Dr. Hamed Ezzat El-Eraky

Nephrology Specialist – MIH

CME Director Of Dakahlia Medical Syndicate

Without an adequate vascular access, HD efficiency

is reduced, which results in increased morbidity

and mortality

Dialysis access is most common vascular surgery

procedure

Access-related problems are responsible for 50% of

the hospitalizations of HD patients

Short-term catheters should be used for acute dialysis and

for a limited duration in hospitalized patients.

Non cuffed femoral catheters should be used in bed-bound

patients only.

Long-term catheters should be used in conjunction with a

plan for permanent access. Catheters capable of rapid flow

rates are preferred.

Catheter choice should be based on local experience, goals

for use, and cost.

Long-term catheters should not be placed on the same side

as a maturing AV access, if possible (RT sided for RT handed).

Patients with advanced CKD disease stage 4 CKD (GFR <30), or based on progression of renal disease) who have elected hemodialysis as their choice of renal replacement therapy should be referred to an access surgeon in order to evaluate and plan construction of AV access

If a prosthetic access is to be constructed, this should be delayed until just before the need for dialysis.

Able to deliver high flow (>400 ml/min)

reliably

Easy to insert and remove

Comfortable and acceptable by patient

Durable

Free of infection

Does not cause venous thrombosis or stenosis

Free of fibrin sheath

Inexpensive

Universally applicable

Multiple access sites

No maturation time can be used

immediately

No direct hemodynamic effects on the

circulation

Allows time for maturation of native AVF

Thrombotic complications simple to correct

The shortest long term patency rates of all permanent access procedures

Lower blood flow rates obligating longer dialysis times

External device

Morbidity

Insertion complications

Thrombosis

Infection

> 3 months -morbidity excessive

Risk of central vein stenosis or occlusion

•Limits chronic access options

These catheters are suitable for

immediate use and should not be

inserted before needed .

The subclavian insertion site should not

be used in a patient who may need

permanent vascular access .

2nd left internal jugular-Higher incidence of flow problems-Higher risk of stenosis

3rd inferior vena cava-Femoral –best alternative-Translumbar

Subclavian-High risk of stenosis-Acceptable only if no further arm access

planned

Chest x-ray is mandatory after subclavian

and internal jugular insertion prior to

catheter use to confirm catheter tip position

Femoral catheters should be at least 19-cm

long to minimize recirculation.

Noncuffed femoral catheters should not be

left in place longer than 5 days and should be

left in place only in bed-bound patients.

Place in right internal jugular

Use ultrasound for cannulation

Use fluroscopy for placement

Place tip well within atrium

The primary determinants of catheter blood flow

(1) are catheter (inner) size dimensions

(2) Tip placement

Blind placement of a relatively stiff device through the right internal jugular vein has created the necessity of using a short catheter to avoid atrial perforation.

The tip of these catheters comes to be located in the proximal part of superior vena cava, and this tip location in smaller blood vessels does not allow for as great a blood flow as catheters located in the distal superior vena cava and the right atrium

NKF-DOQI guidelines recommend placement of a catheter with the tip adjusted to the level of the caval atrial junction or into the right atrium to ensure optimal blood flow.

For untunneled catheters, the catheter length and diameter should be adjusted to the size of the patient.

In general, in patients with a body surface area of 1.5 to 2.0 m2

-A 12-15 cm catheter should be selected for the jugular vein in the low right position and

-A 15-19 cm catheter for the left jugular vein.

-A 14 to 17 cm catheter should be used for the right subclavian vein and

A17 to 22 cm catheter for the left subclavian vein.

Subclavian catheters are more comfortable for

the patient and provide reliable blood flow if

placed in the right atrial cavity( SVC ostum)

It was shown that in the US 46% of all temporary

catheters used in patients starting hemodialysis

treatment were inserted into the subclavian

vein.(may be lower infection)

(against DOQI guidelines)

Recirculation:

With the use of catheters, recirculation

is dependent upon two factors:

the location of the catheter tip

the status of the patient's central

circulation.

Early – malposition

Late - thrombosis

Local infection

- Exit site infection

- Tunnel infection

Systemic infection

- Catheter related bacteremia( CRB )

Frequent – 20 to 30%

- Septic arthritis

- Endocarditis

- Epidural abscess

- Death – 6 to 18%

Nonfunctional non cuffed catheters can be

exchanged over a guide wire as long as the

exit site and tunnel are not infected.

Exit site, tunnel tract, or systemic

infections should prompt the removal of non

cuffed catheters.

The Problem is that

we forget that these

catheters are in the

heart exactly like our

patients who think

that these catheter

are in the neck or

chest .

After decades of success in dialysis research

and treatment, prompt availability of a well-

functioning vascular access for dialysis

remains a disturbing problem.

(Ravani P et al. Am J Kidney Dis 2002; 40:1264-76)