Tunneled Hemodialysis Catheters Research Articles

Effect of intravenous iron on haemodialysis catheter microbial colonization and blood‐borne infection

Intravenous (i.v.) iron is employed to treat absolute and relative iron deficiency in end-stage renal disease patients. However, there exists the possibility that i.v. iron increases infection risk. This pilot study examines whether i.v. iron gluconate acutely increases tunnelled haemodialysis catheter colonization, microbial growth, or blood-borne infection. Nineteen patients with haemodialysis catheters who met criteria to receive an i.v. iron load entered the study. Six matched patients with catheters who did not receive iron were controls. Blood aspirated from the catheter prior to initiation of haemodialysis was sent for qualitative/quantitative cultures. The study consisted of three baseline cultures, five cultures during iron (125 mg of ferric gluconate per treatment), and three cultures following iron administration. Patients were monitored for infection for 30 days following iron. Fifteen iron-treated patients and six controls completed the study. Thirty-three per cent of treated patients were colonized at baseline; 66% were colonized following iron. Thirty-three per cent of controls (2/6) were colonized at baseline; no new colonization developed during follow up. Neither treated patients nor controls had significant microbial growth within catheters; one patient in the iron-treated group developed candidaemia. Intravenous iron is not associated with acute microbial growth in catheters or clinical infection. However, a trend towards increased catheter colonization following iron administration exists.

Conversion of temporary hemodialysis catheters to tunneled hemodialysis catheters

To determine the feasibility and clinical outcomes of conversion of temporary to tunneled hemodialysis catheters using the same venous insertion site. Data from 42 patients with existing temporary hemodialysis catheters referred for placement of tunneled hemodialysis catheters were retrospectively reviewed. In these patients, the temporary catheter was exchanged for a peel-away sheath, and a tunneled catheter was inserted using the existing venous access site. Technical success, procedural complications, and clinical outcomes were evaluated. Hemodialysis records were reviewed to assess catheter patency during a 30-day follow-up period. The study group consisted of 20 males and 22 females (mean age: 58 years). All 42 temporary catheters were successfully converted to tunneled hemodialysis catheters without immediate procedure-related complications. Follow-up data were available for 32 patients (total: 3038; median 71 catheter days). Nine catheters were removed for infection, yielding a catheter infection rate of 0.30/100 catheter days; three catheters were removed for blood flow <200 ml/min. 13 patients had catheters removed when catheters were no longer needed. Three patients died with working catheters. The patency rate was 72% at 30 days, with four catheters functioning at the end of the study period. Conversion of a temporary hemodialysis catheter to a tunneled hemodialysis catheter using the same venous insertion site is a safe procedure that avoids complications associated with venotomy and allows conservation of other central venous access sites. Patency and infection rates in these catheters are comparable to several studies of catheter exchange and de novo placement of tunneled hemodialysis catheters.

Efficacy and Safety of a Retrograde Tunneled Hemodialysis Catheter: 6-Month Clinical Experience with the Cannon Catheter™ Chronic Hemodialysis Catheter

Tunneled catheters play an important role in the delivery of hemodialysis, for both temporary and long-term vascular access. Proper catheter tip positioning is critical for optimal blood flow and performance. The modular Cannon Catheter II Chronic Hemodialysis Catheter is placed tip first, then tunneled back to the exit site, in a simple technique (retrograde tunneling) that provides precise tip placement within the right atrium. This retrospective study evaluated 6-month efficacy and safety of the Cannon catheter in 38 patients. Monthly mean flow, pressure, Kt/V, and URR were determined. Safety parameters included early and late device-related complications, device removals, and device survival. 87% of subjects had history of vascular access failure. Cannon catheters were inserted via an internal jugular vein with retrograde tunneling in all patients without insertional complication. Mean flow ranged from 369.0 to 404.8 ml/min, with a trend for increasing flow over time. High flow allowed delivery of correspondingly high clearance. Mean URR remained > or = 71%; mean weekly Kt/V ranged between 1.55 and 1.60, above current K/DOQI adequacy guidelines. There were no device-related hospitalizations or deaths. Catheter-related bacteremia occurred in 3 patients over the 6 months (0.62 bacteremias/1,000 patient-days), resolving through out-patient treatment. The Cannon catheter provided extended high flow vascular access (> or = 6 months or until hemodialysis catheter-based access was no longer needed) in 95% of patients. Retrograde tunneling of the Cannon Catheter II Chronic Hemodialysis Catheter allowed optimal tip placement and high flow rates, as well as safe, reliable, extended use.

