**6. Nontunneled double lumen catheters complications**

The nontunneled double lumen catheters' complications concern the early ones during the insertion and the late ones such as infection and thrombosis of the vessels.

The severity of acute complications varies with the site of insertion. The lowest rate is in the femoral position. A significant complication is perforation of the femoral artery. Bleeding usually resolves within minutes of direct compression and large femoral or retroperitoneal hematomas occur occasionally [161]. Subclavian insertion complications are more serious. The overinsertion of guide wire can occasionally lead to atrial or ventricular arrhythmias, but they are frequently transient [162]. The penetration or cannulation of the subclavian artery can lead to hemothorax, which may require a thoracotomy tube. The incidence of pneumothorax varies from less than 1% to more than 10% of insertions, depending on the skill and experience of the physician. Pericardial rupture and tamponade also have been described [163, 164]. There is less likelihood of arterial puncture or pneumothorax in ultrasound-guided catheter insertion [165]. Subclavian insertion from the left has an increased risk of pneumothorax and atrial perforation, which can be presented with acute hemopericardium upon initiation of dialysis. Internal jugular vein is the preferred site of insertion because of subclavian stenosis and loss of the ipsilateral arm for future hemodialysis access. This complication appears to occur more often with subclavian (40–50%) than with internal jugular insertions (up to 10%) [166, 167]. At internal jugular insertions, a carotid artery penetration may occur, but there is also a lower risk of pneumothorax (0.1%). Post procedural chest X-ray is taken for confirmation of position of catheter tip and to detect early complications, but delayed complications can occur after catheterization. Thus, the patient should be monitored carefully and managed appropriately according to the presenting signs and symptoms [168].

**Group A (age>60) Group B(age<60)** *P*

According to the 2010 USRDS Annual Data Report, in 2008, hospitalizations increased, to a point of 46% over 1993. Women on hemodialysis were 16% more likely to be hospitalized than men, overall, in 2007–2008. Also, they had a greater risk than men of cardiovascular, infectious and vascular access hospitalizations 11%, 14%, and 29%, respectively. Recently, in a retro‐ spective single-center analysis, our data varies to those we published in 1998. In 145 patients on HD, we found that female had more possibilities to start HD with double lumen catheter than male and also patients with heart failure independent of gender [115]. Patibandla et al. [151] in their logistic regression model found that increasing age, female sex, black race, lower body mass index, urban location, certain comorbidities and shorter pre-end-stage renal disease nephrology care are all associated with a significantly lower like hood of AVF placement as initial access predialysis. Additionally, there are geographic disparities in AVF creation with decreased rates of AVF placement as the first access in metropolitan, but not rural, populations compared with micropolitan communities [152]. Improvement in standardization of care according to practice guidelines is necessary. AVF rate could be increased by improving access to surgical resources and patients education [153]. Enhancing patient self-care abilities and working together with patients on proper vascular access care can prolong vascular access site viability [154]. Intraoperative blood flow measurements greater than 120 ml/min in AVF and less than 320 ml/min in AVGs may be predictive factors of early failure and fistulography is essential to access patency [155]. In addition to the clinical examination, there are numerous radiological assessments of vascular access pre- and postoperative that enrich our diagnostic armamentarium [156]. Recently, Remuzzi and Manini [157] presented a numerical model that in the clinical setting should allow to reduce the incidence of AVF nonmaturation as well as incidence of VA complications. Cannulation of VA is a crucial part of its management in HD patients and the proper use of the rotating site technique might still be the best approach to cannulation [158]. Evidence do not support the preferential use of buttonhole over rope-ladder cannulation [159]. However, according to systematic review of Muir et al. [160], buttonhole cannulation is associated with higher rates of infectious events, staff support requirements and no reduction in surgical AVF interventions compared with rope ladder in home HD patients.

Thrombosis 14/48 39/101 N.S. Aneurysm 10/48 14/101 N.S. Edema 0/48 6/101 N.S. Infection 0/48 2/101 N.S.

**6. Nontunneled double lumen catheters complications**

insertion and the late ones such as infection and thrombosis of the vessels.

The nontunneled double lumen catheters' complications concern the early ones during the

**Table 1.** Complications of vascular access

258 Updates in Hemodialysis

Prevention and treatment of catheter thrombosis are important clinical issues. To prevent formation of thrombus, both lumens of the double lumen catheter are instilled with heparin following hemodialysis [46]. Lytic agents such as urokinase and alteplase are effective in treatment of catheter thrombosis. Alteplase has effectiveness rates in thrombosis treatment comparable to the ones observed with urokinase [169]. Central vein catheters are associated with the development of central vein stenosis [170]. The K/DOQI guidelines therefore recom‐ mend avoiding placement in the subclavian vein, unless no other options are available. If central venous thrombosis is detected early, it responds well to directly applied thrombolytic therapy [170] or to percutaneous transluminal angioplasty when the fibrotic stenosis can be crossed with a guide wire [171]. The infection risks associated with temporary double lumen catheters include local exit site infection and systemic bacteremia, both of which require prompt removal of the catheter and appropriate intravenous antibiotic therapy [48, 172, 173]. Bacteremia generally results from either contamination of the catheter lumen or migration of bacteria from the skin through the entry site, down the hemodialysis catheter into the blood stream [174–176]. It seems that prevention strategies should target the first 6 months after access placement or a remedial access-related procedure as over time the risk decline [177]. Skin flora, *Staphylococcus* and *Streptococcus* species, are responsible for the majority of infec‐ tions. It has been reported that surface modification with bismuth film reduces bacterial colonization of nontunneled HD catheters [178]. Guidelines have been proposed by working group with O'Grady et al. [179], with major areas of emphasis such as educating and training healthcare personnel, who insert and maintain catheters, maximal sterile barrier precautions during CVC insertion, using >0.5% chlorexidine. The use of prophylactic gentamicin/citrate lock seems to be associated with a substantial reduction in catheter-related bloodstream than heparin [180]. Nurse is also a key figure in the preventions of such infections with the adoption of standard precautions such as washing hands, managing HD rooms and other medical devices, managing vascular access, and providing educational support to patient [181].

There is conflicting evidence concerning the risk of infection based on the site of insertion [172, 182, 183]. Coagulase-negative staphylococci, *Staphylococcus aureus*, aerobic gram-negative bacilli, and *Candida albicans* most commonly cause catheter-related bloodstream infection. In most cases of nontunneled CVC-related bacteremia and fungemia, the CVC should be removed. The decision should be based on the severity of the patient's illness, documentation that the vascular-access device is infected, assessment of the specific pathogen involved and presence of complications, such as endocarditis, septic thrombosis, tunnel infection, or metastatic seeding [184].

Overall, compared with the subclavian vein, the internal jugular vein remains the preferred access site in ambulatory patients. In the intensive care unit, either femoral or internal jugular vein placement is satisfactory, with the use of ultrasound making internal jugular vein placement safer.

The best solution is to prevent the infection by proper placement technique, optimal exit site care and management of the catheter within the HD facility [46, 185]. It is generally believed that CVC can adversely affect permanent VA ipsilateral placement outcomes due to central vein stenosis that they cause, but it seems that the primary failure rate of AVF and AVG is not affected by the presence of an ipsilateral catheter, but cumulative access survival is inferior [186].
