Tunneled Cuffed Hemodialysis Catheters Research Articles

#3055 Replacement of tunneled cuffed hemodialysis catheters on coated guidewire: a strategic approach to treat CVC-related infections

Abstract Background and Aims Infections of tunneled hemodialysis central venous catheters (CVCs) are a serious problem, and the outcome of dialysis patients strongly depends on their clinical management. Several specialists are involved in choosing the appropriate technical and clinical strategy but often there is no consensus among them on the proper management. We believe that the role of nephrologists must be pivotal in this setting throughout the entire process, from the choice of vascular access to the management of complications. Here, we present our experience using an approach to replace CVCs that was conceived to minimize the rate of infections. Method We propose a CVC replacement technique to minimize the risk of contamination by using a guidewire coating that allow no contact between the old and new CVC. We carried out a retrospective observational study of tunneled CVCs replacement with this technique performed at the Nephrology Unit of the "A. Gemelli Polyclinic" between January 2020 and June 2023. The following parameters were analyzed: age, sex, infection-supporting pathogen, CVC age, and dialysis age. Results During the reporting period, we carried out a total of 87 CVC guidewire replacement procedures for HD tunneled catheters defined “access to be preserved” using our technique. Among the patients (median age 70,6) undergoing this procedure, n=5 (5.75%) presented with endocarditis (n=4 by Staphylococcus aureus, n=1 by Pseudomonas aeruginosa). The follow-up ranged from 6 months to 3 years. During this time only one patient, with endocarditis, had a recurrent infection caused by Pseudomonas aeruginosa after 3 months from the CVC replacement whereas 12 patients presented a de novo CVC infection caused by a different pathogen (n=4 by Staphylococcus aureus, n=1 by Pseudomonas Aeruginosa. Conclusion Overall, our data are encouraging as the lower rate of recurrent infections in our cohort suggests that our CVC replacement technique can be potentially used even in case of dangerous pathogens.

Clinical outcomes for femoral tunneled-cuffed hemodialysis catheters with different tip positions: A single-center retrospective study.

Tunneled-cuffed catheter (TCC) reaching the mid-atrium has been demonstrated to be associated with improved catheter survival. However, whether similar conclusions can be made for femoral TCC reaching the inferior vena cava (IVC) remains unknown. Data from 47 patients with end-stage renal disease receiving right femoral TCC were retrospectively collected and analyzed. The primary patency, catheter dysfunction, and TCC-associated infection rate were compared between patients with TCC tip at the IVC and those with TCC tip at non-IVC. TCC tips were located at the IVC in 26 patients and non-IVC in 21 patients. The technical success rates for both groups were 100%. The primary patency of the former group were significantly higher than those of the latter group at 3 months (92.3% vs 61.9%, p = 0.011), 6 months (80.8% vs 52.4%, p = 0.017), and 12 months (50.0% vs 28.5%, p = 0.024) follow-up, respectively. Kaplan-Meier curve analysis demonstrated significantly different catheter dysfunction-free survival between the two groups (log-rank p = 0.017). The overall TCC-associated infection rate was similar between the two groups (7.7% vs 9.5%, p = 0.82). Femoral TCC with tips at IVC was associated with higher primary patency, lower catheter dysfunction but similar TCC-associated infection rate as compared with those at non-IVC.

Risk Factors Associated with Dysfunction of Permanent Tunneled Cuffed Hemodialysis Catheters; Single Center Experience

Risk Factors Associated with Dysfunction of Permanent Tunneled Cuffed Hemodialysis Catheters; Single Center Experience Introduction: Permanent tunneled cuffed catheters are frequently preferred for hemodialysis in patients with chronic renal failure (CRF), but the factors associated with the dysfunction of these catheters are not well known. Our goal is to investigate these risk factors. Materials and Methods: All cases with a diagnosis of CRF and a permanent tunneled cuffed catheter inserted into the central vein for the first time in our radiology clinic between 2014 and 2019 and who developed catheter dysfunction were included in the study. Demographic and clinical data of the cases were obtained from file records. The relationship between the causes of catheter dysfunction and the presence of diabetes and hypertension was investigated. Results: Of the total 123 cases, 78 (63.4%) were male, 45 (36.6%) were female, the median age was 55 (28-78). Twenty-nine (23.6%) of the cases had thrombosis, 72 (58.5%) had venous stenosis and 22 (17.9%) had catheter dysfunction due to fibrin sheath. Dysfunction groups were compared with each other in terms of age, gender, duration of operation of the catheter, CRF etiology, comorbid diseases, the vein where the catheter was placed and the use of anticoagulants. The most important cause of catheter dysfunction in the early period was thrombosis (p = 0.003). When the causes of dysfunction were examined, the most common causes of dysfunction were venous stenosis in patients with hypertension, thrombosis in patients with diabetes as a concomitant disease without diabetes in the etiology of CRF, and thrombosis in patients with diabetes in CRF etiology (p 0.05). Conclusion: The use of low-dose anticoagulants plays a protective role against thrombosis. The use of low-dose anticoagulants in patients without contraindications, especially in diabetic patients, may reduce especially early catheter dysfunction.

