Vascular Access In Patients Research Articles

A study of outcome and complications associated with temporary hemodialysis catheters in a Nigerian dialysis unit

Hemodialysis (HD) catheters are commonly used as temporary vascular access in patients with kidney failure who require immediate HD. The use of these catheters is limited by complications such as infections, thrombosis resulting in poor blood flow. We studied the complications and outcomes of nontunneled catheters used for vascular access in our dialysis unit. The records of all patients, with renal failure who were dialyzed over a two-year period and had a double lumen nontunneled catheter inserted, were retrieved. Catheter insertion was carried out under ultrasound guidance using the modified Seldinger technique. The demographic data of patients, etiology of chronic kidney disease, and complications and outcomes of these catheters were noted. Fifty-four patients with mean age 43.7 ± 15.8 years had 69 catheters inserted for a cumulative total of 4047 catheter-days. The mean catheter patency was 36.4 ± 37.2 days (range: 1-173 days). Thrombosis occluding the catheters was the most common complication and occurred in 58% of catheters leading to catheter malfunction, followed by infections in18.8% of catheters. During follow-up, 30 (43.5%) catheters were removed, 14 (20.3%) due to catheter malfunction, eight (11.6%) due to infection, five (7.2%) elective removal, and three (4.3%) due to damage. Thrombotic occlusion of catheters was a major limiting factor to the survival of HD catheters. Improvement in catheter patency can be achieved with more potent lock solutions.

Microbiology of Non-Tunnelled Catheter-Related Infections.

Aerobic bacterial infections often complicate vascular access in patients receiving haemodialysis, leading to Catheter-Related Blood Stream Infections (CRBSI). Various studies report Gram - positive bacteria, Staphylococcus aureus (S. aureus) in particular, as the most common aetiologic agent. Studies on microbiological analysis in this subset of population from India are very few. To examine clinical and bacteriological profiles of haemodialysis patients developing CRBSI, the antibiotic susceptibility of the bacteria isolated from these patients and determine nasal carriage of S. aureus in the study subjects. Using a prospective observational design 127 patients receiving haemodialysis (84 males; 43 females) from October 2011 to March 2013 were enrolled in this study. At each dialysis session, catheters were examined for any evidence of infection. In case of suspicion for infection, pus swab, blood culture and the catheter tips were sent to microbiology laboratory for site specific investigations. Vancomycin injection was empirically administered to these patients pending culture results. Data obtained was examined for relationship of CRBSI with clinical and socio-demographic risk factors. Out of 127 patients, 19 developed CRBSI, 10 developed exit-site infections and 33 patients were noted to have colonization of their catheters. The most common organisms included S. aureus in 24 (45.2%) catheter tips, followed by Pseudomonas aeruginosa in 9 (17%), Acinetobacter spp. in 5 (9%), Enterobacter spp. in 4 (7.5%) and Klebsiella pneumoniae in 3 (5.6%) catheter tips. Bacteraemia was found in 19 (20.7%) patients and P. aeruginosa was the most commonly isolated organism amongst them (38.8%). Staphylococcal nasal carriage was seen in 60 (69%) patients and 36 (41.4%) of these isolates were methicillin-resistant. Significant factors associated with CRBSI included history of bacteraemia, presence of diabetes mellitus, long duration (>15 days) of catheterization and antibiotic use within three months (p<0.05 for all). Although S. aureus was the most common colonizer of non-tunnelled central access catheters among haemodialysis patients, CRBSI was most frequently caused by P. aeruginosa, which may have a bearing on our current antibiotic policy.

How to Perform a Simplified Technique for Transapical Aortic Valve Implantations

Transcatheter aortic valve implantation has become the treatment of choice for inoperable and high-risk patients with severe aortic stenosis. Procedures have widely evolved in the 15 years since the first transcatheter transfemoral valve implantation. In this article, we describe a minimal approach of transapical transcatheter aortic valve implantation using the Edwards Sapien 3 valve and the Certitude system delivery. This approach allows for the implantation of a transcatheter heart valve without peripheral vascular access in patients with severe vascular disease. By not using a right ventricular pacing lead, the risk of ventricle perforation is avoided. The volume of injected contrast media is drastically reduced, which is of particular interest for patients with renal insufficiency. The simplification of the procedure using fewer catheterization maneuvers minimizes bleeding. Finally, the absence of retrograde crossing of the aortic arch decreases the risk of cerebral embolization and aortic dissection.