A Prospective Comparison of Two Types of Tunneled Hemodialysis Catheters: The Ash Split Versus the PermCath

In a prospective randomized study a standard dual-tip hemodialysis catheter (PermCath, Sherwood Medical, St. Louis, MO, USA) was compared with a newer split-lumen catheter (Ash Split, Medcomp, Harleysville, PA, USA). Sixty-nine patients (42 men, 27 women; mean age 62 years) were randomized to receive either the Ash Split (AS) or the PermCath (PC) catheter. The catheters were inserted into the internal jugular vein. The primary outcome evaluated was blood flow measurements during the first six hemodialysis sessions. Secondary outcomes included: technical difficulties encountered at insertion, early complications and late complications requiring catheter removal or exchange. A total of 69 hemodialysis catheters, 33 AS and 36 PC, were successfully inserted in the internal jugular vein (right 60, left 9) of 69 patients. Mean blood flow during dialysis (Qb) was 270.75 ml/min and 261.86 ml/hr for the AS and PC groups respectively (p = 0.27). Mean duration of catheter use was 111.7 days (range 5.4-548.9 days) and 141.2 days (range 7.0-560.9 days) in the AS and PC groups respectively (p = 0.307). Catheter failures leading to removal or exchange occurred in 20 patients: 14 in the AS group and six in the PC group. Survival curves with censored endpoints (i.e., recovery, arteriovenous fistula formation, peritoneal dialysis and transplantation) showed significantly better outcome with PermCath catheters (p = 0.024). There was no significant difference in ease of insertion or early complication rates. The Ash Split catheter allows increased rates of blood flow during hemodialysis but this increase was not significant at the beginning (p = 0.21) or end (p = 0.27) of the first six hemodialysis sessions. The Ash Split catheter is more prone to minor complications, particularly dislodgment, than the PermCath catheter.

Dialysis catheter-related bacteremia: Treatment and prophylaxis

Dialysis catheter-related bacteremia: Treatment and prophylaxis

Use of the Femoral Vein as Insertion Site for Tunneled Hemodialysis Catheters

ABSTRACT Use of the Femoral Vein as Insertion Site for Tunneled Hemodialysis Catheters The femoral vein provides an alternative access site for insertion of tunneled hemodialysis catheters when conventional sites are not available. Tunneled femoral hemodialysis catheters have low primary patency rates and significant complications. Catheter retraction is a unique and common problem. However, the use of the femoral vein remains acceptable in those patients who have limited options for long-term hemodialysis.

Squamous cell carcinoma in situ arising at the exit site of a tunneled catheter

Squamous cell carcinoma (SCC) is a well-known complication of immunosuppression associated with organ transplantation. It may arise de novo or from previously existing in situ lesions (Bowen’s disease). Concurrent human papilloma virus infection often has an etiologic role, and SCC may follow an aggressive course in immunosuppressed patients. The authors describe a liver transplant patient in whom end-stage renal disease developed. She underwent tunneled catheter placement followed by arteriovenous graft placement. Subsequently, a large SCC in situ at the exit site of her prior tunneled hemodialysis catheter occurred. The growth was removed surgically without complication. SCC has not been reported previously to arise from a catheter exit site. This entity is common in renal and other transplant populations and may follow an aggressive course. It should be sought out by careful skin evaluation to include areas not routinely exposed to the sun. Squamous cell carcinoma (SCC) is a well-known complication of immunosuppression associated with organ transplantation. It may arise de novo or from previously existing in situ lesions (Bowen’s disease). Concurrent human papilloma virus infection often has an etiologic role, and SCC may follow an aggressive course in immunosuppressed patients. The authors describe a liver transplant patient in whom end-stage renal disease developed. She underwent tunneled catheter placement followed by arteriovenous graft placement. Subsequently, a large SCC in situ at the exit site of her prior tunneled hemodialysis catheter occurred. The growth was removed surgically without complication. SCC has not been reported previously to arise from a catheter exit site. This entity is common in renal and other transplant populations and may follow an aggressive course. It should be sought out by careful skin evaluation to include areas not routinely exposed to the sun.

