Tunneled Hemodialysis Catheters Research Articles

#1818 Association of combined systemic inflammatory indices with the severity and outcome of tunnelled hemodialysis catheter-related bacteremia

Abstract Background and Aims Systemic inflammation plays a critical role in sepsis. Multiple inflammatory parameters have been used in clinical practice to diagnose and predict outcomes. More recently, systemic inflammatory indices derived from the complete blood count (CBC) such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR) and red blood cell distribution width (RDW) have shown a diagnostic and prognostic value in several critical infectious diseases such as pneumonia, endocarditis, osteomyelitis, COVID-19, severe sepsis and septic shock. The aim of our study was to evaluate NLR, PLR, LMR and RDW in tunnelled hemodialysis catheter-related bacteremia and investigate their predictive value regarding in-hospital mortality and 30-day survival. Method We performed a retrospective study that included patients with tunnelled hemodialysis catheters in our dialysis unit between January 2003 and March 2023 that presented with hemodialysis catheter-related bacteremia. Demographic data, comorbidities, dialysis vintage and catheter vintage and type were registered. The baseline systemic inflammatory indices (NLR, PLR, LMR and RDW) were calculated from the CBC at presentation of bacteremia. Primary outcome was in-hospital mortality and mortality after 30 days. Secondary outcomes were complications during follow-up such as development of septic shock, ICU admission, endocarditis or septic embolic complications, need for catheter removal and the time elapsed till blood cultures were negative. Results The study included 58 patients with tunnelled hemodialysis catheter-related bacteremia. Mean age was 63.8 ± 17 years, and median catheter vintage was 122 days (IQR 84-387). The main causative organism was Staphylococcus aureus in 29 (50%) of the cases, followed by Serratia marcescens (12.1%) and Staphylococcus epidermidis (6.9%). Four patients (6.9%) presented with septic shock, 7 patients (12.1%) developed endocarditis and/or septic emboli, and 47 patients (81%) required removal of the catheter. In-hospital mortality was 6.9% and 30-day mortality was 12.1%. There was a positive correlation between NLR, PLR, LMR and RDW. NLR and RDW were significantly higher in Staphylococcus aureus bacteremia. In the regression analysis, higher tertile of NLR and RDW were associated with Staphylococcus aureus bacteremia. A NLR cutoff of >7 was predictive of Staphylococcus aureus bacteremia (AUC 0.75 [95% CI 0.61-0.89], p = 0.005) with an 86% sensitivity and 60% specificity. There were no differences in these inflammatory indices between survivors and non-survivors during hospital admission. However, RDW was significantly higher in patients who did not survive after 30 days (17.8% [15.7-19.4] vs 15.9% [15-17.1], p = 0.043). An RDW of >16.9% was determined as the predictive cutoff value of 30-day mortality (AUC 0.73, 95% CI 0.54-0.92, p = 0.049) with a sensitivity of 71.4% and specificity of 70%. Conclusion In our cohort of patients with tunnelled hemodialysis catheter-related bacteremia, higher RDW was associated with a poor 30-day survival and a NLR >7 was predictive of Staphylococcus aureus bacteremia. These results suggest that NLR may be useful as a diagnostic index of Staphylococcus aureus bacteremia and RDW can be used to predict 30-day mortality in hemodialysis catheter-related bacteremia.

Tunneled Hemodialysis Catheter Making Its Way into the Spinal Canal: An Unusual Complication

The procedure of tunnelled hemodialysis catheter insertion is generally considered safe. We report the case of a lady who had a malpositioned femoral tunneled hemodialysis catheter that entered into the spinal canal causing neurological weakness. The catheter was later safely removed leading to partial neurological recovery.

Percutaneous Retrieval of a Peeled-off Fragment of a Hydrophilic Wire after a Cuffed Tunneled Hemodialysis Catheter Placement: A Case Report.

Percutaneous Retrieval of a Peeled-off Fragment of a Hydrophilic Wire after a Cuffed Tunneled Hemodialysis Catheter Placement: A Case Report.

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.

The predictive value of systemic inflammatory markers in 902 patients with tunneled hemodialysis catheter.