Detecting the prevalence of bacterial colonization on tunneled cuffed hemodialysis catheters using quantitative PCR targeting 16S rRNA and scanning electron microscopy

Tunneled cuffed hemodialysis catheters (TCC) get colonized by microorganisms, increasing risk for catheter related bacteremia (CRB). Our objective was to detect the prevalence of bacterial colonization of TCC by using quantitative PCR (qPCR) targeting 16S rRNA and by determining the intraluminal adherent biological material (ABM) coverage. A total of 45 TCC were investigated. The 16S rRNA qPCR technique was used to detect bacterial colonization after scraping the intraluminal ABM. Proximal, middle, and distal TCC were evaluated by scanning electron microscopy (SEM) to determine the percentage (%) of intraluminal ABM coverage. All catheters were cultured following sonication. A total of 45 TCC were removed: 7 due to CRB, 3 for suspected CRB and 35 were removed for non-infectious etiologies. Bacterial colonization was detected in 27 TCC by documenting 16S rRNA qPCR (+) results (60%). Seven of these 16S rRNA qPCR (+) catheters were removed due to CRB. There was no difference in demographic, clinical, or laboratory values between the 16S rRNA (+) versus (-) TCC. The 16S rRNA qPCR (-) outcome was highly associated with CRB-free status with negative predictive value of 100%. Bacterial colonization was documented in 10 TCC using catheter cultures (22%), which was significantly less compared to qPCR method (p = 0.0002). ABM were detected in all catheter pieces, with mean intraluminal surface coverage (ABMC) of 68.4 ± 26.1%. ABM was unlikely to be microbial biofilm in at least 36% of removed TCC as their 16S rRNA qPCR and catheter culture results were both negative. Detecting bacterial colonization of TCC was significantly higher with 16S rRNA qPCR compared to catheter cultures. The 16S rRNA qPCR (-) cannot be predicted and was strongly associated with absence of CRB. Intraluminal ABM was not associated with microbial presence in about 1/3 of the TCC. These pieces of evidence may help to improve prophylactic strategies against CRB.

Outcomes of tunneled cuffed hemodialysis catheters: An experience from a tertiary care center in Karachi, Pakistan.

Tunneled cuffed catheters (TCC) are generally used as a temporary means to provide hemodialysis (HD) until permanent arteriovenous access is established. However, certain complications are associated with use of TCCs such as infections, catheter malfunction/malposition or venous stenosis. Limited data is available on outcomes and long term complications associated with TCCs in our country. The aim of this study was to study the outcomes of TCCs and associated long term complications during the course of its usage. We retrospectively studied case records of patients who had TCCs placed for HD at our institution, from January 2016 to June 2018. A total of 116 TCCs were placed during the study period. The mean age of the population was 57.09 years; 58.6% were males. The right internal jugular vein (52.6%) was the most common site of TCC insertion followed by the left internal jugular vein (29.3%). Functioning TCCs were successfully removed in almost two-thirds of cases (65.7%) once their permanent access was mature. Development of catheter related blood stream infection (CRBSI) was seen in 22 patients (19.8%) requiring catheter removal in 14 (12.6%) patients. Mechanical complications leading to catheter removal were seen in seven patients (6.3%). The median catheter duration was 62.5 days ranging from 1 to 343 days. TCCs, though associated with complications particularly CRBSI, are a viable option for short- to intermediate-term use for HD till the maturation of permanent arteriovenous access in a limited-resource setting.

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.

Bedside Tunneled Dialysis Catheter Removal-A Lesson Learned From Nephrology Trainees.

