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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.

Slide2

contents

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

Slide3

INTRODUCTION

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

Slide4

Catheter 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%)

Slide5

Catheter 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

Slide6

ETIOLOGY 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

Slide8

ETIOLOGY 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

Slide9

Catheter 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

Slide10

ETIOLOGY 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

Slide11

PREVENTION 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

Slide12

Systematic 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

Slide13

Thrombolytic 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

Slide14

TREATMENT 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

Slide15

Interventional 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

Slide16

Central 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

Slide17

Central 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

Slide18

Central 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

Slide19

Other 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

Slide20

balloon assisted

endoluminal

dilatation

(

for removal of embedded catheters

)

Photos courtesy of

Dr

Adnan

Hadziomerovic

Slide21

LAST 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

Slide22

SUMMARY 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

Slide23

SUMMARY 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

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