Endovascular Treatment of Multilevel Chronic Total Occlusion Using a Stent Puncture Technique in Buerger's Disease.

We reported a patient with Buerger's disease who presented with critical limb ischemiawith prior recurrent occlusions after multiple surgical and endovascular treatments. Total occlusion of the whole native femoropopliteal and infrapopliteal arteries was observed. The femoropopliteal bypass graft, as well as a stent that was implanted in the mid-popliteal artery, were also occluded. Because of the lack of distal targets for bypass, surgical revascularization was not feasible; therefore, we decided to perform endovascular treatment. To overcome the limitation of vascular access, the previously implanted popliteal stent was directly punctured, and a guide wire was passed through the bypass graft. After the organized thrombus in the bypass graft was aspirated, further recanalization below the popliteal stent down to the plantar arteries was performed successfully. In conclusion, the stent puncture technique is a feasible and safe option for overcoming the limitations of vascular access in patients with multilevel occlusions.

Patient Satisfaction with Nurse Placed Ultrasound Guided Peripheral IV

Objective: Ultrasound (US) guidance for procedures is a well-established adjunct that improves the quality of patient care. Specifically, we assess the impact of nurse performed ultrasound-guided peripheral IV (USGPIV) placement on patient satisfaction with the procedure. Methods: We performed a randomized, prospective controlled study. 10 emergency department (ED) nurses were trained on USGPIVs which included a didactic and supervised placement of 10 US-guided IVs on live subjects. Another cohort of 10 ED nurses received a didactic on using traditional techniques to obtain IVs on difficult vascular access patients. Adult patients were enrolled based on strict inclusion criteria which identified them as having difficult vascular access. Once enrolled, the subjects were randomized into either the US-guided arm or the standard of care (SOC) arm, where the designated study trained nurses carried out peripheral IV placement. If the study nurse failed at IV placement, then a rescue IV was attempted by a non-study provider. The study was stopped once an IV was successfully placed. The patient was given a brief verbal survey to rate their experience from 1-10 (1 was poor and 10 was excellent) regarding the IV technique used by the study nurse. Results: 124 subjects were enrolled and randomized. 62 patients remained in the US-guided study arm and 53 patients in the SOC arm (2 were excluded due to lack of study nurse availability, and 7 patients were lost to followup). The median patient satisfaction in the US-guided group was 10 versus 8 for the SOC arm (p=0.04) Conclusion: Our study demonstrated that patient satisfaction is enhanced when nurses utilize the US-guided approach compared to the SOC palpation technique to establish an IV in difficult access patients. We recommend that nursing staff incorporate this method to IV access in difficult patients to enhance the quality of their patient care experience.

CARE OF A PATIENT'S VASCULAR ACCESS FOR HAEMODIALYSIS: A NARRATIVE LITERATURE REVIEW.

Patients requiring haemodialysis have diverse clinical needs impacting on the longevity of their vascular access and their quality of life. A clinical practice scenario is presented that raises the potential of unsafe cannulation of a patient's vascular access as a result of minimal patient empowerment. Vascular access care is the responsibility of everyone, including the patient and carer. The aim of this narrative literature review (1997-2014) is to explore the current understanding of what factors influence the care of vascular access for haemodialysis. A narrative literature review allows the synthesis of the known literature pertinent to the research question into a succinct model or unique order to enable new understandings to emerge. The bio-ecological model was used to guide the thematic analysis of the literature. The narrative literature review revealed five themes related to care of vascular access: patient experience; relationships-empowerment and shared decision making; environment of healthcare; time; and quality of life as the outcome of care. The management of vascular access is complicated. Current available literature predominantly concentrates on bio-medical aspects of vascular access care. Contextualised vascular access care in the complex ecology of the patient and carer's lives has the potential to enhance nursing practice and patient outcomes.

