**Acute and Chronic Catheter in Hemodialysis**

Andrew S. H. Lai1 and Kar Neng Lai2

*1Department of Diagnostic Radiology 2Department of Medicine Queen Mary Hospital, University of Hong Kong Hong Kong* 

#### **1. Introduction**

106 Technical Problems in Patients on Hemodialysis

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Reliable and sustained access to the circulation is mandatory for the provision of long-term hemodialysis which is critical to the survival of patients with end-stage renal disease (ESRD). An ideal vascular access provides adequate blood flow to meet the hemodialysis prescription, with minimal complications due to infection or thrombosis. The natural arteriovenous fistula (AVFs) comes closest to meeting these criteria while arteriovenous grafts (AVGs) and central venous catheters (CVCs) present other vascular access options. In the United States, promoting a major shift in using fistula as first-choice vascular access has been strongly recommended by the 2001 Kidney Disease Outcome Quality Initiative (K/DOQI) vascular access guideline (NKF-DOQI 2001) and the "Fistula First" national initiative (Tonnessen et al 2005). Ideally, every patient would initiate dialysis with a mature fistula suitable for cannulation. In real clinical setting, this is not true due to combination of the following factors including (i) lacking nephrology follow-up at the time of ESRD, (ii) late nephrology referral, (iii) poor or no planning of fistula placement, (iv) inadequate fistula maturation and (v) poor vascular preparation due to prior venous cannulation.

In current practice, 20-50% of attempted AVFs fail to mature adequately. Despite a recent increase in the number of prevalent patients dialyzing with an AVF (47%) in the US following the fistula-first initiative, 28% of prevalent patients remain dependent on an AVG and 25% on a CVC. In Canada, recent data demonstrate that 50% of patients use an AVF, while 39% and 11% depends on a CVC or AVG, respectively (James et al 2009).

Sadly, hemodialysis CVCs are increasingly being introduced in patients requiring emergency or chronic renal replacement therapy. Table 1 outlines the advantages and disadvantages of CVCs. The percentages of patients undergoing dialysis with vascular catheters are increasing in Europe, ranging from 15% (Germany) to 50% (United Kingdom) of all hemodialysis patients. In the United States, up to 60% of patients start hemodialysis with CVCs (Pisoni et al 2002). Over the last decade, the number of patients using CVCs for hemodialysis doubled (Rayner et al 2004). According to the Dialysis Outcomes and Practice Patterns Study, 18% of patients with end-stage renal failure in the United States and 24% of those in Great Britain have been dialysed with such catheters (Quarello et al 2006). Table 2 summarizes the indication for using CVCs. Recent studies indicate that CVCs are used in 20- 25% of incident (<6 months) chronic kidney disease (CKD) stage 5 patients and still used in 10-20% of prevalent hemodialysis patients (> 6 months) (Rayner et al 2004a, Moist et all 2007). The use of CVCs has been complicated by higher rates of thrombosis, dysfunction,

Acute and Chronic Catheter in Hemodialysis 109

anatomically this provides the most direct route to the superior vena cava and right atrium. The vein should be localized by ultrasound (+/- Doppler). Insertion into the left internal jugular vein is associated with a higher incidence of central stenosis and poorer patency. For selected cases requiring short-term dialysis, the femoral vein can also be used. Subclavian vein should be discouraged as it may jeopardize the long-term arteriovenous access options with complication of subclavian stenosis. The catheters are usually inserted using the Seldinger technique. The catheter can be used immediately after confirming correct

**Acute Chronic** 

To ensure continuous, independent blood flow, catheters are double–lumen. The distal part has two separate openings; one collecting the patient`s blood − "arterial", located 2-3 cm from the catheter end and the second one pumping the blood to the patient − "venous", placed at its end. Temporary catheters are usually made of stiff materials: polyurethane or polyvinyl, and thus are easier to introduce along the guidewire and a hemostasis valve is not needed. The sharp distal tip facilitates the insertion through the subcutaneous tissues. Compared to soft catheters, they are more resistant to bending in the vessel. At body temperature, after contact with the bloodstream, they become plastic, which reduces the risk of vessel damage. Temporary CVCs have no cuffsbut are quipped with dacron muffs. The insertion doe not require "tunnelization", thus fast access to the circulatory system can be provided. They vary in length, therefore the proper choice is easier depending the puncture site and availability of a central vessel. They may be used for several days or up to three weeks. Their main advantage is easy insertion into the vessel using the Seldinger technique with easy replacement not requiring expensive accessory devices, (which may not be always available) such as fluoroscopy or ultrasound. Generally, the blood flow through temporary

The newer catheters are made of silicone with bigger internal diameter which ensures the blood flow of 400 ml/min. Some of them are tunneled. Silicone is thermoset and thus the catheter is soft. Hence it has to be inserted using a dilator and peel-away sheath. Other materials include polyurethane which is thermoplastic and softens at body temperature. This reduces endothelial damage and thrombogenicity (Leblanc et al 1997). The tunneled catheters can be introduced either antegrade (skin to insertion site) or retrograde (insertion

site to skin). The position of soft CVCs should be confirmed by fluoroscopy.

cuff - soft tip

nonthrombogenic

less thrombogenic

Most are tunneled with a retention

Thermoplastic polyurethane – larger internal diameter, biocompatible,

Silicone – larger lumen but needs a peel-away sheath, biocompatible,

Carbothane – copolymer with strength for longevity and softness for flexibility

For use of < 7 days For use of > 3 weeks

Table 3. Comparison between acute and chronic central venous catheters

placement with fluoroscopy.

cm distal of arterial port

pressure

peel-away sheath

Most are not tunneled and without a retention cuff - conical tip for easy insertion

Silicone – larger lumen but needs a

CVCs is limited to 200-250 ml/min.

Most are dual lumen with venous port 2-3

Polyurethane – stiff and withstanding high

and infection compared with AVFs. As a result of this, maintaining CVCs is associated with high costs (Lacson et al 2007). The increased use of CVCs requires a maximal precaution in its management and a stringent practice to reduce its risk and complications.


Table 1. Advantages and disadvantages of central venous catheters for hemodialysis


Table 2. Indications for central venous hemodialysis catheters
