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| Journal of Vascular Access 2002; 3: 169 - 173 |
| Vascular screening prior to placement of tunnelled and cuffed hemodialysis catheters |
A. Falk1, R. Lookstein1, J. Uribarri2, C. Shen3, V. Teodorescu3, J.A. Vassalotti2
1Departments of Radiology, The Mount Sinai-NYU Medical Center, New York, NY - USA
2Departments of Medicine, The Mount Sinai-NYU Medical Center, New York, NY - USA
3Departments of Surgery, The Mount Sinai-NYU Medical Center, New York, NY - USA
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Search Medline for articles by:
 A. Falk
R. Lookstein
J. Uribarri
C. Shen
V. Teodorescu
J.A. Vassalotti
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ABSTRACT
Purpose: To demonstrate the importance of venous vascular screening before the placement of tunneled and cuffed hemodialysis catheters in patients requiring hemodialysis prior to placement and/or maturation of an arteriovenous fistula (AVF) or graft (AVG).
Methods: Between October 1998 and March 2000, all patients requiring hemodialysis access placement were prospectively evaluated with duplex ultrasound for status of upper extremity vessels and central veins prior to selection of a permanent access site. When interim tunneled and cuffed hemodialysis catheters were required, they were placed on the side contralateral to proposed AVF/AVG placement. No catheters were placed without initial vascular screening. The study group was compared to historical controls during a similar period (April 1997 through September 1998) when no vascular screening was performed.
Results: During the study period, 234 screening duplex ultrasound examinations were performed in 244 patients. Ten patients required no screening prior to access site placement. Overall, 353 catheters were placed, 243 (69%) on the right side and 110 (31%) on the left side. During the control period, 394 catheters were placed in 255 patients, 306 (78%) right-sided and 88 (22%) left-sided. The increase in left-sided catheters with ultrasound screening and careful planning for future access sites was significant (p<0.01).
Conclusion: Vascular-screening-directed catheter placement significantly alters the side of catheter placement when compared to a management protocol without prior screening. Such screening helps identify the side of permanent access placement, while directing interim catheters to the contralateral side such that central veins may be preserved for permanent access. (The Journal of Vascular Access 2002; 3: 169-73)
Key Words. Hemodialysis, Catheter placement, Dialysis, Access, Vascular screening, Ultrasound
INTRODUCTION
Approximately 240,000 patients with end-stage renal disease (ESRD) were treated with hemodialysis in the United States in 1999 (1). A permanent vascular access that provides adequate blood flow is necessary for successful dialysis delivery. Because of the lowest rates of thrombosis and infection (2-11), the arteriovenous fistula (AVF) is the preferred type of vascular access in such patients. However, AVF maturation generally takes 3 to 4 months from the time of surgical creation for the vein diameter to increase sufficiently to allow insertion of dialysis needles, rendering it unusable during this period. The next preferred form of hemodialysis access is the arteriovenous graft (AVG), a synthetic bridge graft usually constructed of polytetrafluoroethylene (PTFE). A dialysis AVG should not be routinely used until 14 days after placement, during which time endothelial cells migrate to the PTFE lining and the graft becomes incorporated into a continuous vessel system. Cannulation of a new PTFE AVG should not generally be attempted, even when older than 14 days, until perigraft edema resolves. Ideally, 3 to 6 weeks should be allowed prior to cannulation of a new AVG (12). For these reasons, adequate care of a hemodialysis patient with ESRD requires constant vascular access attention. Also, a requirement for an alternative hemodialysis access site during periods of access maturation should be anticipated. New or alternative accesses may also be required following complications in existing mature accesses. Thus, a long-term approach is an essential part in the management of such patients.
In cases where hemodialysis must be initiated before an access is mature or when hemodialysis must be continued in patients with access failure, a temporary tunneled and cuffed catheter (TCC) is necessary. The National Kidney Foundation’s Diseases Outcomes Quality Initiative (NKF-K/DOQI) Vascular Access Guidelines recommend that, unless other options have been exhausted, central venous catheters be used only as a bridge until the maturation of permanent AVF or AVG (12).
As a practical approach to achieving the goals of vascular access in patients requiring hemodialysis, our management protocol requires pre-operative color Doppler ultrasound vascular mapping for evaluation of upper extremity arteries and veins prior to access placement (13-15). This practice provides vascular information to guide AVF/AVG placement. If such screening were to be carried out prior to the placement of interim catheters, the central outflow veins for AVF/AVG could be preserved by catheter placement directed to the contralateral side. This prospective study is designed to demonstrate the potential importance of ultrasound screening and careful planning prior to the placement of TCC.
MATERIALS AND METHODS
Study period and patient population
From October 1, 1998 to March 31, 2000, all patients referred to interventional radiology for TCC from our inpatient and outpatient university hemodialysis center were enrolled in the study. No patients were excluded. Comparison was made to historical controls over a similar period of time extending from April 1, 1997 through September 30 1988, prior to the establishment of our vascular screening program.