12 Intraosseous Vascular Access Catheter Appears Safe During Extended Dwell: A Preliminary Report

Despite relatively few documented complications associated with intraosseous (IO) vascular access, the US Food and Drug Administration (FDA) restricts catheter dwell time to 24 hours for IO devices. This may contribute to placement of central venous catheters for difficult vascular access patients in whom an IO placement would otherwise suffice, contributing to an increased risk for complications and costs. Many clinicians have requested that the IO catheter dwell time be extended to at least 48 hours. A study was designed to determine the safety of IO access when the catheter is left in place for up to 48 hours. The study protocol is being conducted under an Investigational Device Exemption granted by the FDA and was approved by IntegReview Ethical Review Board. Consenting adult volunteers (target N=120) with renal impairment and/or diabetes were randomized to have an IO catheter (Arrow EZ-IO Intraosseous Vascular Access System,Teleflex Inc., Reading, PA) placed in the proximal humerus or proximal tibia by a trained physician. At the discretion of the investigator, subjects were administered midazolam and fentanyl to mitigate anxiety associated with IO insertion and the pain associated with the initial flush. With a slow continuous saline infusion administered by infusion pump, subjects remained in a secured early phase research unit for 48 hours. IO infusion pain was managed initially with IO lidocaine injections, then as needed with oral acetaminophen. For more severe pain, intravenous/intramuscular Toradol or oral hydrocodone/acetaminophen were administered. After 48 hours, an IO aspirate sample was obtained from the in-situ catheter for culturing and an x-ray was taken of the IO insertion site after removal. After 30 days, subjects returned for physical examination and x-ray imaging of the insertion site. As of April 2015, 24 subjects have completed the study with one subject in follow-up. There have been no serious adverse events or complications associated with the IO catheters. The IO aspirate culture reports have shown no growth of microorganisms associated with osteomyelitis; there has been no radiographic evidence of osteomyelitis or other abnormalities associated with the IO catheter. Pain associated with IO catheter dwell and infusion has been well managed with the additional medications (acetaminophen, Toradol, and hydrocodone/acetaminophen); a finding previously unreported. Preliminary results indicate that IO vascular access can be safely maintained for a period up to 48 hours without risk of osteomyelitis or other serious adverse events. Extended dwell time and increased IO access utilization could result in avoidance of serious complications and costs associated with peripherally inserted central catheters (PICC lines), as well as femoral, subclavian, and internal jugular central venous catheters being placed due to difficult vascular access, when central venous access may not be clinically necessary. Using additional analgesics for IO infusion pain management may be more effective than the current standard of only administering lidocaine into the IO space.

When Arteriovenous Fistulas Are Too Deep: Options in Obese Individuals

Obesity in the hemodialysis population is roughly twice that of the general population. An arteriovenous fistula (AVF) remains the recommended vascular access; however, obesity results in fewer autogenous accesses, more complexity, and higher AVF failure rates. We reviewed our vascular access experience in obese individuals in whom the depth of an AVF prevented reliable cannulation. We reviewed our database of consecutive vascular access patients, identifying individuals in whom the planned venous outflow cannulation segments were too deep and required additional surgical procedures to establish a functional hemodialysis access. These additional procedures included lipectomy, outflow elevation, cephalic transposition, liposuction, or an implantable cannulation guide. During the study period, 1,874 consecutive new patients had an autogenous vascular access constructed. We identified 120 patients in whom an additional procedure was required due to the depth of the cannulation sites; these comprised this study group. Ninety-nine (83%) were female, 85 (71%) were diabetic, and 53 (45%) had previous access operations. Body mass index was 25.4 to 62.8 kg/m(2) (mean 40.8 kg/m(2)), age range was 27 to 81 years (mean 54 years), and follow-up was 1 to 101 months (mean 25 months). Primary and cumulative patency rates for all patients were 63% and 93% at 1 year and 46% and 91% after 2 years, respectively. The most common additional procedure performed was a lipectomy (n = 78), with 1-year primary and cumulative patency rates of 78% and 97% and 2-year rates of 69% and 91%, respectively. A variety of surgical options were found to be successful in establishing a functional autogenous vascular access for individuals in whom cannulation sites were simply too deep. Cumulative patency rates for all patients were 93% at 1 year and 91% after 2 years.

