzed using Kaplan-Meier analysis. ResultsNo statistically significant difference was found in catheter infection-free survival time for GE and CR groups (P = .69), which is not affected by age, sex, presence of diabetes mellitus, or type of causative organism. ConclusionsOur study did not demonstrate a difference in the clinical outcome of CRBSI treated with GE or CR with new catheter insertion 3 to 7 days later. However, guidewire catheter exchange saves veins for future access, reduces the cost and number of procedures, and avoids complications of new venipuncture.

Catheter-related bacteremia and mortality in frequent nocturnal home hemodialysis.

Frequent nightly home hemodialysis (NHHD) has emerged as an attractive alternative to thrice weekly in-center hemodialysis, albeit with preponderant long-term hemodialysis catheter used. Sixty-three NHHD patients from University of Virginia Lynchburg Dialysis Facility were matched 1:2 with 121 conventional hemodialysis patients admitted to Fresenius Medical Care North America facilities from January 1, 2007 to December 31, 2010. Matching considered age (± 5 years), gender, race, dialysis vintage, and diabetes. The primary end-point was the combined incidence of bacteremia/sepsis, for up to 20 months or upon changing to a fistula/graft (with catheter removal), transferring to peritoneal dialysis (PD), or at the time of kidney transplant or death. No significant differences were observed in rate of fistula/graft conversion, transfer to PD, transplant, or death between NHHD and in-center hemodialysis (IHD) groups. For the first catheter used, the rate of catheter-related sepsis was not significantly different between the NHHD (1.77 per 100 patient months) and IHD (2.03 per 100 patient months; P = 0.21). Combining all catheters, the rate of bacteremia/sepsis per 100 patient months in the NHHD group was 1.51 and in the IHD group was 2.01 (P = 0.35). Median catheter lifespan for the first catheter was 5.6 (1.7∼19.0) for NHHD and 4.6 (2.7∼7.8) for the IHD group (P = 0.64), and for all catheters used was 5.2 (Q1∼Q3 = 1.5∼15.2) months in NHHD group, and 4.1 (2.0∼6.8) months in IHD group (P = 0.20). The rate of bacteremia and death is not different for up to 20 months in catheter users who dialyze via frequent NHHD vs. thrice weekly IHD.

Mortality in hemodialysis patients over 65 years of age.

Introduction:Based on the statistics the population in Bosnia and Herzegovina is getting older. In 2013 the average life span for women was 73.6 years and 68.1 for men. The chronic hemodialysis program is mainly reserved for elderly patients with high mortality risk. The most common cause of hemodialysis mortality relates to cardiovascular diseases (60.2%), regardless of frequent innovations and improvement of hemodialysis procedures.The aim of the study:was to determine the mortality rate by age groups with comments on the presence of non-traditional predictors (anemia, hypoalbuminemia, CRP, vascular access and PTH) in dialysis patients in the follow-up period of 36 months.Methods:The study included all patients undergoing chronic hemodialysis treatment at the Clinic of Hemodialysis of the Clinical Center University of Sarajevo (CCUS).Results:Out of a total number of hemodialysis patients (n=232), the specific mortality rate in patients under 65 years of age was 16.8%, and 50.5% in patients over 65 years of age. According to the age groups the mortality rate in elderly patients is as follows: from 65 to 74 years (45.1%), from 75 to 84 years (55.0%), over ≥85 years (75.0%). The most frequent vascular access in patients under and above 65 is arteriovenous fistula (79.6% and 62.1 %), temporary hemodialysis catheter (11.7% and 43.8 %) and long-term hemodialysis catheter (8.8% and 4.2 %). In the age group under 65 years of age the temporary hemodialysis catheter is significantly and more frequently used in diseased patients in respect to survivors (34.8% vs. 7.0%) [χ2(2)=15.769, p=0.001]. Diseased patients from the age group over 65 had a significantly lower mean value of haemoglobin in blood (M=100.9±17.5 g/L) in respect to survivors (M=109.2±17.1)[t(93)=2.339; p=0.021], lower mean value of albumin in blood (Me=32.0; IQR=29.0 do 35.0) in respect to survivors (Me=34.0; IQR=32.0 to 38.0) [U=762.5; p=0.006], and higher mean value of CRP in blood (Me=19.3 mg/L; IQR=6.6 to 52.0) in respect to survivors (Me=7.8; IQR=4.0 to 16.7) [U=773.5; p=0.008]. Diseased patients belonging to the age group over 65 had lower mean value of PTH, but without statistical significance (p>0.05).Conclusion:older age, temporary vascular access, anaemia and hypoalbuminemia are strong predictors of mortality in hemodialysis patients. Old age does not present contraindication for hemodialysis treatment, and treatment of terminal renal illness should not be abandoned.

