Tunneled Dialysis Catheter Placement Research Articles

Comparison of feasibility and effectiveness of tunneled dialysis catheter placement with or without DSA guidance: a propensity score-matched cohort study

Background In some resource-limited regions, the placement of tunneled dialysis catheters (TDC) is often preferred under ultrasound guidance rather than fluoroscopy. This study compared ultrasound-and digital subtraction angiography-guided (DSA)-guided TDC in renal replacement therapy. Methods This retrospective cohort study included all TDC placements performed at our hospital between January 2020 and October 2022. We utilized 1:1 propensity score matching (PSM) to balance the demographic and clinical characteristics of the DSA-guided and ultrasound-guided groups. Dialysis prescriptions and actual dialysis completion were assessed using intraclass correlation coefficients (ICC). Multivariable logistic regression analyses determined the risk factors for early termination of dialysis. The differences in adverse events, catheter function, and catheter tip position were evaluated between the two groups. Results The study included 261 patients (142 in the DSA-guided group and 119 in the ultrasound-guided group). After PSM, 91 patients were included in each group, with no significant baseline differences (p > .1). Both groups achieved adequate catheter blood flow and ultrafiltration volumes without deviations from dialysis prescriptions (ICC ≥ 0.75). The DSA-guided group had fewer early dialysis terminations than the ultrasound-guided group (3.3 vs. 12.0%, p = .026). The position of the catheter tip in the right atrium was more consistent in the DSA-guided group (100 vs. 74.2%, p < .001). Conclusion Hemodialysis catheters inserted under DSA guidance exhibited superior performance compared to those inserted under ultrasound guidance, primarily due to more accurate catheter tip positioning. DSA guidance is recommended when ensuring optimal catheter tip placement.

Tunneled femoral dialysis catheters and factors affecting their outcome: a single institution experience.

To assess a single-center experience with tunneled femoral dialysis catheter usage and outcomes and to identify any operator-dependent factors related to risk of premature catheter failure. Retrospective review of the institutional radiology information system for tunneled femoral dialysis catheter placement from 2010 to 2017 was performed. Patients for whom the catheter was placed for an indication other than dialysis or who were less than 18 years of age at the time of catheter placement were excluded. Premature catheter failure rate, cause of premature failure, catheter patency (in days) and infection rate were assessed. Operator/placement characteristics, including laterality, catheter tip placement, and catheter length were also assessed. A total of 101 patients were included in the study. This included n = 116 catheter placements. Thirty-four percent of patients (n = 40) were lost to follow-up, resulting in n = 61 patients and n = 76 catheters analyzed. Premature catheter failure rate was 48% (n = 36), with low flows being the foremost cause of failure (64%, n = 23). Average primary patency of these catheters was 82.4 days (1-328 days). About 8% of catheters (n = 3) were complicated by infection, resulting in an infection rate of 0.4/1000 catheter days. None of the operator-dependent factors analyzed, including catheter laterality, catheter tip placement, and catheter length, demonstrated a significant association with premature catheter failure. Institutional primary access patency rates are comparable to or higher than previously published data, while infection rates are similar to or lower than those reported in the literature. None of the operator-dependent factors related to placement was shown to significantly decrease the risk of premature catheter failure. These findings suggest that while femoral dialysis catheters do not function well in the long term relative to internal jugular vein dialysis catheters, prior literature may undervalue their utility and function, particularly given that these catheters are used as a "last resort" for many patients.

Comparison of the complications and long-term results of heparin-coated and non-heparin-coated symmetric-tip hemodialysis catheters.