An Era of Antimicrobial Resistance: Imminent Threats of Superbugs to Vascular Access Clinicians and Patients

Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation J. Hudson Garrett; An Era of Antimicrobial Resistance: Imminent Threats of Superbugs to Vascular Access Clinicians and Patients. Journal of the Association for Vascular Access 1 September 2015; 20 (3): 133–136. doi: https://doi.org/10.1016/j.java.2015.06.002 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest Search

Vascular access in diabetic patients. Are these patients "difficult"?

Diabetics with stage V chronic kidney disease (CKD) on hemodialysis (HD) are considered as "difficult patients", because of problems with creation of the vascular access. There is controversy regarding the results and recommendations for preparation of the vascular access in these patients. The aim of this retrospective study was to evaluate the results of creating different types of arteriovenous fistula (AVFs) in consecutive series of patients starting dialysis treatment. The analysis was performed in 741 patients (385 females and 356 males), average age 61.4±7 years, who started dialysis treatment in our department between January 2005 and December 2012. Native AVFs were created in all patients. No patients received an AVF requiring synthetic graft material. The number of patients with diabetic nephropathy was 166 (22.4%). Among them, 30 (18%) had type 1 diabetes and 136 (82%) type 2. In this group the occurrence of calcification in the forearm artery was estimated on the basis of physical examination, Allan's test, Doppler ultrasound and forearm X-ray. In a subgroup of patients with atherosclerotic changes in the arterial system the frequency of failed AVFs was analyzed. These results were compared with the group without diabetes. The number of procedures necessary for successfu AVF creation and type of access was counted in both groups. The assessment of the procedure frequency and AVF location in diabetic and in non-diabetic patients was made by χ² test with Yates correction. In the group of 166 patients with diabetes, in 100 cases (60%) atherosclerotic changes in forearm arteries were observed. In a subgroup of 30 patients with type 1 diabetes atherosclerosis was observed in 17 adults (57%). In this subgroup creation of a suitable forearm AVF in the first procedure in 9 patients was possible and in the other 8 cases the atherosclerotic changes necessitated repeated procedures and were an important obstacle to create the AVF. In the subgroup of 136 patients with type 2 diabetes, atherosclerosis in the forearm artery was observed in 83 cases (61%). In this subgroup the creation of a native AVF was possible in 40 patients during the first procedure and in 43 cases additional intervention was needed, but only in 8 cases was atherosclerosis the cause of fistula failure. Generally, among 166 patients only in 16 cases (10%) did atherosclerosis present an important obstacle for AVF creation, but the number of necessary procedures to create one functioning AVF was significantly greater in this population (2 v 2.7, p=0.0001). A functioning AVF in patients with diabetes was found significantly frequently in the arm localization in comparison to non-diabetic patients (4.3 v 2%, p=0.0478). Atherosclerotic changes in forearm arteries in diabetic patients appear in 60% of hemodialysis patients and make it difficult to create an AVF only in 10% of diabetic patients, but it is possible to create a native AVF in 90% of diabetic patients, although this requires more procedures. In patients with diabetes, AVF in the wrist region should be preferred.

Brachial Artery-Brachial Vein Fistula for Hemodialysis: One- or Two-Stage Procedure-A Review.