This study aimed to assess the predictive role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and mean platelet volume, on catheter survival in chronic hemodialysis patients, analyzing both infectious and non-infectious complications. A retrospective analysis encompassed 1279 tunneled catheter insertion procedures involving 902 patients between March 2014 and October 2018. Patients were categorized into two main groups: (i) initial placement and (ii) exchange. The exchange group was further stratified into four subgroups: infection, dysfunction, displacement, and transitioning temporary hemodialysis catheters to long-term ones. Hematologic ratios were calculated from baseline hemogram data, including neutrophil, lymphocyte, monocyte, and platelet counts, while mean platelet volume was derived from the same hemogram. The patients in theexchange groupdisplayed significantly higher lymphocyte and monocyte values (p < 0.001), while lower values were noted for neutrophil-lymphocyte ratio and platelet-lymphocyte ratio (p < 0.001). The transition group displayed higher monocyte values and lower mean platelet volume and lymphocyte-monocyte ratio values (p < 0.05). In the infection-related exchange subgroup, higher neutrophil count, mean platelet volume, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio values were observed compared to other groups (p < 0.05). Cases related to catheter dysfunction exhibited increased lymphocyte-monocyte ratio but lower neutrophil, monocyte, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio values (p < 0.05). This study highlights the interest of specific inflammatory markers, particularly monocytes, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio, in the management of tunneled catheters, notably in patients undergoing exchanges. However, cut-off values, essential for constructing management algorithms, are currently lacking, and prospective multicenter studies are neededfor further elucidation.

The stuck haemodialysis catheter—a case report of a rare but dreaded complication following kidney transplantation

BackgroundTunnelled cuffed haemodialysis catheters are at increased risk of incarceration or becoming ‘stuck’ via fibrotic adhesion to the central veins when left in situ for prolonged periods of time. Stuck catheters cannot be removed using standard techniques such as bedside dissection of the cuff. Whilst there are several strategies published for the removal of these incarcerated lines, there is no consensus on the best approach. Here we present a challenging case of a stuck haemodialysis catheter in the acute post transplantation period.Case PresentationA 66-year-old female on haemodialysis presented for kidney transplantation with a tunnelled-cuffed haemodialysis catheter in situ for five years. Following transplantation, removal of the line was unsuccessful despite dissection of the cuff, with traction causing a choking sensation with tracheal movement. Eventually, the line was removed without complications utilising sequential balloon dilatation by interventional radiology and the patient was discharged without complications.ConclusionsThis case serves as a timely reminder of the risks of long-term tunnelled haemodialysis catheters and as a caution towards proceeding with kidney transplantation in those with long-term haemodialysis catheters in situ. Greater nephrologist awareness of interventional radiology techniques for this challenging situation will help to avoid more invasive strategies. The risks of a stuck catheter should be included in the discussions about the optimal vascular access and transplantation suitability for a given patient.

The Effect of Residence Time of No-tunneled Hemodialysis Catheters on Infection and Thrombosis Outcome. Identification of CVC’s Time Cut-off

Introduction: Permanent vascular access (arteriovenous fistula (AVF), arteriovenous graft (AVG)) is susceptible to acute events that reduce patency. The temporary central venous catheter (CVC) constitutes bridging therapy for primary vascular access dysfunction. The impact of “residence time” on the rate of dysfunction/thrombosis or infection remains to be explored. AIM: 1) To evaluate the impact of CVC residence time on outcomes (infection or Thrombosis/dysfunction) in consecutive temporary CVCs adjusted for the insertion site (upper site vs. lower site). 2) To establish a cut-off resident time. Patients and methods: Seventeen prevalent hemodialysis patients with three consecutive CVCs are followed up prospectively in an observational study for a period equivalent to the permanence of the CVCs. The data is recorded at the beginning of the CVC time. The diagnosis of catheter-related bloodstream infection and thrombosis/dysfunction is made following the K-Doqi 2019 guidelines. Statistical analysis: Seventeen hemodialysis patients (51 CVCs) were included. The ‘CVC resident time’ of each individual patient ((i.e. βcoefficient (log-transformed)*AUC)) was determined using LMM and then inserted into multivariate Cox models to assess infection and dysfunction/thrombosis outcomes (Joint Models). The AUC was calculated at various baseline levels of CVC time (10th……50th percentile). The cut-off point for thrombosis in CVC time corresponds to the mean of the CVC time at the 30th percentile of all CVCs. Results: The CVC time is different for CVC’s site insertion and sequence. From the analysis of multivariate joint models, CVC resident time appears not to be significant for infection, but heterogenicity for the insertion site (ref3-4=upper site) is significant for the outcome of thrombosis/dysfunction. From the study of survival analysis, the free survival from outcomes by CVC site insertion appears to be significant for thrombosis/dysfunction. The average time of CVCs’ calculation at the 30th percentile is 14 days (cut-off). Conclusion: No tunneled hemodialysis Catheter (NTHC) residence time is considered not to be a risk factor for infection, but it represents a risk factor for lower access thrombosis. After the cut-off time of 14 days, the advantage of the higher NTHCs is lost.