Tunneled catheters are effectively used in patients receiving chronic dialysis due to end-stage renal disease. However, the dysfunction of catheters caused by infection or thrombus requires repetitive procedures. In this study, we aimed to compare the long-term results of heparin-coated and non-heparin-coated tunneled dialysis catheters. The study included a total of 161 patients who underwent tunneled dialysis catheter placement. Heparin-coated and non-heparin-coated tunneled catheters were placed in 81 and 80 patients, respectively. Of all the patients, 89 (55.3%) were male and 72 (44.7%) were female. The mean age of the patients was 64.3 ± 15.3 years. The patients were followed up for 12 months. Catheter infection developed in 10 (6.2%) of the cases, of which seven (70%) resolved with antibiotic therapy and the remaining three (30%) required catheter replacement. There was no significant difference between the groups in terms of the catheter infection rate (p = 0.84). Fibrin sheaths developed in nine (5.5%) patients. Fibrin sheath development was found to be significantly higher in the non-heparin-coated catheters (p = 0.017). There was no significant difference in fibrin sheath formation between the patients with and without systemic antiaggregant use (p = 0.864). The mean catheter durability time was determined to be 11 months in both groups (p = 0.704). Catheter survival was similar in heparin-coated and non-heparin coated catheters. This study showed that the rate of fibrin sheath development was significantly lower in heparin-coated tunneled catheters than non-heparin-coated catheters. There was no significant difference between the two catheters in terms of the rates of infection and mechanical complications.

Comparison of supraclavicular brachiocephalic and femoral vein approaches for tunneled dialysis catheter placement in patients with thrombosed internal jugular veins.

There is still debate on the best access route in case of bilateral internal jugular vein thrombosis. We aimed to compare the safety, effectiveness, and outcomes of tunneled dialysis catheter placement via supraclavicular brachiocephalic and femoral vein approaches in patients with bilateral internal jugular vein thrombosis. Between January 2018 and December 2021, data of the patients in whom tunneled dialysis catheters were placed via the supraclavicular brachiocephalic vein (n = 42) and femoral vein (n = 57) approaches were extracted. Patient demographics, technical and clinical success rates, complications, and outcomes were noted. The Likert scale was used to assess patient satisfaction. Forty two (42.4%) patients were men, and the mean age was 61.9 (range, 12-93) years. The technical and clinical success rate was 100% for both groups. No major complication was encountered. The mean follow-up period was 497.5 (range, 32-1698) catheter days. Thirty-day patency was similar for the brachiocephalic vein and femoral vein group (40 [95.2%] vs. 55 [96.5%], p = 0.754). Also, primary and cumulative patency rates were comparable (p = 0.158; p = 0.660). The infection rate was 2.6 and 4.1 per 1000 catheter days for the brachiocephalic vein and femoral vein group. The infection-free survival was significantly higher in the brachiocephalic vein group (71.9% vs. 35.3% at 12 months, p < 0.001). Patient satisfaction was higher in the brachiocephalic vein group (median satisfaction, 5 vs. 4, p < 0.001). Both supraclavicular brachiocephalic vein and femoral vein approaches have high technical and clinical success with comparable patency rates. However, low infection rate and high patient satisfaction make the supraclavicular brachiocephalic vein approach a reasonable alternative before proceeding to the femoral vein access.

Recent Evaluation by a Nephrologist Prior to First Arteriovenous Access Creation Is Associated with Less Tunneled Dialysis Catheter Placement

Recent Evaluation by a Nephrologist Prior to First Arteriovenous Access Creation Is Associated with Less Tunneled Dialysis Catheter Placement

Abstract No. 29 Tunneled Dialysis Catheter Placement within Intensive Care Unit (ICU) Patients: Influence of Catheter Tip Design on Clinical Performance