Purpose The purpose of the study was to investigate the patency rate of the brachial vein transposition-arteriovenous fistula [BVT-AVF] and to review the available literature regarding the comparison of the one-stage with the two-stage procedure. Methods A multiple electronic health database search was performed, aiming to identify studies on brachial vein superficialization. Case reports and series with five or less patients were excluded from the study. End points of the study were the patency rates at 12, 24, and 36 months of follow-up. The patency of the one- or two-stage BVT-AVF procedure was investigated. Results Overall, 380 BVT-AVFs were analyzed. The primary patency rate at 12 months ranged between 24 and 77%. Rate of early fistula malfunction or failure of maturation of the fistula resulting in loss of functionality ranged from 0 to 53%. Forearm edema, hematomas, wound infection, and early thrombosis were among the most common complications. Limited data were available for the comparison of patency rates between the one- and the two-stage procedure because of the absence of sufficient comparative studies. However, series with one-stage procedure presented a lower patency rate at 12 months compared to series with two stages. Conclusion Patency rates after BVT-AVF, although not excellent, has encouraging results taking into account that patients undergoing these procedures do not have an accessible superficial vein network; failure of maturation and the increased rate of early postoperative complications remain a concern. The BVT-AVF is a valuable option for creating an autologous vascular access in patients lacking adequate superficial veins.

EFFECT OF PRE ESTABLISHED NURSING CARE STANDARDS ON NURSES΄ KNOWLEDGE AND PERFORMANCE ABOUT HEMODIALYSIS VASCULAR ACCESS CARE

Hemodialysis nurses have an essential role in ensuring conformity to the hemodialysis standards and providing effective and safe patient care. Also, hemodialysis nurses play a vital role in providing efficient, coordinated, and focused patient care ,tasks that contribute to direct patient care are subdivided into three phases (the pre dialysis phase, the intradialytic phase and the termination phase). Education and training are two components of staff development that occur after an employee’s orientation. Methodology: quasi experimental research design was conducted in the hemodialysis unit of International Mansoura Hospital (IMH). Socio demographic data & Nurses' Knowledge about nursing care standards of hemodialysis vascular access patients questionnaire sheet was designed after reviewing the related recent literature to assess nurses' knowledge. It contains 12 questions related to nursing care standards of hemodialysis vascular access. Performance checklist regarding hemodialysis vascular access care including 12 steps was designed. All available nurses (30) during the study period employed in hemodialysis unit with various age, qualifications, years of experience, different level of education, and willing to participate voluntarily. Results: The present study revealed that: (a) the total means knowledge score of nurses was increased after sessions. (b) The total mean practice score of nurses was increased after sessions. Conclusion: Nursing care standards recommendations are essential for nurses working at the hemodialysis unit. Nurse's level of education and years of experience was positive correlation with their knowledge and performance, but it was not statistically significant.

Cannulation of arteriovenous fistulas by the buttonhole technique: a case study

Aim: To describe the case of a patient with chronic kidney disease (CKD) undergoing cannulation of arteriovenous fistulas by the buttonhole technique for hemodialysis treatment, and comparing it to cases submitted to the conventional technique. Method: A case study of an adult male patient carrying CKD, held in the Dialysis Center of Sao Goncalo / RJ between March and May 2014, whose analysis was based on the literature. Results: We observed no complications three months after cannulation by buttonhole; the patient reported reduction in pain during the procedure; the limb with the fistula remained aesthetically intact. Discussion: Results of comparative studies of the two techniques are shown to be different, although they point to major benefits of the buttonhole technique: decreased pain, extended life of the AVF, reduction of bleeding and bruising. Conclusion: The buttonhole technique can be useful for new vascular access and hypersensitive patients.

Hypnoanesthesia in Vascular Access

PurposeA case is presented wherein hypnosis alone provided anesthesia for the ultrasound-guided placement of a device into right basilic vein. This is the first reported case of hypnoanesthesia for ultrasound-guided vascular access. MethodEricksonian hypnosis was employed by the operator while a second clinician performed the vascular access procedure. The general method of induction and the anesthetic suggestions are disclosed and discussed. ResultsThe patient's experience was painless and, by her own repeated reports, pleasurable. ConclusionsHypnosis is merely a refinement of everyday communication wherein ideas are expressed to increase the likelihood of their actualization. This case illustrates how a few carefully chosen sentences can alter a vascular access patient's entire experience.