Semi-permanent dual-lumen tunneled (or tunneled-cuffed) hemodialysis catheters (TDC) are increasingly utilized during renal replacement therapy, while awaiting permanent access maturation or renal recovery. Although there is a wealth of literature focused on placement, infection prevention, and maintenance of catheter patency, circumstances and indications for TDC removal are less well understood. Timely removal of these catheters is an important management decision, with the length of TDC duration representing the largest cumulative risk factor for catheter-associated blood stream infections. Waiting for assistance from surgical or radiological services-which may not be available in all hospitals-may result in delays in services and potential harm to the patients. Imparting and maintaining procedural skills to remove infected TDC may be very valuable for training programs in clinical nephrology. In this article the current literature on bedside TDC removal, including potential anticipated complications during removal, are reviewed. To date, the authors have documented successful implementation of bedside TDC removal in training programs from two different settings, including both in- and outpatients and with trainee involvement. In summary, training general nephrologists for bedside TDC removal will afford immediate removal of infected hardware in ill patients and avoid potential delays in outpatient setting.

Controlling exit site infections: Does it decrease the incidence of catheter‐related bacteremia in children on chronic hemodialysis?

The aim of this retrospective study was to investigate whether the application of a chlorhexidine-impregnated dressing (Biopatch) at the exit site of tunneled-cuffed hemodialysis catheters has any effect on the incidence and etiology of catheter-related bacteremia (CRB). This study was carried out over a 5-year period in a single center, where, in the first 2(1/2) years, the exit sites were cleansed with betadine at every hemodialysis session and then covered with a transparent dressing (pre-Biopatch Era). During the next 2(1/2) years, Biopatch was applied to the exit site once a week after cleansing with betadine, and then covered with a transparent dressing (Biopatch Era). The application of Biopatch significantly decreased the incidence of exit site infections (ESI) (P<0.05). However, there was no difference in the incidence of CRBs or their microbiological distribution. The improved ESI rate had no effect on the overall catheter survival time. The antimicrobial sensitivities of the Gram-positive microorganisms were statistically different for the 2 different types of infections (P<0.05). In conclusion, even though Biopatch is effective in decreasing the incidence of ESI, it has no effect on the incidence of CRB, the etiology of CRB, or the overall catheter survival time. The distinct difference between the antimicrobial sensitivities of the ESI and CRB suggests that they are not a spectrum of the same pathogenesis. These preliminary data support the intraluminal pathogenesis of CRB, rather than the exit site as a possible entry point for the extraluminal route.

Catheter survival and comparison of catheter exchange methods in children on hemodialysis

This retrospective study was done to compare the infection-free and overall survival of first and subsequent tunneled cuffed hemodialysis catheters in children. Subsequent catheters were exchanged by two different methods (a) removal and replacement (R&R), or (b) wire-guided exchange (WGE) using the same tunnel and vessel. The study involved 59 children (27 male, 32 female; mean age 13.9 +/- 4.6 years) undergoing maintenance hemodialysis in a pediatric unit over a period of 60 months. From a total of 175 catheters (57 first catheters, 81 WGE, 37 R&R) and 38,888 catheter days, 74/175 (42%) catheters were exchanged because of catheter-related bacteremia (CRB) and 43/175 (25%) for malfunction or cuff extrusion. One-year survival rates for first and consecutive catheters was 26% and 21%, respectively. The overall survival of first catheters, and those exchanged by WGE and R&R for both infectious and non-infectious reasons, was not statistically different. However, infection-free survival of first catheters was significantly prolonged in comparison with that of subsequent catheters (P < 0.001). The infection-free survival and the overall survival were not affected by etiology of primary disease, gender, serum albumin, or hemoglobin. Overall catheter survival increased with age >10 years. There was a significant association between gram-negative and polymicrobial CRB and requirement for R&R (P < 0.02). Our findings suggest that WGE is safe in a clinically stable child if the tunnel and the exit site are not infected and has the potential benefit of preserving the vascular access site. The shorter infection-free survival in subsequent catheters suggests a cumulative disadvantage with prolonged catheter use.

Cefotaxime lock improves survival of tunneled cuffed hemodialysis catheters in diabetics

Cefotaxime lock improves survival of tunneled cuffed hemodialysis catheters in diabetics

Catheter lock heparin concentration: Effects on tissue plasminogen activator use in tunneled cuffed catheters