Squamous cell carcinoma in situ arising at the exit site of a tunneled catheter

Squamous cell carcinoma (SCC) is a well-known complication of immunosuppression associated with organ transplantation. It may arise de novo or from previously existing in situ lesions (Bowen's disease). Concurrent human papilloma virus infection often has an etiologic role, and SCC may follow an aggressive course in immunosuppressed patients. The authors describe a liver transplant patient in whom end-stage renal disease developed. She underwent tunneled catheter placement followed by arteriovenous graft placement. Subsequently, a large SCC in situ at the exit site of her prior tunneled hemodialysis catheter occurred. The growth was removed surgically without complication. SCC has not been reported previously to arise from a catheter exit site. This entity is common in renal and other transplant populations and may follow an aggressive course. It should be sought out by careful skin evaluation to include areas not routinely exposed to the sun.

Locking of tunneled hemodialysis catheters with gentamicin and heparin

Catheter-related infection (CRI) is a major cause of morbidity and mortality in patients receiving hemodialysis. Antibiotic locking of these catheters has been shown to increase both the success of systemic antibiotic treatment in line sepsis, and to reduce the incidence of sepsis. We have studied the use of gentamicin locking of catheters (in combination with standard heparin rather than previously reported citrate) to reduce CRI rates. Furthermore, we have investigated the effects of this strategy on epoetin requirements and vascular access function. Fifty patients were studied. Patients were randomized to catheter-restricted filling with either standard heparin (5000 IU/mL) alone, or gentamicin and heparin (5 mg/mL). Epoetin requirements and hemoglobin response were monitored over the study period. The gentamicin-locked group suffered only one infective episode (0.3/1000 catheter days) compared to 10 episodes in six patients in the heparin alone group (4/1000 catheter days, P= 0.02). The isolated organisms were equally split between Staphylococcal species and coliforms. There were no statistically significant differences in delivered dialysis dose (Kt/V) or QA between the two groups. Use of antibiotic locking was associated with both a higher mean hemoglobin (10.1 +/-0.14 g/dL vs. 9.2 +/- 0.17 g/dL in the heparin group, P= 0.003) and a lower mean epoetin dose (9000 +/- 734 IU/week vs. 10790 +/-615 IU/week in the heparin group, P= 0.04). The practice of locking newly inserted tunneled central venous catheters with gentamicin and heparin is an effective strategy to reduce line sepsis rates, and is associated with beneficial effects on epoetin requirements.

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.

An alternative approach to the central circulation from above the diaphragm.

This is a review of a new fluoroscopically guided safe technique to place tunneled cuffed hemodialysis (HD) catheters via the supraclavicular location. Right supraclavicular catheters were placed in 12 patients who had no patent internal jugular veins. The placements were all successful and without serious complications. Over the 2 years of follow-up, two episodes of thrombosis/stenosis (16.7%) resulted in catheter removal. The rate of infection was 8%, or one episode in 1204 patient-days. The average length of use was 111 days. The average rate of blood flow was 354 cc/min. The right supraclavicular approach for tunneled HD catheters is safe and compares favorably to the internal jugular approach for patients with limited access options.

Retrospective Assessment of Risk Factors to Predict Tunneled Hemodialysis Catheter Outcome