Etiological Factors Affecting Single Versus Multiple Tunneled Hemodialysis Catheter Cuff Extrusions in the Saudi Population.

To identify underlying factors associated with single versus multiple expulsions of tunneled hemodialysis catheter cuffs and their associated complications. A multicenter, five-year retrospective data analysis was conducted on hemodialysis patients with tunneled catheters. Patient data included age, gender, BMI, and associated comorbidities. The type of procedure (new tunnel insertion vs. exchange), exit site infection, and catheter-related bloodstream infection (CRBSI) were also included. The data of 122 patients was analyzed. Seventy-eight patients had diabetes mellitus, 102 patients had hypertension, and 24 had ischemic heart disease. Fifty-one patients were on antiplatelet therapy, and nine patients were on oral steroids. The access site for 98 patients was the right internal jugular; for 19 patients, it was the left internal jugular; five patients had a femoral dialysis catheter. Patients were grouped into two categories: those with single cuff extrusion episodes and those with multiple cuff-out episodes. Sixty-three patients had one cuff extrusion, and 59 had multiple cuff-out episodes during the study period. Patients who had CRBSI and hypertension and were aged between 61 and 95 had multiple episodes of cuff extrusion and reached statistical significance. Exit-site infection, diabetes mellitus, antiplatelet therapy, gender, catheter site, and BMI had no statistical significance between the two groups. Tunneled catheter cuff extrusion is a frequent phenomenon. Catheter-related bloodstream infection, hypertension, and age of 61 to 95 years are high-risk factors for multiple episodes of cuff extrusion.

A 4-year tunneled hemodialysis catheter malpositioned into the azygos vein and how to remedy the hemodialysis circuit.

Mispositioning in the azygos vein is a rare but hazardous complication of central venous catheterization. A patient was admitted for a dysfunctional hemodialysis tunneled cuffed catheter (TCC) placed in the azygos vein for 4 years. Computed tomography angiography revealed multiple sites of occlusion, including the superior vena cava (SVC), right and left innominate veins (IVs), and right femoral vein. Percutaneous transluminal angioplasty and a TCC replacement based on a segment-by-segment recanalizing strategy were performed. First, an 8-Fr sheath was inserted through the left femoral vein approach to retrogradely traverse the occlusive SVC followed by a guidewire extending to the occlusive left IV. A left transjugular 15-cm snare was inserted to capture the transfemoral guidewire and achieve recanalization from the left IV to the SVC. Second, a transjugular guidewire was advanced through the dysfunctional TCC yet shunted into the left IV due to the inability to cross the SVC. A left transfemoral 15-cm snare was inserted to capture the guidewire and achieve complete recanalization from the right internal jugular vein to the SVC. Balloons were passed over the guidewires to dilate the obstructive lesions sequentially, and a new TCC was inserted successfully with the tip positioned in the right atrium.