Tunneled dialysis catheter tip design may affect freedom from catheter dysfunction and/or infection; improved performance within a critical care setting may reduce costs and need for catheter guidewire exchange or removal. This study compared rates of catheter failure between a symmetrical, helical-tip catheter (VectorFlow) with a conventional split-tip catheter (Ash-Split) among ICU patients undergoing tunneled dialysis catheter placement. A retrospective database identified a total of 1734 tunneled dialysis catheters placed at an academic institution over a 7-year period. Of these, 340 catheters (19.6%) were placed within ICU patients, which included VectorFlow (n = 112, 32.9%) and Ash-Split (n = 228, 67.1%) catheters. Rates of catheter failure requiring guidewire exchange or removal from a composite outcome of malfunction or infection were compared with Kaplan-Meier estimates, and covariates potentially influencing catheter failure were assessed with Cox proportional hazards modeling. Catheter failure occurred within 90 days in 34.8 ± 3.4% of ICU patients. Among patients with VectorFlow catheters, primary unassisted patency at 30, 60, 90 and 180 days was 87.4 ± 3.6%, 78.0 ± 5.1%, 75.1 ± 5.0% and 60.1 ± 8.2% compared with 75.0 ± 3.3%, 62.8 ± 4.1%, 60.7 ± 4.2% and 44.3 ± 5.5% among patients with Ash-Split catheters (P = 0.022). Cox modeling of body mass index, patient age, sex, left jugular (vs. right) placement and indication for placement (initiation of hemodialysis access vs. failed surgical arteriovenous access) showed no effect on catheter patency; patients with Ash-Split catheters had a hazard ratio of catheter failure 1.72 times higher than patients with VectorFlow catheters (P = 0.024) in univariate modeling and a hazard ratio of 1.81 in multivariate modeling (P = 0.017). The VectorFlow catheter was associated with significantly higher rates of primary patency than the Ash-Split catheter among ICU patients, independent of multiple clinical and anatomic factors. These data support a VectorFlow-first placement strategy within this patient population.

Supraclavicular Brachiocephalic Vein Access for Tunneled Dialysis Catheter Placement in Patients with Bilateral Internal Jugular Vein Thrombosis

Supraclavicular Brachiocephalic Vein Access for Tunneled Dialysis Catheter Placement in Patients with Bilateral Internal Jugular Vein Thrombosis

Revision of Aneurysmal Arteriovenous Access with Immediate Use Graft Is Safe and Avoids Prolonged Use of Tunneled Hemodialysis Catheters

Aneurysmal arteriovenous fistulas (AVF) can pose a difficult treatment dilemma for the vascular surgeons. Prolonged tunneled dialysis catheters (TDCs) in patients requiring long-term dialysis are associated with significantly increased mortality compared to AVF. We aimed to elucidate the outcomes of aneurysmal arteriovenous (AV) access revision with aneurysm resection and Artegraft® (LeMaitre, New Brunswick, NJ) Collage Vascular Graft placement to avoid prolonged use of TDCs. We reviewed all patients with aneurysmal AV access in whom the access was revised with aneurysm resection and jump graft placement at a single institution from 2018 to 2021. Outcomes were time to cannulation, reintervention rates, time to reintervention, and patency (primary, primary assisted, and secondary). Patency rates were estimated with Kaplan-Meier Survival analysis. A total of 51 revised aneurysmal AV accesses in 51 patients were studied, of which 23.5% (n=12) had perioperative TDC placement. Three patients were done for emergent bleeding. The cohort was 62.8% male (n=32) with a median age of 58years (interquartile range: 49-67). Most patients had brachiocephalic AVF (n=37 [72.6%]). The median follow-up time was 280days. The median time to cannulation was 2days. Time to cannulation was significantly longer in patients with perioperative TDC as compared with those without TDC (24days vs. 2days, P<0.001). Reintervention was required in 41.2% of patients (n=21), at median time of 47days. At 30, 90, 180, and 365days, primary patency rates were 84.3%, 78.3%, 66.6%, and 54.9%; primary assisted patency rates were 94.1%, 88.1%, 79.4%, and 79.4%; and secondary patency rates were 100%, 97.8%, 91.6%, and 91.6%, respectively. The revision of aneurysmal AV access (urgent or elective) with Artegraft as jump graft is safe, with acceptable short- and mid-term patency results. This allows dialysis patients to continue to have a functional access, decreasing the need for a tunneled catheter and reducing the associated risk of sepsis and increased mortality. This should be considered for all patients with aneurysmal, dysfunctional fistulas to maintain AV access and avoid TDC placement.