Hemodialysis Arteriovenous Vascular Access Creation After Kidney Transplant Failure

Little is known about vascular access in patients starting hemodialysis therapy after kidney transplant failure. Retrospective cohort study. Adult patients (aged≥18 years) who started hemodialysis therapy in Ontario, Canada, from January 1, 2001, through December 31, 2010, after kidney transplant failure. Patient clinical and demographic characteristics. Proportion and timing of arteriovenous (AV) vascular access creation (fistula or graft) 12 months prior and up to 24 months after starting hemodialysis therapy. Event rates and outcome predictors. Our cohort included 683 patients with a mean age of 48 years and >50% with comorbidity index score< 3. In the 12 months predialysis and 24 months postdialysis, 16% and 47% of patients had an AV access created, respectively. In the postdialysis period, 13%, 26%, and 38% of patients had an AV access creation at 3, 6, and 12 months, respectively. History of coronary artery disease, diabetes mellitus, and peritoneal dialysis use prior to transplantation were associated with a lower likelihood of AV access creation. Residual selection bias from unmeasured variables beyond the data elements. In Ontario, AV access creation, both before and after starting hemodialysis therapy, is low in patients with kidney transplant failure despite their being younger and healthier compared to the overall hemodialysis population. This highlights the need for a predialysis care pathway in the transplantation clinic and an active strategy to identify this patient cohort receiving hemodialysis to align modality and access choices.

A retrospective study of palindrome symmetrical-tip catheters for chronic hemodialysis access in China

Hemodialysis catheters remain necessary for long-term vascular access in patients for whom arteriovenous access may be problematic or impossible. Developments in catheter design have improved long-term catheter functionality, and reduced the rate of infection and complications associated with their use. This retrospective study of 284 cases of chronic catheterization in 271 patients treated between 2009 and 2011 using Tal Palindrome™ symmetrical-tip (N = 118) or Quinton™ Permcath™ step-tip (N = 166) hemodialysis catheters evaluates the efficacy and the safety of symmetrical-tip dialysis catheters for chronic hemodialysis, compared with a step-tip catheter. Measurements of catheter performance included mean catheter dwell time, incidence of low blood flow, and rates of infection and catheter-related blood stream infection (CRBSI). The symmetrical-tip catheter had a significantly longer mean dwell time compared with the step-tip catheter; 329.4 ± 38.1 versus 273.1 ± 25.4 d (p < 0.05). In addition, the rate of occurrence of low blood flow per 1000 catheter days was lower for the symmetrical-tip compared with the step-tip catheter; 1.13 versus 6.86 (p < 0.01). The symmetrical-tip catheter was also associated with a lower incidence of complications; the rates of infection (0.28 vs. 0.78; p < 0.01) and CRBSI (0.15 vs. 0.44; p < 0.01) were lower compared with those for step-tip catheters, and catheter removal occurred less often for the symmetrical-tip catheter (8% vs. 16%; p < 0.05). The symmetrical-tip hemodialysis catheter was associated with a longer mean dwell time, lower incidence of low blood flow, and lower infection rate compared with the step-tip catheter.

Use of the subcutaneous venous network of the forearm to create an arteriovenous fistula

The reconstruction of vascular access in patients with kidney allograft failure is a challenging problem. A case of a 62-year-old man with transplanted kidney insufficiency is described. The patient was initially dialyzed with a wrist radial-cephalic arteriovenous fistula. In the post-transplantation period, the enormously dilated venous part of the anastomosis was ligated and the part of the vein suspected of being the source of bacteremia was excised. The man was referred to our department due to kidney allograft failure for vascular access creation. During preoperative assessment, we unexpectedly found a soft thrill on the forearm. Doppler ultrasound confirmed fistula patency, although the blood supply was not sufficient to perform dialysis. Angiography showed the blood flow from the radial artery to the cephalic vein, through a complicated vessel system consisting of inter alia a dilated vein of the subcutaneous venous network. We successfully used this vein as the vascular access outflow for fistula recreation. In conclusion, making use of veins of the subcutaneous venous network of the forearm for creation of a native fistula should be considered in selected cases.

