AUTHORS Lisa Miller MD Jennifer MacRae Msc MD Mercedeh Kiaii MD Edward Clark MD MSc Christine Dipchand MD Msc Joanne Kappel MD Charmaine Lok MD Msc Rick
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Slide1
CHAPTER 6
Hemodialysis
TUNNELED CATHETER Non-infectious complications
AUTHORS:
Lisa Miller MD, Jennifer
MacRae
Msc
MD,
Mercedeh
Kiaii
MD, Edward Clark MD MSc, Christine
Dipchand
MD
Msc
, Joanne
Kappel
MD, Charmaine
Lok
MD
Msc
, Rick Luscombe RN, Louise Moist MD MSc, Matthew Oliver MD
MHSc
, Pam Pike MD, Swapnil
Hiremath
MD MPH.
On
Behalf Of The Canadian Society Of Nephrology Vascular Access Work Group.
Slide2contents
Introduction
Catheter Dysfunction
Etiology of Catheter Dysfunction
Prevention of Catheter Dysfunction
Treatment
of Catheter
Dysfunction
Central Vein Stenosis
Other Complications
Last Option Access
Summary of Recommendations
Slide3INTRODUCTION
Non-infectious hemodialysis catheter complications include catheter dysfunction, catheter-related thrombus and central vein stenosis.
The
definitions, causes and treatment strategies for catheter dysfunction are reviewed
in this chapter.
Catheter
-related thrombus is a less common, but serious complication of catheters, requiring catheter removal and systemic anticoagulation. In addition, the risk factors, clinical
manifestation,
and treatment options for central vein stenosis are outlined
HD
central venous catheters are associated with both infectious and non-infectious complications
Occur at
time of catheter insertion or at any time over the duration of catheter use
Common non-infectious complications include:
Catheter thrombosis
Mechanical dysfunction
Central vein stenosis
Slide4Catheter Dysfunction
Many definitions for catheter dysfunction can be found in the
literature
Proposed Definitions for Catheter Dysfunction
High arterial
pressures (<-250mmHg)
High venous pressures (> 250 mmHg)
High pressure alarms
Decreased blood flow rates
Inability to withdraw and/or flush catheter lumens
Need to reverse lines
Reduced urea clearance (
Kt
/V <1.2, or urea reduction ratio < 65%)
Slide5Catheter Dysfunction
NKF
/DOQI defines catheter dysfunction as failure to attain and maintain an extracorporeal blood
flow (
Qb
)
of ≥ 300 mL/min at a pre-pump arterial pressure more negative than -250 mm Hg;
Qb
alone may not be adequate for detection of catheter dysfunction
Approx. 1/3
rd of tunneled catheter removal are attributed to inadequate blood flow for HDCatheter dysfunction (Qb < 300 ml/min) occurred in almost 2/3 of patients during at least one treatment; ≥ 1 catheter dysfunction per month in 30%*Interventions: instillation of thrombolytic agents; catheter exchangeConsequences: disruption in the delivery of dialysis care; increase in health resource utilization
*
Analysis of data from DaVita dialysis facilities and US Renal Data System of HD patients receiving treatment exclusively through a catheter
Slide6ETIOLOGY OF Catheter
DYSfunction
Early Catheter
Dysfunction
(likely to occur within first week post insertion)
Usually a mechanical issue:
Patient
malpositioning
Mechanical
kinking of catheter (see figure 1)
Incorrect catheter tip
location
Figure 1:
Courtesy of: The Atlas of Dialysis Vascular Access by Dr.