To identify factors that may influence the function, outcome, and complications associated with tunneled hemodialysis catheters. Radiology reports and hemodialysis, medical, and Clinical Information System (computerized patient medical record system) records were retrospectively reviewed in 221 consecutive patients who underwent tunneled hemodialysis catheter placement by interventional radiologists between January 11, 1996 and January 13, 2000 at Dartmouth-Hitchcock Medical Center. Various patient characteristics (diabetes, smoking, hypertension, age, sex, atherosclerotic cardiovascular disease, history of cardiac catheterization, coumadin use, functional status, and obesity) were assessed for their relationship to the outcome of hemodialysis catheters. Catheter outcome was examined by calculating infection rate, thrombosis rate, fibrin formation rate, mechanical malfunction rate, and total complication rate. With these patient characteristics and outcome variables, multiple regression analysis was performed with STATA (College Station, TX) statistical analysis software. Of the 221 patients reviewed, 39 patients were lost to follow-up. Among the remaining 182 patients, 427 catheters were placed for a total number of 36994 catheter-days. For overall complication rate, multiple regression analysis revealed a statistically significant positive correlation only for hypertension (P =.032). Total complication rate was 0.76 events per 100 catheter-days (95% CI: 0.53-1.00) for patients with a documented history of hypertension and 0.27 events per 100 catheter-days (95% CI: 0.08-0.45) for patients without (P =.024, paired student t test). For patients with diabetes versus patients without, the infection rates were 0.34 episodes per 100 catheter-days (95% CI: 0.15-0.53) and 0.12 episodes per 100 catheter-days (95% CI: 0.06-0.18), respectively, (P =.011, paired student t test). Thrombosis rate for patients on coumadin was 0.13 events per 100 catheter-days (95% CI: -0.14-0.40), while thrombosis rate for patients not taking coumadin was 0.03 events per 100 catheter-days (95% CI: 0-0.05) (P =.036, paired student t test). Hypertension is a risk factor for poor outcome of tunneled hemodialysis catheters as measured by total complication rate requiring catheter removal or exchange. In this retrospective study, no other specific risk factors predicted an increased need for removal or exchange of tunneled hemodialysis catheters.

Use of the Femoral Vein as Insertion Site for Tunneled Hemodialysis Catheters

Use of the Femoral Vein as Insertion Site for Tunneled Hemodialysis Catheters.

Arteriovenous fistula creation: should US nephrologists get involved?

Survival of a hemodialysis (HD) patient depends on reliable access to the circulatory system. This usually is achieved by creating an arteriovenous fistula (AVF), placing an arteriovenous graft (AVG), or inserting a tunneled HD catheter (THC). Of the 3 options, the AVF, originally created by nephrologists,1 remains the preferred form of vascular access. Despite clear evidence of superior outcomes (stenosis, thrombosis, and access failure) for AVFs and increased mortality and costs associated with AVGs or THCs, use of an AVF as permanent vascular access remains disappointingly low in the United States compared with Europe and Japan (67% to 93%).

Relation between Access‐Related Infection and Preinfection Serum Albumin Concentration in Patients on Chronic Hemodialysis

Hemodialysis (HD) access-related infection is a major cause of morbidity and mortality in HD patients. We tested whether hypoalbuminemia is a risk factor for HD access infection and whether mortality of HD catheter infection is affected by removal of the infected catheter. We analyzed the records of 87 patients on chronic HD who were hospitalized for HD access-related infection. We obtained data on age, sex, preinfection serum albumin level, comorbidities, complications, infecting organism, type of infection, mode of management, and mortality. We compared preinfection serum albumin levels in 79 patients with HD access infection with the serum albumin levels of 198 control patients on chronic HD without HD access infection admitted to the hospital during the same time for other reasons. In the HD catheter infection subgroup, we compared mortalities between patients treated with catheter removal plus antibiotics as the primary mode of management and those treated initially with antibiotics alone. Preadmission serum albumin level was lower in the HD access infection group (2.4 +/- 0.6 g/dL) than in the control group (3.2 +/- 0.6 g/dL, P < 0.0001). Logistic regression identified preadmission serum albumin level as a strong independent predictor of HD access infection. In a logistic regression model, with age, sex, HIV status, diabetes, and type of HD vascular access (excluding arterovenous fistula) as the covariates, the odds ratio of HD access infection was 9.8 (95% confidence interval [CI] 4.9-19.7) for a serum albumin level </= 3.0 g/dL (P < 0.0001), 10.4 (95% CI 4.97-21.6) for a serum albumin level </= 2.5 g/dL (P < 0.0001), and 28.0 (95% CI 5.8-135.9) for a serum albumin level </= 2.0 g/dL (P < 0.0001). Case mortality was 25.0% (4/16) in patients with tunneled HD catheter infection initially treated with antibiotics alone and 2.8% (2/71) in those treated with catheter removal plus antibiotics at the time of presentation (P = 0.0096). Hypoalbuminemia is associated with increased risk of HD access infection. Treatment of HD access infection with antibiotics alone is associated with increased risk of death.