Inside-Out Central Venous Catheter Placement Through an Occluded Stent

In this video, we present the case of inside-out tunneled dialysis catheter placement through an occluded brachiocephalic stent and demonstrate the role of intraoperative cone-beam computed tomography guidance in enhancing the safety of this procedure.

Challenges with tunneled dialysis catheter placement with subcutaneous emphysema.

Central vein catheter is a convenient and preferred vascular access for blood purification therapy in intensive care unit. Utilizing ultrasound to access the central vein is considered standard of care. However, critically ill patients can pose challenges while acquiring an optimal ultrasound image. The presence of subcutaneous air pockets, concerns for air embolism, and excessive bleeding from the exit site is one such clinical situation. We describe our experience with a unique situation while placing a tunneled dialysis catheter in a COVID-19 patient with acute respiratory failure and subcutaneous emphysema.

Revision Of Aneurysmal Arteriovenous Access With Immediate Use Graft Is Safe And Avoids Prolonged Use Of Tunneled Hemodialysis Catheters

<h3>INTRODUCTION AND OBJECTIVES</h3> Tunneled dialysis catheters (TDC) in patients requiring long-term dialysis are associated with significantly increased mortality compared to arteriovenous fistulas (AVF). Aneurysmal AVF pose a difficult treatment dilemma for vascular surgeons. We aimed to elucidate the outcomes of aneurysmal AV access revision with aneurysm resection and Artegraft Collage Vascular Graft placement to avoid prolonged TDC use. <h3>METHODS</h3> We reviewed patients with aneurysmal AV access in which the access was revised with aneurysm resection and jump graft placement at a single institution from 2018 to 2021. Outcomes were time to cannulation, reintervention rates, time to reintervention and patency. <h3>RESULTS</h3> A total of 41 patients with revised aneurysmal AV access were studied, of which 26.8% (n=11) had perioperative TDC placement. Three patients were done for emergent bleeding. The cohort was 58.5% male (n=24) with a median age of 58 years (IQR: 49-65). Most patients had brachiocephalic AVF (n=31 [75.6%]). Median follow up time was 315 days. Median time to cannulation was 3 days. Time to cannulation was significantly longer in patients with perioperative TDC as compared with those without TDC (24 days vs 1 day, P<0.001). Reintervention was required in 39.0% of patients (n=16), at median time of 30 days. At 30, 90, and 180 days, primary patency rates were 82.9%, 75.5% and 66.6%, primary assisted patency rates were 92.7%, 85.2% and 76.1%, and secondary patency rates were 100%, 97.4% and 90.9% respectively. <h3>CONCLUSIONS</h3> Revision of aneurysmal AV access with Artegraft as jump graft is safe, with acceptable short and mid-term patency results. This allows dialysis patients to continue to have a functional access, decreasing the need for tunneled catheter and reducing the associated risk of sepsis and increased mortality. This should be considered for all patients with aneurysmal, dysfunctional fistulas to maintain AV access and avoid TDC placement

Biochemical Factors Affecting Thrombosis Development in Permanent Tunneled Hemodialysis Catheter.

