Hemodialysis catheters - from placement to complications: Our experience

Transcription

1 Hemodialysis catheters - from placement to complications: Our experience Poster No.: C-2048 Congress: ECR 2010 Type: Scientific Exhibit Topic: Interventional Radiology - Vascular Authors: E. T. H. Liu, S. K. Venkatesh, A. Vathsala; Singapore/SG Keywords: hemodialysis catheters, infection and catheter dysfunction, tip placement Keywords: Interventional vascular, Vascular, Percutaneous DOI: /ecr2010/C-2048 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Purpose To present our experience in the management of hemodialysis catheters. Page 2 of 28

3 Methods and Materials A retrospective analysis of consecutive patients from January 2007 to December 2008 undergoing permanent hemodialysis catheter insertion in our centre and subsequent follow up at the satellite renal dialysis centers was performed. Information on catheter type, clinical indications for insertion and catheter related complications were reviewed through hospital based patient data records. Contrast angiograms/venograms as well as post procedure chest x-rays of these patients were also reviewed. Patients:The study population comprised of 827 subjects (420 men and 407 women). The study population comprised of 46.6% Chinese, 38.5% Malay, 9.3% Indians and the remaining from other race/ethic groups. The average age of these patients was 57.8 years (range, 15 to 85 years). Each patient was followed up from the time of the catheter insertion till removal of that catheter. The average duration of the permanent catheters being kept in-situ was 138 days. The indications for dialysis were as follows: - Initiate hemodialysis 38% Mechanical problems in existing catheters 25% Temporary dialysis due to failed AV 15% fistulas or infected AV grafts Catheter related sepsis 15% Approximately 80% of these cases were new catheter insertions with the remaining 20% were performed as catheter exchanges. Catheter placement:- Page 3 of 28

4 Prior to insertion of the catheters, the patient's coagulation profile and full blood count were reviewed. Patients with prolongation coagulation (ie prothrombin time > 15 and/or platelets < 100) had to be corrected before the catheter insertion. All catheters were inserted with image guidance with ultrasound for vein puncture and fluoroscopy for track dilatation and final placement of catheter. Site of puncture :- Right internal Jugular vein 76.6% Left internal jugular vein 19.% Other sites including external jugular, 4% subclavian, femoral veins Excluded 3 cases Follow up :Incidences of early, mid and late complications were recorded as well as the reasons for subsequent catheter removal. Patients were followed up closely till the point where the catheter is removed. Reasons for catheter removal :- Conversion to chronic access 27.2% Mechanical problems 24.3% Catheter related infections 17% Conversion of modality 6.8% Others including death 24.7% Page 4 of 28

5 Images for this section: Fig. 0: Pre perm catheter insertion. Guidewire inserted under fluroscopic guidance to ensure guidewire tip is placed in the inferior vena cava. Page 5 of 28

6 Fig. 0: Venogram done to ensure adequate placement of the catheter tip. Tip in the right atrium. Page 6 of 28

7 Results Technical success rate for the catheter insertion based on two subsequent hemodialysis sessions was 100%. Catheter tip placement level :- Cavoatrial junction 70.5% Right atrium 21.5% Inferior vena cava 7.9% In our series, we found that majority of the catheters were placed at the cavoatrial junction and it is the preferred site by the Interventional Radiologists. However, we note that the placement of the catheter tip is also partly influenced by the length of the catheters used as well as the entry site of the catheters. Mainly 3 different types of catheters were used in our series. Catheters lengths were taken from the catheter tip to the ports. They are namely Bard's Hemoglide curve catheters (25, 29, 33 cm lengths), Bard's Hemostar straight catheters (24, 28, 32 cm lengths) as well as Covidien's Palindrome straight and curve catheters (24, 28 and 32 cm lengths). Other catheters were also used as outlined in the table. Catheter Types :- Hemoglide curve (25, 29, 33 cm) 505 Hemoglide straight (24, 28, 32 cm) 101 Palindrome curve (24, 28, 32 cm) 106 Palindrome straight (24, 28, 32 cm) 95 Maxid straight (24, 28 cm) 3 Medcomp curve & straight 8 Vascath (17, 22 cm) 4 Quinton straight 2 Mahukar 5 Page 7 of 28