Tunneled Hemodialysis Catheter Tip Design and Risk of Catheter Dysfunction: An Australian Nationwide Cohort Study

Rationale & ObjectiveHemodialysis catheter dysfunction is an important problem for patients with kidney failure. The optimal design of the tunneled catheter tip is unknown. This study evaluated the association of catheter tip design with the duration of catheter function. Study DesignObservational cohort study using data from the nationwide REDUCCTION trial. Setting& Participants: 4722 adults who each received hemodialysis via one or more tunneled central venous catheters in 37 Australian nephrology services from December 2016 to March 2020. ExposureDesign of tunneled hemodialysis catheter tip, classified as symmetrical, step, or split. OutcomeTime to catheter dysfunction requiring removal due to inadequate dialysis blood flow assessed by the treating clinician. Analytical ApproachMixed, three-level accelerated failure time model, assuming a log-normal survival distribution. Secular trends, the intervention, and baseline differences in service, patient, and catheter factors were included in the adjusted model. In a sensitivity analysis, survival times and proportional hazards were compared among participants’ first tunneled catheters. Results355 of 3871 (9.2%), 262 of 1888 (13.9%), and 38 of 455 (8.4%) tunneled catheters with symmetrical, step, and split tip designs, respectively, required removal due to dysfunction. Step tip catheters required removal for dysfunction at a rate 52% faster than symmetrical (adjusted time ratio = 0.48, 95% CI = 0.34-0.69), and 76% faster than split tip catheters (adjusted time ratio = 0.24, 95% CI = 0.11-0.52) in the adjusted accelerated failure time models. Only symmetrical tip catheters had performance superior to step tip catheters in unadjusted and sensitivity analyses. Split tip catheters were infrequently used and had risks of dysfunction similar to symmetrical tip catheters. The cumulative incidence of other complications requiring catheter removal, routine removal, and death prior to removal were similar across the three tip designs. LimitationsTip design was not randomized. ConclusionsSymmetrical and split tip catheters had a lower risk of catheter dysfunction requiring removal than step tip catheters.Funding: Grants from government (Queensland Health, Safer Care Victoria, Medical Research Future Fund, National Health and Medical Research Council, Australia), academic (Monash University), and not-for-profit (ANZDATA Registry, Kidney Health Australia) sources. Trial RegistrationRegistered at ANZCTR with study number ACTRN12616000830493.

Safety and durable patency of tunneled hemodialysis catheter inserted without fluoroscopy.

A tunneled hemodialysis (HD) catheter is preferred due to its lower incidence of infection and malfunction than non-tunneled ones. For safer insertion, fluoroscopic guidance is desirable. However, if the patient is unstable, transfer to the fluoroscopy may be impossible or inappropriate. From June 2019 to September 2022, 81 tunneled HD catheter insertion cases performed under ultrasound guidance without fluoroscopy and 474 cases with fluoroscopy in our institutional HD catheter cohort were retrospectively compared. Immediate complications, later catheter-associated problems, including infections and catheter dysfunction, were comparable between the two groups (p = 0.20 and p = 0.37, respectively). The patency of tunneled catheters inserted without fluoroscopy was comparable to the patency of tunneled catheters inserted with fluoroscopic guidance (p = 0.90). Tunneled HD catheter insertion without fluoroscopy can be performed safely and has durable patency compared to the insertion with fluoroscopy. Therefore, this method can be considered for the selected unstable patients (e.g., ventilator care) in the intensive care unit.

Low Posterior Internal Jugular Vein Approach for Tunnelled Haemodialysis Catheter Insertion: A Report on Outcomes at a Single Centre.

The impact of technical differences in cannulation technique for tunnelled haemodialysis catheter insertion is undetermined. We aimed to assess clinical outcomes of the low posterior approach for internal jugular vein tunnelled catheter placement. A retrospective audit was undertaken on consecutive tunnelled catheter procedures performed at a single centre between January 2016 and June 2022. Only catheters specifically placed with a low posterior internal jugular approach were included. The study's primary outcome was 12-month catheter survival, evaluated using the Kaplan-Meier survival curve and log-rank test. Secondary outcomes included catheter performance and procedure-related complications. During the study period, 391 tunnelled internal jugular haemodialysis catheters were inserted in 272 patients using the low posterior technique. The 12-month primary patency rate was 68%. Catheter insertion was successful in 96% of cases. Peri-procedural complications occurred in 4% of cases, most frequently bleeding. The most common reasons for catheter loss were dysfunction (10%) and bacteraemia (6%). The best predictors of catheter failure were advanced age (HR 1.02, 95% CI 1.00-1.04) and in-centre dialysis treatment locality (HR 2.04, 95% CI 1.19-3.45). The low posterior approach for internal jugular vein tunnelled catheter insertion is effective and safe. We demonstrated a 12-month catheter survival rate of 68%. Further research comparing the low posterior approach with other internal jugular vein cannulation techniques is warranted.