It is critical to clarify the biochemical factors associated with thrombosis development following tunneled dialysis catheter (TDC) insertion. The study involved retrospective analysis of charts of patients hospitalized for permanent TDC placement between 2013 and 2020 in a tertiary academic center. Patients undergoing a hemodialysis schedule with permanent TDC for more than three months were included in the study. To determine predictive factors associated with thrombosis development in permanent TDC, patients were assigned to one of two groups, according to the extent of thrombosis. The groups were compared in terms of demographic characteristics, blood test values, complication and length of follow-up period. A total of 350 patients (204 female, 146 male) were enrolled into the study. In patients with thrombosis the mean BMI was found significantly higher (p = 0.001) and presence of diabetes mellitus was significantly common (p = 0.014). Patients with thrombosis had significantly higher D-dimer (6.5 vs. 2.4 µg/mL, p = 0.001) and procalcitonin levels (4.1 vs. 1.4 ng/mL, p = 0.001). Additionally, patients with thrombosis had a significantly higher rate of infective complications (p = 0.014). Logistic regression analysis revealed that BMI > 30 kg/m2 and infective complications increased thrombosis risk 3.842 and 3.104 times (p = 0.004 and p = 0.038, respectively). Additionally, D-dimer level > 3 µg/mL and procalcitonin level > 2 ng/mL were significantly associated with the development of thrombosis (p = 0.001 and p = 0.007). The present study demonstrated that the presence of infection, higher BMI > 30 kg/m2, D-dimer level > 3 µg/mL and procalcitonin level > 2 ng/mL were found to increase the incidence of thrombosis.

Bacterial Load Associated With Tunneled Dialysis Catheters in Symptom-Free Hemodialysis Patients.

This study aimed to evaluate the rate of asymptomatic bacterial infection of tunneled dialysis catheters (TDCs) removed due to maturation of native arteriovenous fistula (nAVF) or catheter dysfunction in hemodialysis patients with no clinically apparent infection. A total of 229 patients (43.2% [n = 99] female and 56.8% [n = 130] male), who underwent hemodialysis through a TDC, were included in this study. Tip cultures of TDCs removed in an operating room and under sterile conditions were collected. All patients were asymptomatic for catheter infection and had not received antibiotic therapy for the last month. The median duration of catheterization was 80days (min: 5, max: 2880). Bacterial growth was observed in a total of 62 (27.1%) patients. The most common microorganisms were Staphylococcus epidermidis and Staphylococcus aureus. The asymptomatic infection rate was highest in catheters placed through the right and left subclavian veins; however, this was not statistically significant due to the small number of patients. Placement and usage time of TDCs were found to be the most significant factors for bacterial growth in the catheter tip culture (P < .001). Prolonged duration and use of the catheter is significant in terms of bacterial load. The use of TDC as vascular access in renal replacement therapy should be avoided as much as possible.

Safety of bedside placement of tunneled dialysis catheter in COVID-19 patients.

COVID-19 patients admitted to the ICU have high incidence of AKI requiring prolonged renal replacement therapy and often necessitate the placement of a tunneled dialysis catheter (TDC). We describe our experience with two cases of COVID-19 patients who underwent successful bedside placement of TDC under ultrasound guidance using anatomical landmarks without fluoroscopy guidance. Tunneled dialysis catheter placement under direct fluoroscopy remains the standard of care; but in well selected patients, placement of tunneled dialysis catheter at the bedside using anatomic landmarks without fluoroscopy can be safely and successfully performed without compromising the quality of care and avoid transfer of COVID-19 infected patients outside the ICU.

Safety and efficacy of placement of tunneled hemodialysis catheter without the use of fluoroscopy.

The implantation of acute or chronic vascular accesses for hemodialysis (HD) in end-stage kidney disease patients is a critical skill procedure for nephrologists, with an impact on short- and long-term outcomes of the modality and patient survival. Placement circumstances, however, may depend on the availability of technological support and will likely vary across the world. We retrospectively reviewed our local experience with ultrasound-guided tunneled dialysis catheter (TDC) insertions but without access to fluoroscopic guidance. Data were available for 63 patients with TDCs placed by faculty nephrologists at the dialysis unit procedure rooms between March 2015 and February 2018. We reviewed circumstances of TDC placement, patient characteristics, and procedural outcomes. The mean age was 62 (±41) years, and 46% of the patients were male. All TDC placements were technically successful and no major complications occurred. Most TDCs (52.8%) were a de novo placement. In the de novo patient group, there were 27 right-sided internal jugular vein (IJV) and 6 left-sided IJV cannulations. Blood pump flow was 284.6 (±58) mL/min via the temporary catheter 1month before and 316.7 (±46) mL/min 1month after TDC placement (p < 0.0001). The majority of catheter tips (63%) reached the right atrial placement position successfully. Technologically successful TDC placement can be performed without fluoroscopic tip guidance and result in improved access flows and dialysis efficacy when compared to temporary hemodialysis catheters.