Developing a comprehensive diagnostic and interventional nephrology program at an academic center

Procedure-related delays in the treatment of patients with renal disease can be minimized and nephrology care can be delivered more efficiently by a nephrologist trained in nephrology-related procedures. Referrals to a radiologist for renal ultrasound and biopsy, to a surgeon for dialysis access placement, and to an interventional radiologist for dialysis catheter placement and vascular access procedures are time consuming and inconvenient to patients with renal disease. Moreover, such an approach may result in delays in the availability of critical diagnostic information and a break in the continuity of care. In an effort to optimize the care of nephrology patients, we developed a diagnostic and interventional nephrology (DIN) program that effectively deals with nephrology-related procedures in a timely manner. At present, some of the commonly performed nephrology-related procedures at our center include diagnostic ultrasonography, ultrasound-guided renal biopsy, peritoneal dialysis access procedures, permanent tunneled hemodialysis catheter placement, and endovascular procedures for arteriovenous dialysis access dysfunction. To date, we have performed 893 procedures during a period of 2 years. This article describes our approach and the tools required to develop a DIN program at an academic medical center.

Successful treatment of a lifesite hemodialysis access system pocket infection with large-volume kanamycin solution irrigation

Bridge devices—dialysis catheters and subcutaneous access devices—play a critical role in increasing the placement of arteriovenous (AV) fistulas by providing hemodialysis vascular access while AV fistulas mature. The LifeSite Hemodialysis Access System (Vasca Inc, Tewskburg, MA), a fully implantable, subcutaneous dual valve access system, has been shown to have lower complication rates, higher blood flow rates, and better long-term device survival than conventional tunneled hemodialysis catheters, indicating it may better meet the requirements for optimally bridging to a fistula. This case study of a 48-year-old black man undergoing chronic hemodialysis for renal failure because of insulin-dependent diabetes describes a simple approach for resolving localized pocket infections associated with the LifeSite System by drip irrigation of the valves and tissue pockets with an antibiotic solution. Eight weeks after implantation of the LifeSite System, the patient exhibited symptoms of infection of the lateral LifeSite valve tissue pocket, which on culture was shown to be caused by Staphylococcus aureus. Flushing the LifeSite valve and tissue pocket with a large volume of kanamycin solution, in conjunction with intravenous vancomycin and routine irrigation of the valve with isopropyl alcohol, resolved the infection after 1 treatment. The LifeSite System successfully bridged the patient to a transposed basilic vein fistula created through a 2-stage surgical procedure. The LifeSite System provided uninterrupted access for hemodialysis over a period of 6 months while the fistula matured. The LifeSite System should allow surgeons to attempt fistula construction in more patients, including diabetics, access-challenged patients, and patients with small vessels, who may benefit from a nontraditional surgical approach toward fistula creation.

Access-related Infection and Pre-infection Albumin in Hemodialysis

Infection of hemodialysis (HD) access is a major cause of morbidity and mortality. Certain conditions predisposing to infection (malnutrition, chronic inflammation) are associated with hypoalbuminemia. To test whether pre-existing hypoalbuminemia has any relationship with HD access infections, we analyzed the records of 87 patients on chronic HD who had access-related infection as the reason for hospital admission between July 1999 and June 2001. We obtained data on age, gender, pre-infection albumin levels, co-morbidities, complications, type of infection, infecting organism, mode of management and mortality. We compared average pre-infection albumin levels of 79 patients with access infection with those of 198 control patients on chronic HD during the study period without documented access infection. We also compared mortalities between patients with HD tunneled catheter infection treated with antibiotics alone and those treated with antibiotics plus access removal. The mean pre-infection serum albumin was lower in subjects with access infection than those without access infection (2.4 ± 0.6 vs. 3.2 ± 0.6 g/dL, P < 0.0001). Logistic regression including several clinical confounders among its candidate variables identified hypoalbuminemia as a strong predictor (P < 0.0001) of access infection. The odds ratio (OR) of access infection increased progressively with decreasing pre-infection serum albumin: OR of access infection was 8.0 (95% confidence interval {CI} 4.5–16.6) for albumin ≤ 3.0 g/L, 11.0 (95% CI 4.4–22.3) for albumin ≤ 2.5 g/dL, and 27.9 (95% CI 6.1–128.1) for albumin ≤ 2.0 g/dL. Women had a marginally higher chance of tunneled HD catheter infection than men (P = 0.08). Case mortality was 25%(4 in 16) in patients with tunneled HD catheter infection treated with antibiotics alone and 2.8%(2 in 71) in those treated with antibiotics plus access removal or change over a guide wire (P = 0.0096). Hypoalbuminemia, a predictor of adverse outcomes in HD, is associated with an increased risk of HD access infection. Women with tunneled HD catheter have a tendency to higher rates of access infection than men. Treatment of tunneled HD catheter infection with antibiotics alone is associated with increased risk of death.