Exchange of Extracorporeal Membrane Oxygenation Cannulas for Hemodialysis Catheters in Children Requiring Renal Replacement Therapy.

Pediatric patients requiring extracorporeal membrane oxygenation (ECMO) may require renal replacement therapy even after decannulation. However, data regarding transition from ECMO cannulation to a hemodialysis catheter in pediatric patients is not currently available. Patients <18years old who had an ECMO cannula exchanged for a hemodialysis catheter during decannulation at a tertiary care children's center from January 2011 to September 2022 were identified. Data was collected from the electronic medical record. A total of 10 patients were included. The cohort was predominantly male (80.0%, n = 8) with a median age of 1day (IQR 1.0, 24.0). All ECMO cannulations were veno-arterial in the right common carotid artery and internal jugular vein. The median time on ECMO was 8.5days (IQR 6.0, 15.0). One patient had the venous cannula exchanged for a tunneled hemodialysis catheter during decannulation, two were transitioned to peritoneal dialysis, and seven had the temporary hemodialysis catheter converted to a tunneled catheter by Interventional Radiology (when permanent access was required) at a median time of 10days (IQR 8.0, 12.5). Of these 7 patients, 28.6% (n = 2) developed catheter-associated infection within 30days of replacement, with one requiring catheter replacement. Transient bloodstream infection occurred in 10.0% (n = 1) within 30days of ECMO cannula exchange. Venous ECMO cannula exchange for a hemodialysis catheter in children requiring renal replacement therapy after decannulation is possible as a bridge to a permanent hemodialysis or peritoneal catheter if renal function does not recover, while supporting vein preservation.

Assessment of dysfunctional tunneled hemodialysis catheters and outcome of endovascular salvage techniques: a simple solution to a complex problem.

The aim of this study was to evaluate the causes of the dysfunctional tunneled cuffed catheters (TCCs) using multi-spiral computed tomography venography (MSCTV), and to analyze the outcomes of endovascular salvage techniques. This retrospective review data from 27 patients who experienced TCC dysfunction between July 1, 2016 and January 31, 2021 was conducted. Patients' demographic data, clinical signs and symptoms, and imaging data were collected from interventional radiology database. MSCTV showed a range of abnormalities in the hemodialysis (HD) patients, including central venous occlusion (n = 4), fibrin sheath formation (n = 3), malposition of the catheter tips (n = 4), central venous perforation (n = 1), thrombus formation (n = 12), regular catheter exchange without determined lesions (n = 3). Interventional catheter salvage procedures were performed, such as catheter exchange, balloon disruption of a fibrin sheath, angioplasty for central vein stenosis, and stent deployment. The technical success rate for catheter insertions was 100%, and no procedure-related severe complications were observed. The 30-day catheter patency for all assessable catheters was 85.2%. The use of MSCTV showed abnormal findings in almost 88.9% of cases concerning dysfunctional TCC. In this study, the examined appropriate endovascular techniques were found to be safe and technically successful, with a low incidence of procedure-related complications.

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.

HEMODIALYSIS TUNNELED CATHETERS LOCK WITH TAUROLOCK™ VERSUS A COMBINATION OF GENTAMYCINE AND HEPARINE

Purpose: Catheter-related infections and thrombosis are the most common complications associated with the use of tunneled hemodialysis catheters. The aim of our study was to determine the incidence of these complications in patients who underwent "locking" of their tunneled catheters and compare the cost of different options with their effect. Materials and Methods: The study was conducted in the period 01.10.2021 - 31.03.2022. Twenty-three men and twenty-two women with a mean age of 60.82 (+/-13.629) years were randomly divided into three groups of 15 (fifteen) people each. Group A – catheter locking with TauroLock™ only, group B – with gentamicin and heparin; group C – with TauroLock™ for three months, then with heparin and gentamicin for the next three months. Results: The median duration for tunneled catheters was 8,105 catheter-days. One complication was reported in each of the three groups. Reported costs for patients treated with TauroLock™ were calculated at 3 EUR/each dialysis session and for patients treated with gentamicin and heparin – 0.88 EUR/dialysis session. Conclusion: The data from our study unequivocally support the thesis that locking the catheter with a TauroLock™ is comparable to the effect of the solution containing an antibiotic and anticoagulant.