Vacchharajani
,
esrdncc.org
/
wp
-content/uploads/2015/12/Access-
Atlas.pdf
Slide7
ETIOLOGY OF Catheter
DYSfunction
Early Catheter
Dysfunction
(occurs within first week post insertion)
Catheter
tip should be positioned at the junction of the superior vena cava and right atrium and confirmed with fluoroscopy
Early
dysfunction, especially if tip of catheter is not positioned deep enough, or touching vessel wall,
should prompt consideration of catheter
position
Problems can sometimes be
resolved by repositioning the patient or adjusting the patient’s neck position, which may fix a kink or move the catheter tip away from a vessel wall
Slide8ETIOLOGY OF Catheter
DYSfunction
Late
(delayed)
Catheter Dysfunction
Occurs
weeks, months or even years after
the catheter has been
functioning well previously
Injury of vascular wall
can occur
at time of
insertion, from manipulation or repositioning of catheter
Vascular wall injury results in both turbulent blood flow and stimulation of the coagulation and inflammatory cascadesFibrin sheath (combination of fibrinogen, lipoproteins, albumin and coagulation factors) can begin to form within 24 hours of insertion or vascular wall damage (see figure 2)Sheath may partially or completed encase the catheterLeads to disturbance of catheter blood flow
Associated with the development of thrombosis and infections
Slide9Catheter DYSfunction
: FIBRIN SHEATH
Photo Source: Robert K. Peel, and John H.
Turney
Nephrol
. Dial. Transplant. 2003;18:1026
Figure 2:
A
removed
Tesio
line showing a clean venous blue lower line, and a red upper line with an extensive fibrin sheath attached
Slide10ETIOLOGY OF Catheter
DYSfunction
Thrombosis
Occurs both in early and late catheter dysfunction;
m
ore
commonly associated with late dysfunction
Major
contributors to thrombus formation:
Intimal vessel injury
Turbulent blood flow
Activation of coagulation cascades
Fibrin sheath formation
Can occur intraluminally causing direct obstruction to blood flow
Extraluminal thrombus such as right atrial or mural thrombus may cause extrinsic compression of the catheter, resulting in poor blood flow and inadequate dialysis
Slide11PREVENTION OF
Catheter Dysfunction
Catheter instillation solutions; anticoagulant solutions
Locking solutions are instilled into catheters between hemodialysis
treatemtns
to minimize catheter patency
Sodium
citrate (4%) or concentrated heparin solutions (1000 u/ml)
Standard recommended locking solutions
No difference in thrombolytic use or catheter removal for poor flow
Consider infection prevention and local practice patterns for choice
Citrate use may be associated with reduced bleeding events compared to
heparin
Recombinant tissue
plasminogen activator
(
tPA
)
PreCLOT
trial showed
overall catheter malfunction was 14
% decrease in catheter malfunction when
tPA
(1 mg in each lumen) was combined with two heparin (5000 u/ml) sessions in a thrice weekly
regimen
Catheter-related and all-cause bacteremia rates were also lower in
tPA
group
vs
heparin group
Slide12Systematic Pharmacologic Therapy
Antiplatelet agents e.g. aspirin,
clopidogrel
platelet aggregation and inhibit thrombus formation
Limited conclusive evidence to recommend their use for the prevention of catheter thrombosis
Potentially higher risk of bleeding should be considered
Oral anticoagulants e.g. warfarin
Failed to show a significant benefit in prevention of catheter malfunction
Associated with a significantly higher risk of bleeding in dialysis patients
PREVENTION OF
Catheter Dysfunction
Slide13Thrombolytic Agents and Protocols
Before thrombolytic use be sure to attempt:
Flushing
catheter with saline
Checking catheter for kinks
Patient repositioning
Uncertainty exists regarding best protocol for thrombolytic use
Comparison of d
well
vs PUSH
protocols
demonstrated no statistical difference of achieving a post thrombolytic blood flow ≥ 300 ml/min
ALTE-DOSE study compared 1.0mg vs 2.0 mg dwell dose of
tPA and found that catheter loss was significantly higher in 1mg groupTreatment OF Catheter Dysfunction
Slide14TREATMENT OF Catheter
Dysfunction
Thrombolytic Regimens
Type
Dose
Time
Delivery
Non-functioning CVC
(Qb < 150/200 mL/min or inability to withdraw)
(short or long dwell)
Typical dose: 2 mg
rt
-PA instillation, (1 mg in each port)
Alternative dose: 2 mg per lumen
30 min after instillation (short dwell)
Alternative:
wait additional 2 hrs (long dwell) if 30 min. fails
rt
-PA instilled as dwell for 30 - 60 min.