The optimal cost-effective heparin concentration for locking tunneled cuffed hemodialysis catheters (TCC) is unclear. We performed a retrospective review of tissue plasminogen activator (tpa) use in TCC in 2 hemodialysis units that used different heparin concentrations for TCC lock to evaluate the effectiveness of lower dose heparin as a lock for TCC. Catheter blood flow rate per treatment, units of heparin given during treatments, patient hemoglobin values and use of warfarin, and tpa use were compared for all patients using TCC for at least 3 months in 2 in-center hemodialysis units between 11/04 and 5/05. Both units used the same type of catheters and biocompatible, non-re-use dialyzers. Unit A used heparin 1000 U/mL for catheter locks, and Unit B used heparin 10,000 U/mL for catheter locks. Twelve of 19 Unit A patients, tpa and 14 of 45 Unit B patients received intracatheter during the study period (p=0.0009). There were no differences in the number of patients on warfarin, treatment blood flow rate, or mean hemoglobin levels between the 2 groups. The mean heparin units given during hemodialysis treatments was higher in Unit A patients (3.92+/-2.2 vs. 3.83+/-2.5 1000 U, p=0.05). Assuming a 4.1 mL total catheter lumen volume, the cost of heparin 1000 U/mL lock was 0.20 dollars per treatment and heparin 10,000 U/mL cost 2.67 dollars/treatment; tpa cost 89.02 dollars/use. Using the 10,000 U/mL heparin as a catheter lock was associated with less frequent use of tpa. However, the significantly lower cost of the 1000 U/mL heparin could result in significant savings despite higher tpa use. This retrospective, uncontrolled study of a small number of patients suggests that comparing low and high heparin concentrations as a TCC lock would be worthwhile. Prospective studies would be helpful to define the most appropriate and cost-effective lock for TCC.

Insertion of Long-Term Tunneled Cuffed Hemodialysis Catheters via the External Jugular Vein by using a Simple, Safe and Reliable Surgical Technique

ObjectiveDescription of our technique for the insertion of long-term tunneled cuffed hemodialysis (HD) catheters via the external jugular vein.MethodsFrom 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.ResultsDuring 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 &gt;300 ml/min. No major complications occurred.ConclusionsLong-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.

Hemodialysis Complications

Hemodialysis Complications

Treatment of dialysis catheter infections in 2004

Hemodialysis catheter associated infections are a major source of morbidity and mortality in end stage renal disease patients. There is disagreement about the management of catheter infections, particularly concerning the removal of potentially infected tunneled dialysis catheters. A dialysis catheter should generally be removed when an infection involves a temporary hemodialysis catheter, a septic patient, a patient with a tunnel tract infection, or a patient with evidence of a metastatic infectious complication. In treating stable patients with clinically mild catheter associated bacteremia, parenteral antibiotics alone have a low success rate in eliminating the infection. Antibiotic locks are an emerging strategy for treating these patients, but at present higher rates of success and lower costs are achieved by exchanging the catheter over a guidewire. Antibiotic lock solutions, antibiotic coated catheters, and totally implantable dialysis access systems may play a large role in prevention of catheter associated infections in the future; however, further randomized controlled trials of these strategies are needed. Future efforts should concentrate on limiting the use of traditional tunneled cuffed hemodialysis catheters by early referral to vascular surgery for the creation of an arterio-venous fistula.

Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters.

In the existing literature, there is a paucity of data regarding large atrial thrombus (AT) formation occurring as a complication of tunneled cuffed hemodialysis catheter (TCC) use. This study was performed to determine the risk factors, mortality and the appropriate management of TCC-AT. We report 6 new cases of TCC-AT and have amalgamated these data with data from 16 previously published cases of TCC-AT found by performing a PubMed literature search (total of 22 cases). Demographic data were collected prospectively over 2 years in 85 consecutive patients initiating hemodialysis who were using a TCC as their primary vascular access, so that comparisons could be made between the 6 patients with TCC-AT versus all patients with a TCC at our center. In patients with TCC-AT, the mean time from TCC insertion was 4.5 months, and infection was present at the time of diagnosis in 68% of cases. The mean thrombus size was 3.7 cm, range 1.5-8 cm. All but 1 case were visualized by echocardiography; the remaining case required magnetic resonance imaging. Management included TCC removal and thrombectomy (n = 9), TCC removal and anticoagulation (AC) (n = 6), TCC removal alone (n = 5), and no intervention (n = 2). The overall mortality was 27%, and 5 of the 6 deaths (83%) occurred in patients with bacteremia. The mortality associated with each management strategy was as follows: TCC removal and thrombectomy (0%), TCC removal and AC (33%), TCC removal alone (40%), and no intervention (100%). AT is a serious complication of TCC use in hemodialysis patients and may be associated with a high mortality rate. TCC-AT may occur more commonly than previously reported and therefore warrants a high index of suspicion.