Catheter related atrial thrombus caused by Abiotrophia defectiva: A case series and review of literature.

Catheter related atrial thrombus (CRAT) is a devastating complication associated with tunneled hemodialysis catheter. Abiotrophia defectiva is a rare fastidious pathogen implicated predominantly in culture negative infective endocarditis. Here we report three cases of CRAT in maintenance hemodialysis patients with variable clinical presentation caused by Abiotrophia defectiva. Video assisted thoracoscopic retrieval of atrial thrombus is a novel technique which is scarcely reported in medical literature for surgical management of large atrial thrombus. Our cases were managed by timely administration of antibiotics and anticoagulants followed by surgical retrieval of atrial thrombus with removal of tunneled dialysis catheter. This case series illustrates the importance of prompt diagnosis, appropriate anticoagulation with antibiotics, and mini-invasive surgical removal of atrial thrombus for the management of CRAT.

#6898 CATHETER RELATED BLOODSTREAM INFECTION IN NON-TUNNELED HEMODIALYSIS CATHETERS IN A RESOURCE-LIMITED HOSPITAL IN MERIDA, YUCATAN, MEXICO

Abstract Background and Aims There is scarcity in epidemiological data regarding chronic kidney (CKD) disease in low- and medium-income countries, and information about vascular access infectious complications is limited. In Mexico, access to renal replacement therapy (RRT) is burdensome for the uninsured patients. The General Hospital Agustin O'Horán, is a secondary care level unit in Yucatan, which receives uninsured patients from southeast Mexico. In our hospital, patients who are not candidates for peritoneal dialysis start hemodialysis with non-tunneled hemodialysis central venous catheters (NTHC), mainly due to the late nephrology referral and the shortage of vascular access specialists in our unit which prevents for the timely creation of an arteriovenous fistula or the placement of a tunneled hemodialysis catheter (THC). Permanence of NTHC is the main risk factor for catheter related bloodstream infection (CRBI) and according to the literature, Gram positive microorganisms are the most common isolated microbes. The aim of our study was to describe the incidence and risk factors for CRBSI in our hospital, from January to December 2022. Method We conducted a prospective and observational study in patients older than 18 years with CKD who were candidates to start hemodialysis and who had a NTHC inserted in our hospital from January to December 2022. We evaluated the incidence, organisms and risk factors related to CRBSI. Results During the study period, 94 NTHC were placed, 63.8% of them were inserted in women. Median age of the population was 49.4 years, and the most frequent comorbidities were diabetes mellitus (63.8%), hypertension (86.2%) and renal lithiasis (27.7%). 73.4% of the NTHC were Mahurkar® catheters and most of the insertions (73.4%) were not ultrasound guided. The right jugular vein was the most common insertion site (72.3%), followed by the left jugular vein. Mean catheter use duration was 71 ± 66 days. 27 patients had evidence of CRBI, the incidence rate was 0.78 per 1000 catheters-day. CRBI was more frequent in patients with prolonged catheter use (more than 30 days) (p&amp;lt;0.001) (Table 1). In respect to blood cultures reports, 51.83% were Gram positive organisms and 48.12% were Gram negative (Table 2). Conclusion Vascular access survival without infectious complications is of paramount importance in hemodialysis patients. The prolonged used of NTHC with the associated risk for developing CRBI negatively impacts the health outcomes in our population. In accordance to previously published literature, the main isolated microbes in our hospital comprise Gram positive bacteria. One of the biggest challenges in our country is to provide our CKD population with better vascular access options like THC or arteriovenous fistula to improve the outcomes and reduce infectious complications.