Prospective study of 51 patients with immediate or early malfunction of long-term hemodialysis catheters

Introduction: Long-term dialysis catheters provide an important access for hemodialysis for patients with end-stage renal disease. They are however associated with a significant incidence of early malfunction. The present study aims at identifYing the various causes of long term dialysis catheter early malfunction as well as the accuracy of the currently used diagnostic modalities for assessment of such causes. Patients and methods: 51 patients (24 males 27 females, mean age 64.6 years) with early long term dialysis catheter malfunction were included in the study. All patients were evaluated by duplex ultrasonography and magnetic resonance venography (MRV) and results ofthe two diagnostic modalities were compared. Results: Both duplex scan and MRV demonstrated central venous thrombosis in 4 patients (7.8%). Central venous attenuation or stenosis secondary to previous catheter insertion was identified in 13 cases (25.5%) by MRV but was only detected in 3 cases (5.9%) by duplex ultrasonography (p > 0.001). Conclusion: Causes of catheter malfunction in the present study included malposition, intra or peri-catheter thrombosis, and central vein attenuation or stenosis. While duplex scan and MRV were equally accurate in detection of central venous thrombosis, MRV was much more sensitive in detection of central vein attenuation or stenosis. We recommend the wider use of MRV for investigating patients with early malfunction of such dialysis catheters as well as for preoperative evaluation of patients with previous catheter insertion

Placement of long-term hemodialysis catheter (permcath) in patients with end-stage renal disease through external jugular vein.

Background:The number of patients with End-Stage Renal Disease (ESRD) has progressively increased in the population. Kidney transplantation is the specific treatment for such patients; however a majority of patients will require hemodialysis before kidney transplantation. The present study aims to investigate using the external jugular vein (EJV) for Permcath placement in these patients.Materials and Methods:This descriptive and analytical study was conducted in Alzahra Medical Center, Isfahan, in 2012. Catheters were inserted by cutting down the right EJV. The patency rate and potential complications were studied. The obtained data was analyzed using SPSS 21.0.Results:Out of 45 live patients, within three months of surgery, 40 patients (81.6%) had no complications and dialysis continued through Permcath. Permcath Thrombosis occurred in two patients (4.4%). Catheter infection led to the removal of it in one patient (2.2%) 1.5 months after surgery. And accidental catheter removal occurred in one patient.Conclusion:Placement of the permcath in the external jugular vein can be a safe, uncomplicated, and reliable method for patients requiring hemodialysis, and can be a life-saving alternative in patients without accessible internal jugular vein.

A Refinement of Hong's Technique for the Removal of Stuck Dialysis Catheters: An Easy Solution to a Complex Problem

A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety. We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists. All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel. Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus' egg in this previously risky field.

Sodium citrate 4% versus heparin as a lock solution in hemodialysis patients with central venous catheters

The effects of heparin versus sodium citrate 4% as a lock solution on catheter-related infections (CRIs), catheter patency, and hospitalizations in long-term hemodialysis patients with central venous catheters (CVCs) were compared. Data for patients receiving heparin lock solutions were collected from July 2008 to July 2009. Data on patients receiving sodium citrate 4% lock solution were collected from September 2009 through December 2010. Patients who were receiving the heparin lock solution who continued to have a CVC in September 2009 were transitioned from heparin to sodium citrate catheter 4% lock solution. New patients with CVCs placed after September 2009 received sodium citrate 4% without a period of using heparin lock solution. Pertinent information on patient medical history, bleeding or clotting events, infections, and hospitalization was collected. Data were collected retrospectively for the heparin group and prospectively for the sodium citrate group. Data were collected from 360 patient-months among 60 patients during the heparin treatment period and from 451 patient-months among 58 patients during the sodium citrate period. Thirty-three patients were common to both study groups. There were significantly more CRIs and CRIs per 1000 catheter-days in the heparin than the sodium citrate treatment group. Secondary outcomes of hospitalizations and catheter thrombosis were comparable. CRIs and thrombosis led to significantly more catheter exchanges or removals in the heparin group than the sodium citrate group. In patients with long-term hemodialysis catheters, a lock solution of sodium citrate 4% was associated with fewer CRIs and similar effectiveness when compared with heparin 5000 units/mL.

Chlorhexidine-based antiseptic solutions effectively reduce catheter-related bacteremia

The aim of this retrospective study was to investigate if the application of chlorhexidine-based solutions (ChloraPrep) to the exit site and the hub of long-term hemodialysis catheters could prevent catheter-related bacteremia (CRB) and prolong catheter survival when compared with povidone-iodine solutions. There were 20,784 catheter days observed. Povidone-iodine solutions (Betadine) were used in the first half of the study and ChloraPrep was used in the second half for all the patients. Both groups received chlorhexidine-impregnated dressings at the exit sites. The use of ChloraPrep significantly decreased the incidence of CRB (1.0 vs 2.2/1,000 catheter days, respectively, P = 0.0415), and hospitalization due to CRB (1.8 days vs 4.1 days/1,000 catheter days, respectively, P = 0.0416). The incidence of exit site infection was similar for the two groups. Both the period of overall catheter survival (207.6 days vs 161.1 days, P = 0.0535) and that of infection-free catheter survival (122.0 days vs 106.9 days, P = 0.1100) tended to be longer for the catheters cleansed with ChloraPrep, with no statistical significance. In conclusion, chlorhexidine-based solutions are more effective for the prevention of CRB than povidone-iodine solutions. This positive impact cannot be explained by decreased number of exit site infections. This study supports the notion that the catheter hub is the entry site for CRB.