8 Note that 4 catheters were not identified. We found that 15% of catheter tips placed at the cavoatrial junction resulted in mechanical failure as compared to 6% of catheter tips which were placed at the right atrium and 2% of catheter tips which were placed at the lower superior vena cava. This maybe attributed to the relatively more narrowed segment as compared to the superior vena cava or the right atrium. No immediate major complications were encountered in our series. However, minor complications, which includes bleeding, pain over the insertion site and mal-positioning of the catheters, were encountered, abet small in number. Close observation and monitoring post procedure ensured that localised bleed and pain were treated adequately. Routinely performed post procedure CXRs allowed the Interventional Radiologist to review the position of the catheter tip and make the necessary adjustments prior to returning the patient to the ward. Subsequently, the discharged patients are followed up at the satellite dialysis centers, which are scattered throughout various town centers. These patients have easy access to the centers as they are required to undergo a thrice-weekly dialysis session. Dialysis nurses at these centers are trained to identify patients with potential catheter problems early on. Reduced flow rates during dialysis are an indication of potential mechanical catheter failure. Localised skin infection at the catheter site or sepsis may also be encountered. These patients are then referred directly to the primary renal physician for further management. Management would include fibrin sheath removal, use of anti-thrombolytics, change of catheters and the use of antibiotics for sepsis. A close working relationship between the referring Renal physician and the Interventional Radiologist ensures that management and treatment is prompt. Catheter insertions or exchanges as well as venograms/ venoplasties can then be performed. Discussion: Patients undergoing hemodialysis require a reliable vascular access via venous routes, which include the internal jugular and subclavian veins. The preferred venous access is the right internal jugular vein, which provides for a straight course to the right atrium/heart. It is also associated with a lower incidence of venous thrombosis/stenosis and it is also technically easier to insert under radiological guidance [1]. The left internal jugular vein is technically more difficult to insert due to its tortuous path along the left brachiocephalic vein prior to entry into the SVC. Page 8 of 28

9 Subclavian routes are often avoided due to the high risk of pneumothorax even under radiological guidance [2]. There is also a risk of catheter fatigue and fracture as well as pinch off effects by the overlying costoclavicular ligaments, the first rib and serratus anterior muscle. The catheters are inserted low in the neck, preferably within 1 cm above the clavicle. If the catheter is placed higher (ie 3 to 4 cm) above the clavicle, there is a risk of creating a kink in the catheter and thus causing dysfunction. Mal-positioning of the permanent catheter is one of the causes of catheter dysfunction. There have been reported incidences of catheters causing erosions of the adjacent SVC and right atrial walls. Catheter tip placements close to the right atrium have been advocated to minimise erosions and dysfunction [3]. Arrhythmias and valvular vegetations are said to occur if tip is placed too low in the atrium. However, we did not encounter any such complications in our series. Wong et al reported that malpositioning could be minimised with better initial placement of the catheters with the tips placed further into the right atrium [4]. Subsequently, Cadman et el reported no complications observed with the catheter tip being placed in the right atrium [5]. We found a higher incidence of catheter malfunction in our series when the catheter tips were placed at the cavoatrial junction (15% of cases) as compared to the ones placed at the right atrium (6% of cases) or the lower superior vena cava (2% of cases). Catheter tip positioning can also migrate cephalad (2-3 cm) when the patients recovers from a supine position during catheter insertion to a sitting up/upright position post procedure [6,7]. This was taken into consideration during each procedure and routine erect CXRs (sitting CXR if patient is not ambulant) were performed within the radiology department to ensure adequate catheter positioning prior to discharging the patient back to the ward. (Figs 1 to 5 showing post procedure CXRs with the catheter tips at various levels). Catheter placement must also take into account the arterial port, which should not lie adjacent to the vessel wall to prevent malfunction. Careful manipulation of the catheter with the use of guidewires under fluoroscopic guidance ensures that the arterial port does not abut against the wall. Through prolonged catheter use and repeated catheters insertions at both the jugular and subclavian venous sites, subsequent stenoses and occlusions may and often develop, which may necessitate further intervention. Catheter dysfunctions are also Page 9 of 28

10 frequently encountered and these are often related to fibrin sheath formation, central venous thrombosis and catheter intra-luminal thrombus formation. Initial signs of catheter dysfunction can be detected during hemodialysis sessions were there is decrease in the flow rates (<200 ml/min). (Figs 6 to 12 showing occlusions to both the superior vena cava at various levels as well as along both left and right brachiocephalic veins). The rate of catheter dysfunction in our series was 0.22 per 100 catheter days, which is comparable to other published reports [11,12], which varied from 0.2 to 0.5 per 100 catheter days. At our centre, fibrin sheath formation and intra-luminal thrombus formation are treated with urokinase and heparin/warfarin respectively. Balloon venoplasty is also used to disrupt the fibrin sheath and fragment it. Fibrin sheath stripping to remove the fibrin from the catheter tip is an alternative method. Another option is for an exchange of the catheters. However, this catheter exchange alone may not be sufficient to dislodge or disrupt the fibrin sheath. (Fig 13) With catheter thrombosis, patients may develop severe complications such as pulmonary embolism or superior vena cava syndrome requires prompt recognition and intervention. Catheter related infections increases both morbidity and mortality of patients requiring dialysis. Coagulase negative Staphylococcus species and Staphylococcus aureus are the most common infective agents [8]. Infection can lead to infective endocarditis, osteomyelitis, septic arthritis, septic central venous thrombosis and even death. Varying rates of infection have been reported in the literature from 0.27 to 0.55 episodes per 100 catheter days [9,10]. The rate of infection in our series is per 100 catheter days, which is favorably comparable to the other reported studies. There appears to be an apparent higher rate of infection with catheter tips placed at the cavoatrial junction (10.3% of cases of catheter removal) as compared to catheter tips placed at the right atrium (5.9% of cases) and lower vena cava (1.6% of cases). However, this is likely to be attributed to more cases being inserted and placed at the cavoatrial junction as compared to the other placement levels. Aggressive management and treatment of these infections is advocated. Catheter removal in such patients is mandatory and a period antibiotic treatment is provided. Catheters were only reinserted when the course of antibiotics have been completed and there are negative cultures. The use of newer catheters with silver or antimicrobial/ antiseptic coatings has not shown to significantly reduce the incidence of infections in these patients [13,14]. Page 10 of 28