#4047 ULTRASOUND-GUIDED RIGHT INTERNAL JUGULAR TUNNELED CATHETER INSERTION FOR HAEMODIALYSIS: PRACTICES AND OUTCOMES FROM A SINGLE CENTRE

Abstract Background and Aims Internal jugular vein tunneled catheters are important vascular access for haemodialysis (HD). In our practice, Left-sided internal jugular (LIJ) catheter insertion is performed in radiology under direct X-ray screening. Most right-side internal jugular (RIJ) catheters are inserted under ultrasound guidance in dedicated renal procedure rooms. Vascular access can become challenging with the potential for venous stenosis and thrombosis with catheter use. The aims of this study are to evaluate our practices and outcomes of non-radiologically inserted RIJ tunneled HD catheters and to investigate the predictors of procedure failure. Method 200 successive RIJ tunnel HD catheters inserted from June 2016 under ultrasound guidance at our centre were included in this analysis. Data including demographics, co-morbidities, first or higher order insertion, outcome (success or failed attempt), and immediate complications were collated from electronic patient records. Binary logistic regression analysis was conducted to investigate the predictor for failure in catheter insertion. Results Of the 200 patients, 152 (76%) were first-time insertions and 48 (24%) were second or higher-order insertions. The median age of our cohort was 58 years, with a predominance of males (68%) and white ethnicity (82%). 36.5% were diabetic, with 37.5% having a history of cardiovascular disease. Nearly 30% of patients were on an antiplatelet agent, and 8% were on anticoagulants, which were appropriately managed before line insertion. Pre-operative median haemoglobin was 93 g/dl, with clotting screen and platelet counts in the target range. There was a statistically significant difference in the success of insertion, depending on the insertion being first or subsequent (96.1% vs 81.2%; p = 0.001). The reason for failure in insertion included on-table observation of a small calibre vein on ultrasound or failure to thread wire/dilator due to possible stenosis or thromboses. All line rewire (12/48) procedures were performed successfully. Immediate complication (&amp;lt;1 week) was recorded in 9% of patients, predominantly tunnel bleeding (n = 7) and malposition (deep or high; n = 7) (Table 1). Second or higher-order RIJ catheter insertion showed a higher risk for failure in a multivariable binary logistic regression analysis. (OR: 6.4; CI: 2.1-20.5; P = 0.002) (Figure 1). Of the higher-order insertions, the longer duration between the first and subsequent catheters showed a higher risk for failure (OR:1.19; CI-1.04-1.4; p = 0.010). Conclusion Second or higher-order catheter insertions with a longer duration between the first and the subsequent insertion carry a significant risk of failure due to vein stenosis and thrombosis. Therefore, a careful case-to-case triaging of patients based on previous access history is warranted before listing patients for routine ultrasound-guided insertion.

Endovascular Closure of an Acquired Vascular Fistula, an Uncommon Complication of a Tunneled Hemodialysis Catheter: A Case Report.

The objective of this case is to report an endovascular occlusion of an acquired vascular fistula using an Amplatzer Vascular Plug II. Also, it is to review the available literature on risk factors, pathophysiology, and related management strategies about complications of the tunneled central venous catheter (TCVC). The case was a 40-year-old man with a chronic kidney disease (CKD) on dialysis and with a history of several previous TCVC placements, along with recurrent infections. The last TCVC developed a fistula between the superior vena cava and the right pulmonary artery, shown by computed tomography (CT). We decided to remove a long-term TCVC and occluded the fistula applying an endovascular embolic device, an Amplatzer Vascular Plug II, subsequently. The patient was given parenteral treatment during 10 days of hospitalization. Over 9 months of follow-up, the device was appropriately positioned and did not obstruct the vascular flow. Tunneled central venous catheters are frequently used for hemodialysis in patients in the last stage of CKD who do not have an arteriovenous fistula. Occasionally, delayed complications such as adherence or catheter migration occur. This case illustrates an endovascular treatment with excellent results and low risk of morbidity and mortality. The purpose of this work is to present an endovascular occlusion by means of an Amplatzer® Vascular Plug II in a residual fistula. The endovascular way is decided in situations, for instance, once the cardiothoracic surgeons argue that the patient is not in general conditions to tolerate surgery, the surgical procedure would be complex, or, in a surgical approach with a difficult-to-resolve hemorrhage. We explain the technique and the materials we used for an excellent result and a low risk of complications. This case is intended to serve as an aid in the treatment of similar events.