Factors associated with a tunneled dialysis catheter in place at initial arteriovenous access creation

ObjectiveArteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival. MethodsWe performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival. ResultsOf 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P < .05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P < .001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P = .03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P = .02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P = .36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P = .63). ConclusionsThe absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals.

Spontaneous Dislodgement of Tunneled Dialysis Catheters after De Novo versus Over-The-Wire-Exchange Placement

PurposeTo evaluate dislodgement of tunneled dialysis catheters (TDCs) in de novo (DN) placement with ultrasound versus over-the-wire exchange (OTWE). Materials and MethodsData were collected retrospectively on all TDC placements at this institution from 2001 to 2019 and were excluded if no removal date was recorded or if dwell time was more than 365 days. Information on TDC brand, placement, insertion/removal, and removal reason were collected. Multiple logistic regression evaluated factors associated with TDC dislodgement. DN placement and OTWE were compared for rate of dislodgement (generalized estimating equations method) and TDC dwell time (survival analysis). ResultsIn total, 5328 TDCs were included with 66% (3522) placed DN and 32% (1727) via OTWE. Mean dwell time was 65 ± 72 days, and dislodgement occurred in 4% (224). TDC dislodgement rates in the DN and OTWE groups were 0.48 and 0.93 per 1000 catheter days, respectively. Brand (Ash Split vs. VectorFlow), placement technique (OTWE vs. DN), laterality (left vs. right), and site (left vs. right internal jugular vein) were significant predictors of dislodgement. OTWE placement exhibited 1.7 times the odds of dislodgement (95% confidence interval, 1.2–2.6; P = .004) compared to DN and had significantly higher probability of dislodgement across time (hazard ratio = 2.0; P < .001) compared to DN. Dislodgement rates for OTWE vs. DN were 8% vs. 3% (3 months), 13% vs. 6% (6 months), and 38% vs. 17% (1 year). ConclusionsTDC spontaneous dislodgement rates were significantly and consistently higher after OTWE compared to DN placement. These data support more careful attention to catheter fixation after OTWE placement.

Basics of Tunneled Dialysis Catheter Placement for Haemodialysis – Single Centre Experience

/non tunneled dialysis catheters or through arteriovenous fistulas/grafts. The tunneled dialysis catheters act as bridge dialysis devices during maturation period of arteriovenous fistulas/grafts and also serve as the last option for end stage renal disease patients who have exhausted all the other dialysis accesses. The aim and objective is to review the basic key concepts of internal Jugular, External Jugular and Subclavian tunneled venous catheter placement, techniques utilized, complications encountered, issues of suboptimal functioning and their management. Subjects and Methods: This was a prospective observational study done in department of Radio diagnosis, Narayana medical college, Nellore. About 54 cases were performed in our institution from December 2018 to Mar 2020 (including three pediatric patients). The age range of these patients is 10 to 75 years. Results: Out of 54 cases, one case had failed, as the guide wire didn’t pass across the brachiocephalic vein. Venogram revealed high grade stenosis of right brachiocephalic vein. There were major complications in two cases, minor complications in five cases with delayed complications in two cases. Conclusion: Tunneled catheters play a key role in serving as bridging devices during maturation of AVF/AVG or as the last option in chronic kidney disease patients in whom all other options have exhausted. Intervention radiologist should have good experience and an overall knowledge of the issues involved in placement of tunneled dialysis catheters, knowledge about the complications, technical issues of suboptimal functioning, for optimal catheter placement and also for improving catheter function.