Safety and feasibility of a strategy of early central venous catheter insertion in a deployed UK military Ebola virus disease treatment unit.

Early central venous catheter (CVC) insertion in Ebola virus disease (EVD) is a novel approach and has not previously been described. This report delineates the safety, feasibility and clinical implications of early CVC insertion as the optimum means of vascular access in patients with EVD, in the setting of a deployed military Ebola virus disease treatment unit in Sierra Leone. In the gastrointestinal phase of EVD, a 7-French 20-cm triple-lumen CVC was inserted using aseptic technique. Data were collected prospectively on all cases to include baseline and subsequent blood test variables, insertion site and technique, and complications associated with CVC placement. Twenty-three patients underwent CVC insertion as follows: subclavian, 21 (88 %); internal jugular, 2 (8 %); axillary, 1 (4 %). The mean duration of CVC placement was 5 days. There were no significant procedure-related adverse events. Despite coagulopathy being present in 75 % of cases, CVC insertion was safe, and there was only 1 case of significant catheter site bleeding. A total of 152 needle venepunctures were avoided owing to the presence of a CVC, a mean of 7 (±3.8) per case over the average stay. The early use of CVCs in Ebola virus disease is safe, effective and facilitates patient care. It should be considered a feasible additional route of venous access, where physician expertise and resources allow.

Catheter-related atrial thrombus: tip of the iceberg?

Although guidelines recommend catheters as a last resort for establishing a vascular access in patients undergoing dialysis, they continue to be used widely for this purpose. Catheter-related atrial thrombus (CRAT) is rarely reported in this group of patients, and it can lead to serious complications. The aim of this study was to determine the incidence of CRAT in patients undergoing hemodialysis with permanent-tunneled catheters. A total of 50 patients undergoing hemodialysis with permanent catheters were included in this study. The diagnosis of CRAT was based on transthoracic echocardiography findings. Thrombus was present in nine patients (18%) and related to the tip of the catheter in all cases. Except for one patient with two foci of thrombus, all patients had a single focus. There were no significant associations between the development of thrombus and the duration of catheter use or the location of the catheter. Furthermore, catheter-related atrial thrombus did not appear to have a significant effect on mortality. The asymptomatic character of CRAT can be responsible for the low reporting rates, and its exact role in increased mortality and morbidity related with catheter use remains unknown. While planning management strategies, information on different options for vascular access routes and possible catheter-related complications should be provided to all patients who will undergo dialysis, together with a discussion involving other replacement alternatives for end-stage renal disease.

Vascular access for long-term hemodialysis/hemodiafiltration patients in Japan.

Many patients are receiving long-term hemodialysis (HD) or hemodiafiltration (HDF) treatment in Japan. Vascular access is a lifeline for patients on HD or HDF, and proper maintenance of vascular access is one of the key factors that make long-term HD and HDF possible. We investigated the conditions of vascular access in patients undergoing chronic HD or HDF in our hospital group in Japan to assess the relationship between the type of vascular access and long-term treatment. We studied the conditions of vascular access in 899 patients who were on chronic HD or HDF, including patients who had been on dialysis for over 20 years as of December 2014. There were 125 patients who had been on dialysis treatment for over 20 years, with the longest dialysis vintage being 37 years, and they accounted for 13.9% of the total number of subjects. The primary disease was diabetes in two cases and chronic glomerulonephritis in the rest. There were 105 patients with an arteriovenous fistula and only 20 with an arteriovenous graft (AVG) (16.0%), whereas 91 had an AVG (11.7%) among the 774 patients who had been on dialysis treatment for less than 20 years, which indicated that the percentage of patients with an AVG increased with dialysis vintage. An arteriovenous fistula was the main type of vascular access used in patients who had been on dialysis treatment for over 20 years, which is very rare, even on the global scale. However, switching to an AVG is unavoidable in cases of vein deterioration due to long-term use. Access via an AVG is expected to increase further in long-term patients in the future.