11 Page 11 of 28

12 Images for this section: Fig. 0: CXR : Catheter tip placed at the lower superior vena cava Page 12 of 28

13 Fig. 0: CXR : Catheter tip placed at the cavoatrial junction Page 13 of 28

14 Fig. 0: CXR : Catheter tip placed at the right atrium Page 14 of 28

15 Fig. 0: CXR : Left sided perm catheter with tip placed in the right atrium Page 15 of 28

16 Fig. 0: CXR : Left sided perm catheter with tip placed in the lower superior vena cava Page 16 of 28

17 Fig. 0: Venogram showing partial left brachiocephalic vein occlusion during left IJ vein puncture Page 17 of 28

18 Fig. 0: Venogram showing stenosis of the superior vena cava with collaterals Page 18 of 28

19 Fig. 0: Venogram showing almost complete left brachiocephalic vein stenosis despite presence of a nitinol stent. Numerous collaterals noted. Page 19 of 28

20 Fig. 0: Venogram showing almost complete superior vena cava stenosis with collateral flow. Note the catheter placed along the left brachiocephalic vein Page 20 of 28

21 Fig. 0: Venogram showing complete stenosis at the lower superior vena cava. Adjacent azygous vein noted Page 21 of 28

22 Fig. 0: Venogram show almost complete lower superior vena cava stenosis. Minimal contrast flow into the right atrium. Page 22 of 28

23 Fig. 0: Venogram showing narrowing at the mid superior vena cava during a right IJ puncture. Page 23 of 28

24 Fig. 0: Venogram via right sided catheter showing tight narrowing/stricture at the lower superior vena cava with filling defect (thrombus in-situ). Note the contrast back flow along the hemiazygous system. Patient had subsequent thrombolysis done and catheter removed. Page 24 of 28

25 Conclusion Hemodialysis catheters remain the mainstay for many chronic renal failure patients who require dialysis. We found that careful placements of the catheters at the level of the lower inferior vena cava and the right atrium are associated with lower incidence of catheter dysfunction and thrombosis/fibrin sheath development. The level of catheter placement did not appear to influence the incidence of infection but rather the careful use of aseptic hygiene techniques and patient education as well as good nursing care procedures have led to low infection rates. Page 25 of 28

26 References 1. Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT. Tunneled infusion catheters increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000; 217: Macdonald S, Watt AJ, McNally D, Edwards RD, Moss JG. Comparison of technical success and outcomes of tunneled catheters inserted via the jugular and subclavian approaches. J Vasc Interv Radiol 2000; 11: Chalmers N. The role of vascular radiology in hemodialysis access. Semin Dial. 2002; 15: Wong JK, Sadler DJ, McCarthy M, Saliken JC, SO CB, Gray RR. Analysis of early failure of tunneled hemodialysis catheters. AJR 2002; 179: Cadman A, Lawrence JA, Fitzsimmons L, Spencer-Shaw A, Swindell R. To clot or not to clot? That is the question in central venous catheters. Clin Radiol 2004; 59: Nazarian GK, Bjarnason H, Dietz CA Jr, Bernadas CA, Hunter DW. Changes in tunneled catheter tip position when a patient is upright. J Vasc Interv Radiol 1997; 8: Kowalski CM, Kaufman JA, Rivitze SM, Geller SC, Waltman AC. Migration of central venous catheters : implications for initial catheter tip positioning. J Vasc Interv Radiol 1997; 8: Banerjee SN, Emori TG, Culver DH, et el. Secular trends in nosocomial primary blood stream infections in the United States : National Nosocomial Infections Surveillance System. Am J Med 1991; 91:86S - 89S. 9. Allon M. Dialysis catheter related bacteremia : treatment and prophylaxis. Am J Kidney Dis 2004; 44: Groeger JS, Lucas AB, Thaler HT et al. Infections morbidity associated with long term use of venous access devices in patients with cancer. Ann Intern Med 1993; 23: Page 26 of 28

27 11. Wilkin TD, Kraus MA, Lane KA, Treotola SO. Internal jugular vein thrombosis associated with hemodialysis catheters. Radiology 2003; 228: Trerotla SO, Johnson MS, Shah H et al. Tunneled hemodialysis catheters : use of a silver coated catheter for prevention of infection - a randomised study. Radiology 1998; 207: Bach A, Eberhardy H, Frick A, Schmidt H, Bottiger BW, Martin E. Efficacy of slivercoated central venous catheters in reducing bacterial colonization. Cri Care Med 1999 Mar; 27(3): Page 27 of 28

28 Personal Information eugene_tze_hsien_liu@nuhs.edu.sg Department of Diagnotic Radiology National University HealthCare System To Felicia for her inspiration Page 28 of 28