**Author details**

a good pulse, but the hands are tender and swollen, usually immediately after surgery, and there is muscle weakness [234]. The cause is likely ischemia of the nerves, and rapid surgical reevaluation is needed. Wound and skin complications and greater incidence of thrombosis of VA associated with recombinant human erythropoietin have been reported (rHuEPO) [235].

Early or late catheter dysfunctions are the functional complications of TCs. Kinking and unsuitable positioning of the catheter tip may be the cause of early dysfunction and can be managed under fluoroscopic guidance. Around or at the catheter tip, fibrin sheaths and thrombi can be formed constituting late causes of failure. Balloon angioplasty can disrupt fibrinous sheaths, improving flow through a new catheter in the same location. Valliant et al. [236] have demonstrate in their study that there is no significant increase in bacteraemia and subsequent catheter dysfunction rates after fibrin sheath disruption by balloon procedure compared to simple over the wire exchange. Symptomatic occlusions of the central veins usually require the removal of the catheter and system anticoagulation and must be weighed in the context of a continued need for dialysis and other available access options. Yoon et al. recently referred a novel two-stage hemodialysis reliable outflow (HeRO) graft implantation technique that avoids the use of a femoral bridging hemodialysis catheter in internal jugular vein (IJV) catheter-dependent patients with contralateral central venous occlusion and thus lowering the risk of infection related to a femoral catheter [237]. The use of catheter is related to a higher incidence of infection and could compromise dialysis adequacy [238, 239]. Catheterrelated infections (CRI) are linked with increased all cause morbidity and mortality. The 8– 10% of MRSA bacteraemia in the UK occurs in patients receiving long-term hemodialysis. It appears that the catheter locking with appropriate antimicrobial lock solutions (ALS) decrease the infections' incidence in HD patients [180, 240, 241]. It seems that prophylaxis with genta‐ micin of the catheter lumens reduces bacterial infection morbidity and mortality-related bacteremia of catheter without obvious bacterial resistance, making such use advisable [242]. Even taurolidine–citrate–heparin catheter lock solution reduces staphylococcal bacteraemia rates in HD patients [243] and improves the inflammatory profile in HD patients with TCs [244]. Del Pozo et al. [245] in their prospective study showed that an evaluation of tunneled catheters with intracatheter leukocyte culture helps in the early colonization of HD catheters, giving the possibility to eradicate biofilm without the removal of catheter. Recent studies have demonstrate that the "shower and no-dressing" technique appears to be a safe TC option that improves quality of life [246, 247], although there is skepticism and uncertainty about the

Unfortunately, there are no revolutionary changes in the field of vascular access for hemo‐ dialysis in the last years. According to the guidelines, AVFs are still the best choice. Luckily, AVGs' survival has been increased, but still TCs are used in a great portion of ESDRD patients.

**9. Tunneled catheter complications**

264 Updates in Hemodialysis

appropriate dressing [248].

**10. Final conclusions and remarks**

Eirini Grapsa1\* and Konstantinos Pantelias2

\*Address all correspondence to: grapse@otenet.gr

1 National and Kapodistrian University of Athens, Aretaieio, University Hospital, Athens, Greece

2 Protypo Nefrologiko Kentro Athinon, Athens, Greece