Alternatives: push 1/3rd of dose every 10 min.; advance the initial pushed
rt
-PA at 10/15 min intervals with 0.3mL
saline ; or deliver via infusion pump over 30 min.
Poor
functioning CVC
w dialysis stopped
2-4 mg
As above
As above
Poor
functioning CVC
w dialysis ongoing (
intradialytic
infusion)
2-4 mg
Over 1 hour
Via infusion pump
-
delivered in the dialysis circuit with CVC lumens reversed for 30 min. then
with normal positions for next 30 min.
Poor
functioning CVC
post dialysis (lock, post HD dwell, overnight dwell)
1 - 2mg per lumen
Until next dialysis
rt
-PA instilled as push ;
allowed to dwell in catheter lumen 48-72
hrs
, until next HD session
Slide15Interventional Therapies
Fibrin sheath reported to be present in 70% of catheters changed for malfunction
Options
Angioplasty
(fibrin sheath
plasty
)
Performed at time of catheter exchange to disrupt the fibrin sheath
Reports of longer catheter patency, modest gains in blood flow and clearance
Observational studies indicate rates of subsequent infection or catheter dysfunction post catheter exchange are on par with patients who did not have a fibrin sheath
Fibrin sheath stripping
Performed using a snare or an intravascular brush
Long-term data on efficacy is lacking
Treatment OF Catheter Dysfunction
Slide16Central vein stenosis
Occurrence rate of up to 40% in prevalent hemodialysis patients
Caused by prior or current use of CVCs such as hemodialysis catheters, peripherally inserted central venous catheters (PICCs) and cardiac implantable electronic devices (CIEDs)
Common sites for stenosis to occur: subclavian vein, innominate vein, cephalic arch, superior vena cava
Risk Factors for central vein stenosis
risk for development of central vein stenosis is associate with use of any central vein device and to some degree location of central vein device
Stenosis of subclavian vein catheters occurs ~ 30-50%
Internal jugular catheter stenosis occurs as high as 25-40%
Indwelling CIEDs causing stenosis have been reported in 22-64% of patients
Hemodialysis patients with
ipsilateral
arteriovenous access creation
Slide17Central vein stenosis
Clinical manifestations
Symptoms occur as result of venous hypertension behind obstruction, though may go undetected
Symptoms include: arm edema, pain and erythema from venous engorgement (with possible skin breakdown),
ipsilateral
breast
sweelling
and dilated collateral veins on upper chest, shoulder and arm
Patients may develop superior vena cava syndrome and rarely pleural effusions
In AV access hemodialysis patients specifically; engorged, pulsatile AVF, positive arm elevation test, increased difficulty needling access, increased bleeding post dialysis, poor dialysis adequacy
Diagnosis
High risk of suspicion should occur with patients with previous history of CVS, history of multiple catheters, physical features present
Diagnostic imaging modalities should be used to confirm diagnosis including; duplex ultrasonography, angiography, magnetic resonance angiography
Slide18Central vein stenosis
Management of central vein stenosis
Conservative management
No intervention required – asymptomatic patients require only close observation for any changes in symptoms
Percutaneous
transluminal
angioplasty
Treatment of choice for symptomatic central venous stenosis
Can be performed alone or with stenting
Initial success with angioplasty without stenting ranges between 70-90%
Most patients require repeated angioplasty because lesions recur
Resistant lesions or rapidly recurring lesions may have better
resulst
with cutting balloon or angioplasty plus stentingSurgeryDue to potential for morbidity this should be considered only as last resort after repeated angioplasty with or without stenting has failed
Slide19Other COMPLICATIONS
Catheter-Associated Thrombus
Catheter-Related Right Atrial Thrombus (CRAT)
Difficult to Remove
Embedded Catheter
Serious complications include:
pulmonary embolism, s
eptic emboli, long-term central venous stenosis, cardiac arrhythmias