P1347A DYNAMIC ULTRASOUND-IMAGING-BASED GUIDED TECHNIQUE TO TUNNELED DIALYSIS CATHETER BY MICROBUBBLES

Abstract Background and Aims In patients with end-stage renal disease (ESRD), the use of cuffed, tunneled dialysis catheters (TDCs) for hemodialysis has become integral to treatment plans. Fluoroscopy is a widely accepted method for the insertion and positioning of cuffed dialysis catheters, because it is easy to use, accurate and reliable, and has a relatively low incidence of complications. The purpose of our study was to evaluate the feasibility of tunneled hemodialysis catheter placement without the use of fluoroscopy but with a dynamic ultrasound-imaging-based guided technique. Method From January 2015 to December 2017, we performed an observational prospective cohort study of 56 patients with ERDS who required TDC placement. Results The overall success rate for ultrasound-guided central access was 100%, with a mean number of 1.16 (± 0.4) attempts per patient. There were no incidences of guide wire coiling/kinking, carotid puncture, pneumothorax, or catheter malfunction. Catheter flow during dialysis was 286 (± 38) ml/min. The total number of catheter days was 7,451, with a mean of 133 days and a range of 46 to 322 days. Life table analysis revealed primary patency rates of 100%, 96%, and 53% at 30, 60, and 120 days, respectively. Conclusion Dynamic ultrasound-based visualization of microbubbles in the right atrium is a highly accurate method to detect percutaneous implantation of large-lumen, tunneled, central venous catheters without the need for fluoroscopic guidance technology.

Periprocedural Outcomes in Patients on Chronic Anticoagulation Undergoing Fistulograms

Management of antithrombotic therapy with warfarin in patients undergoing fistulograms and possible interventions is controversial and difficult because of lack of adequate outpatient bridging options. Our goal was to assess periprocedural outcomes in patients managed using different anticoagulation strategies. A retrospective, single-institution analysis of all patients on chronic anticoagulation with warfarin undergoing fistulograms from 2011 to 2017 was performed. Anticoagulation management strategies were classified as suspended warfarin (SW), continued warfarin (CW), and a heparin bridge with suspended warfarin (HB). Periprocedural outcomes were analyzed. There were 87 patients on chronic anticoagulation with warfarin who underwent 175 fistulograms. Median age was 63years, and 43.4% were women. Indications for warfarin included atrial fibrillation (53%), prior pulmonary embolism/deep vein thrombosis (29%), and hypercoagulable state (14%). Distribution was SW (60%), CW (26%), and HB (14%). Approximately half (53%) were same-day procedures, 30% occurred during access-related admissions, and 14% were performed during nonaccess-related admissions. Common indications for a fistulogram included difficulty with dialysis (63.4%), access thrombosis (20.6%), and poor maturation (10.3%). Interventions included angioplasty (82.9%), thrombectomy/embolectomy (20.6%), and stenting (8.6%). Thirty-day outcomes for SW versus CW versus HB were similar for bleeding complications (5.7%, 6.5%, 8.3%; P=0.89), systemic thrombotic complications (3.8%, 2.2%, 0%; P=0.569), access rethrombosis (7.6%, 13%, 12.5%; P=0.517), and tunneled dialysis catheter placement (11.4%, 13%, 12.5%; P=0.958). After excluding procedures performed during a nonaccess-related admission, length of stay (LOS) was highest among HB (9.6±7.8days) compared with SW (2.6±5.9days) and CW (1±2.8days), (P<0.0001). CW therapy in patients undergoing fistulograms was not associated with increased morbidity and was associated with shorter LOS. Bridging with heparin is not associated with improved outcomes, warranting a thorough consideration of continuing warfarin is safe and may streamline preservation of dialysis accesses without significantly increasing resource utilization.