Tunneled Hemodialysis Catheters: Placement and complications

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1 Tunneled Hemodialysis Catheters: Placement and complications Arif Asif, M.D. Director, Interventional Nephrology Associate Professor of Medicine University of Miami, FL

2 Tunneled Hemodialysis Catheters: Placement and Complications

3 Despite the highest risk of mortality, a significant number of chronic hemodialysis patients continue to receive dialysis using a tunneled hemodialysis catheters. 21% Chronic caths

4 While there are many disadvantages, there are some advantages of tunneled hemodialysis catheters Relative simple insertion procedure Can be insert into multiple sites even in patients with exhausted upper and lower extremity veins Compared to an arteriovenous fistula or a graft, no maturation time or prolonged healing period is not required Some of the complications could be handled relatively easily

5 Problems Thrombosis, infection, stenosis The access does not last as long as a fistula or a graft Lower blood flow rates

6 Catheter design Diameter is major factor 19 % diameter increase - flow increases 2X 50 % diameter increase - flow increases 5X Increasing from 2.0mm to 2.1mm increases flow 21% Catheter length is less important l9% increase in diameter will compensate for doubling of length Slide from Gerald Beathard, M.D.

7 Optimal Catheter design Use largest diameter available Use shortest length compatible with proper placement

8 Tunneled Catheter Placement: While anatomical landmarks are important to identify internal jugular vein, ultrasound should be strongly considered to identify the vein and reduce complications. In fact, ultrasound is considered mandatory by many leaders in catheter insertion. Courtesy of Tony Samaha, M.D.

9 A micropuncture needle could be used to enter the internal jugular vein. Courtesy of Tony Samaha

10 Local anesthesia is infiltrated and a tunnel created for the catheter Courtesy of Tony Samaha

11 Catheter insertion can be accomplished with or without a peel-away sheath. Courtesy of Tony Samaha

12 Optimal site Right internal jugular vein

13 Other Sites Femoral Left internal jugular Trans-lumbar (IVC) Subclavian High risk for stenosis Acceptable only if no further arm access planned

14 Cannulation of the Vein Ultrasound guided cannulation should be mandatory

15 Location of Internal Jugular Slide form Gerald Beathard

16 Slide form Gerald Beathard

17 Tip Position Fluoroscopy is mandatory for tip position

18 Placement without fluoroscopy Slide form Gerald Beathard

19 Optimum Catheter Tip Position:

20 Optimal tunneled HD catheter Place in right internal jugular Use ultrasound for cannulation Use fluoroscopy for placement Place tip well within atrium

21 Complicating Issues

22 Catheter Dysfunction Thrombosis and sheath formation are the most common cause of catheter dysfunction and access loss 1,2 Occurs in 30% to 40% of patients undergoing hemodialysis 3,4 1. Blankestijn. In Hemodialysis Vascular Access: Practice and Problems. 2001; 2. NKF. Am J Kidney Dis. 2001;37(suppl 1); 3. Little. Am J Kidney Dis. 2002; 4. Moss. Am J Kidney Dis. 1988; 5. Feldman. J Am Soc Nephrol. 1996; 6. Feldman. Kidney Int

23 Impact of blood flow on Dialysis Dose Dose Decay Progression Patient health; QOL Kt/V Morbidity & Mortality ; QOL Increasing BFR 300 ml/min Q B Decreasing BFR Held et al. Kidney Int. 1996;50: ; Hakim et al. Am J Kidney Dis. 1994;23: ; Owen. JAMA. 1998;280:

24 Inadequate Dialysis Dosing Increases HD Treatment Time and Costs Every 0.1 in Kt/V is independently associated with 11% more hospitalizations 12% more hospital days $940 increase in Medicare inpatient expenditures United States Renal Data System, 2003; Sehgal et al. Am J Kidney Dis. 2001;37(6):

25 Thrombolytics have been used to treat catheter thrombosis High level of safety and efficacy Efficacious as lytic to restore flow 1 Efficacious to maintain blood flow 2 Lower incidence of complications Cost-effective 1. Prabhu 1997; Atkinson 1990; Paulsen 1993; Crowther Twardowski 1998; Dowling 2000; Spry 2001; Eyrich 2002

26 rtpa protocol for intraluminal thrombus 2mg tpa mixed with NS to total volume of catheter lumen Fill lumens with mixture to fill volume and wait 15min Inject 0.3ml of saline to move active enzyme toward the tip of catheter every 5 min X 3 Aspirate from catheter If aspirates easily, do forceful flush If cannot aspirate easily, may repeat procedure If still unsuccessful, probably dealing with fibroepithelial sheth Adapted from from Beathard G., G., Seminars in in Dial Dial14:441-45,

27 Fibroepithelial Sheath Fibroepithelial sheath is major problem Catheter exchange is solution tpa is of short term value only Photo Courtesy: G. Beathard

28 Treatment of Fibrin Sheath Sheath mostly associated with venous stenosis Treatment of stenosis will obliterate sheath

29 Fibroepithelial Sheath: Pre and post treatment Left IJ catheter Sheath Right atrium

30 Catheters can cause central venous stenosis

31 BRCHPH SVC BRCHPH SVC Complete occlusion of superior vena cava Right Atrium

32 Balloon angioplasty can be successful in selected cases

33 Post angioplasty BRCHPH SVC BRCHPH SVC RA

34 Pre-angioplasty of central venous occlusion Post-angioplasty of central venous occlusion

35 Catheter can be accidentally dislodged

36 In some cases of a new catheter could be inserted through the same exit site after sterile preparation Asif et al: Seminars in Dialysis 2007 Funaki et al: JVIR 1998

37 Wire insertion

38 Imager over the wire

39 Angiography is then performed to confirm central veins and the atrium

40 A new catheter is then fed onto the Wire and into the atrium

41

42 New tunnel creation is usually performed for the following conditions Badly placed catheter with a kink Infected exit site

43 Kink Infected exit site

44 Site of new tunnel drawn

45 New tunnel created under Local anethesia

46 Wire insertion through the new tunnel

47 Catheter insertion through the new tunnel

48 Kink New Tunnel Kink

49 Catheter can cause exit site infection, endocarditis and discitis Image from Tony Samaha

50 Conclusions At present tunneled dialysis catheters play a major role in providing dialysis therapy Right internal jugular vein continues to be the preferred site Ultrasound and fluoroscopy are mandatory Thrombosis, stenosis and infection remain the most important problems associated with catheters Due to these problems, catheter continue to be associated with the highest risk of mortality compared to fistulae and grafts in hemodialysis patients