Treat with anticoagulation without removing catheter
Duration of treatment depends on extent of thrombosis, risk of bleeding and ongoing need for use of catheter
Although limited data and no general guidelines,
anticoagulation for 3
mths
is a general recommendation
Associated with an overall mortality rate of 18%
Thrombus <6 cm, recommend removal of the catheter and anticoagulation
Thrombus >6 cm, cardiac abnormalities or contraindications to anticoagulation, consider surgical thrombectomy
Consider catheter exchange over guidewire with tip in superior vena cava rather than right atrium or thrombolysis
Typically embedded or tethered
inside the central vein system
Options: open surgery, cutting and burying, endoluminal dilatation
(see visuals slide 19)
Burying the catheter has been associated with infection; however, a single-centre experience
with e
ndoluminal dilatation suggests this approach may result in uncomplicated removal of such catheters
Note: Central
Vein
Stenosis can be found in Chapter 4
Slide20balloon assisted
endoluminal
dilatation
(
for removal of embedded catheters
)
Photos courtesy of
Dr
Adnan
Hadziomerovic
Slide21LAST OPTION ACCESS
Commonly used last access options include:
(
for more detail see Chapter 3:
Arteriovenous
access)
HeRO
Device (Hemodialysis Reliable Outflow)
When inserted, bypasses any central venous stenosis without the need for a graft-to-vein anastomosis (See Chapter 3
)
Translumbar
Catheters
Inserted into the inferior vena cava via the translumbar routeReserved for dialysis patients who have exhausted all other access options
Technically challenging, and may be associated with procedure related complications (eg
retroperitoneal hematoma
)
Transfemoral
Catheters
Less technically challenging to insert
Consider catheter length (usually 70 cm in length; cuff at 45 cm) and infection prophylaxis, given their exit site in close proximity to the
groin
Slide22SUMMARY OF RECOMMENDATIONS
Catheter dysfunction is a frequent and common cause of catheter loss; may occur early, most often the result of mechanical issues or late, most often due to thrombotic occlusion or fibrin sheath
Sodium citrate (4%) or concentrated heparin solutions (1000 units/ml) are the current standard recommended anticoagulant locking solutions infused into the catheter lumens to maintain catheter patency between hemodialysis treatments
Antiplatelet agent and systemic oral anticoagulation have not proven beneficial in improving catheter patency, and may increase risk of bleeding
Thrombolytic agents can be used to successfully restore patency in thrombotic/occluded catheters. If unsuccessful, catheter exchange with fibrin sheath
plasty
is recommended
Central vein stenosis is a common vascular access complication, occurring in up to 40% of hemodialysis patients with a catheter
Central vein stenosis is often asymptomatic until creation of an ipsilateral arteriovenous access
Slide23SUMMARY OF RECOMMENDATIONS
Reduce risk factors for central vein stenosis: minimize number and exposure time to central venous catheters, CIEDs, PICCs. Attempt creation of arteriovenous access on opposite side of any central venous access device
Symptomatic CVS should be treated with percutaneous transluminal angioplasty. Stenting is generally not recommended except for recoil elastic lesions and recurrence within 3 months of angioplasty. Surgery should be considered a last resort
Right atrial thrombus is a less common, but serious complication of catheters, requiring systemic anticoagulation and possibly catheter removal
In the event of poor arteriovenous access and/or loss of upper extremity central veins, alternative access options include
transfemoral
catheters,
translumbar
catheters, and the
HeRO
device. These options require skilled interventionalists, and optimal approaches are dictated by local experience and expertiseBalloon-assisted
endoluminal
dilatation can be used for removal of embedded
catheters