Using Cuffed and Tunnelled Central Venous Catheters as Permanent Vascular Access for Hemodialysis: A Prospective Study

Background. Adequate care of a hemodialysis patient requires constant attention to the need to maintain vascular access (VA) patency. VA complications are the main cause of hospitalization in hemodialysis patients. The native arteriovenous fistula (NAVF), synthetic arteriovenous grafts fistula (GAVF) and silastic cuffed central venous catheters (CVCs) are used for permanent vascular access (PVA). CVCs are primary the method of choice for temporary access. But using this access modality is increasing more and more for PVA in elderly hemodialysis patients and when other PVA is not possible. The primary aim of this study is to investigate survivals and complications of the CVCs used for long-term VA. Methods. We prospectively looked at 92 CVCs (Medcomp Ash Split Cath, 14 FR × 28 cm (Little, M.A.; O'Riordan, A.; Lucey, B.; Farrell, M.; Lee, M.; Conlon, P.J.; Walshe, J.J. A prospective study of complications associated with cuffed, tunnelled hemodialysis catheters. Nephrol. Dial. Transplant. 2001, 16 (11), 2194–2200) with Dacron cuff) inserted in 85 (50 females, 35 males) chronic hemodialysis patients (the mean age: 56.6 ± 14.1 years) from 07 1999 to 01 2002. The overall survival and complications were followed up. Furthermore, the patients were evaluated for demographic and clinical characteristics. Data were analysed by chi-square, Wilcoxon rank and Kaplan–Meier survival tests. Results. The median duration of CVC survival was 289 days (range: 10–720). Eleven (11.9%) CVCs were removed due to complications. In 79 (92.9%) patients, 1, in 5 (5.8%) patients, 2 and in 1 patient, 3 CVCs were inserted. Of the 85 patients, 56 have CVCs functioning. In addition, 27 (31.76%) patients have CVCs functioning for over 12 months, 17 (20%) patients have CVCs functioning for 6 months. The total incidence of CVC related infections was 0.82 episodes/1000 catheter days. Besides, thrombosis was occurred in 10 (10.8%) CVCs. The most frequent indications for CVC removal were patient death (69.4%), thrombosis (16.6%) and CVC-related infections (13.8%). Conclusions. CVCs are primarily used for temporary access. But this study indicates that CVC may be a very useful alternative permanent vascular access for hemodialysis patients when other forms of vascular access are not available.

Placement of Tunnelled Hemodialysis Catheters across Stenotic and Occluded Central Veins

Purpose The purpose of this study was to evaluate the efficacy of placement of tunneled hemodialysis catheters in patients with occluded or stenotic central veins. Materials and Methods Data were prospectively collected for 26 patients (11 male, 15 female, mean age 52 years) referred for placement of tunneled hemodialysis catheters with central venous stenoses or occlusions. The central venous occlusions or stenoses were recanalized using traditional interventional catheter and guidewire techniques. Results Thirty central venous access procedures were performed of which 28 (93%) procedures resulted in successful tunneled catheter insertion. Twenty-one internal jugular venous (13 right, 8 left) and 7 subclavian venous (3 right, 4 left) catheters were placed. Eighteen stenotic and 10 occluded venous segments were crossed including the brachiocephalic vein (n = 22), subclavian vein (n = 2), and the superior vena cava (4). One patient required insertion of a metallic stent to facilitate passage of the hemodialysis catheter across an occluded brachiocephalic vein. No procedure-related complications occurred. No episodes of upper extremity swelling or superior vena cava syndrome occurred following catheter insertion. Conclusion Insertion of tunneled hemodialysis catheter across occluded or stenotic central veins is technically feasible and safe. The use of occluded or stenotic central veins for catheter access preserves patent central veins for future shunt access.