Vascular screening and catheter placement
Prior to placement of hemodialysis catheters, all patients underwent vascular duplex ultrasound screening for evaluation of upper extremity arteries and/or veins as well as central veins for permanent access site guidance (13-15). Duplex examination using an ATL 5000 system (ATL Ultrasound, Bothell, WA) was undertaken to assess the cephalic and basilic veins for patency, size, absence of wall abnormalities, and continuity with the deep system. Patency and size of the subclavian veins were also determined. The distal ulnar and radial arteries were evaluated for size and wall abnormalities. Peak systolic velocities (PSV) of these arteries were noted. Patients meeting all the following criteria underwent AVF creation: a) cephalic or basilic veins measuring at least 2 mm in diameter and in continuity with the deep venous system; b) patent ipsilateral subclavian vein; c) an appropriate artery measuring at least 2 mm in diameter having a PSV of 50 cm/sec or greater. If no veins suitable for AVF creation were identified using the above criteria, AVG insertion was directed by the vascular ultrasound screening results. If patients required interim management with TCC, the catheters were then placed on the side contralateral to the site selected for placement of AVF or AVG. Catheters were placed under sonographic and fluoroscopic guidance using standard technique (16-18). Prior to the institution of Doppler screening, central catheters were placed at the discretion of the interventionalist, preferably on the right side, as described above.
Statistical analysis
A Chi-Square test was used to compute statistically significant differences between right- versus left-sided catheter placement between the study population and the control group.
RESULTS
During the control period in the absence of ultrasound screening, a total of 394 tunneled and cuffed hemodialysis catheters were placed in 255 patients (137 male, 118 female), with a mean age of 54 years (range: 3-91; median: 54). Three hundred and six or 78% of catheters were placed on the right side and the remaining 88 or 22% placed on the left side; a majority of the catheters were placed in the internal jugular vein (Tab. I).
During the study period, a total of 234 Duplex ultrasound screening examinations were performed in 244 patients (130 male, 114 female), with a mean age of 52 years (range: 3-91; median: 51). Ten patients required no screening prior to the selection of access site. One of these patients, treated with peritoneal dialysis, had acquired peritonitis. In this patient, a right-sided catheter was placed after discussion with the nephrologist and vascular surgeon. The other 9 patients could no longer receive a permanent access on one upper extremity, and therefore, the catheter was placed on that side, conserving the contralateral extremity for future permanent access. Overall, 353 TCC were placed in these patients, with 243 or 69% of catheters being placed on the right side and the remaining 110 or 31% being placed on the left side. On both sides, a majority of the catheters were placed in the internal jugular vein (Tab. I).
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Table I
Rates of catheter placement by vein type before and after the institution of ultrasound (US) screening
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The increase in placement of left-sided catheters with US screening and careful planning was significant (31% vs 22%, p<0.01).
DISCUSSION
A temporary central venous catheter is often necessary in patients with ESRD who are undergoing hemodialysis. Historically, catheter placement occurred in the operating room. However, in the last decade, the superiority of radiologic placement has been demonstrated (19) and has now become the standard approach in most institutions. Catheterization of the subclavian vein as well as the internal jugular vein have been reported. However, reports of the lower complication rate with jugular insertion have culminated in an increase in the use of the internal jugular vein as the preferred site (20, 21). The NKF-K/DOQI Vascular Access Guidelines mandate that the right internal jugular vein be the preferred insertion site for tunneled and cuffed hemodialysis catheters and should be preferred over the right external jugular vein, the left internal and external jugular veins, and subclavian veins. Evidence of lower procedural complications, lower venous thrombosis rates and less premature removal of catheters with internal jugular vein placement versus subclavian vein placement support this recommendation (21, 22). In this study, internal jugular vein placement was predominant in both control and study groups.
In general practice (without sonographic screening), the most common cause of left-sided catheter placement is an encountered problem on the right – either occlusive changes in the veins or the presence of a developmental venous abnormality. In our patients, when a venous stenosis or occlusion was encountered, all attempts were made to cross such ‘blocks’. For instance, if an innominate occlusion was encountered, attempts were made to cross it, preferentially, from a jugular vein, or alternately, through a subclavian approach. If an occluded internal jugular vein was found, then placement of the catheter via an external jugular vein or the innominate vein was attempted. If a catheter could not be placed opposite to the side of the planned AVF or AVG, a femoral TCC was placed.
Our criteria for preoperative noninvasive screening were developed in mid 1998 after evaluation of information regarding lower extremity vein bypass grafts. Since success has been reported with the use of veins as small as 2 mm in situ, this caliber was adopted as our criterion in screening for the ability to create an AVF. The diameter of a vein may vary with volume status, and, therefore, a single small measurement was not considered enough to eliminate the possibility of creating an AVF. Venous duplex ultrasound was performed without the use of a tourniquet, unless veins smaller than 2.5 mm were identified. When such smaller veins were encountered, the ability of the small vein to dilate to a diameter of 110% greater or more was taken as an indication that the vein was suitable for use as a fistula. The use of this screening protocol directed placement of TCC and AVF or AVG.
In the lifespan of TCCs, catheter-related thrombosis can be a significant problem, with asymptomatic thrombosis reported to occur in 66% of oncology patients (23-25) and symptomatic thrombosis in up to 13% of patients (26). Infection is another major complication and has been reported to occur in up to 54% of catheters. Importantly, such complications may result in the premature removal of catheters, an event that often results in the permanent loss of the affected vein and ipsilateral extremity for subsequent central access. In ESRD patients, this may often become a dialysis limiting and, by extension, a survival limiting development. Therefore, the management of the patient with ESRD who requires hemodialysis and long-term vascular access should be carefully planned with the knowledge of such risk factors and the aim of prolonging long-term vascular access.
Complications due to thrombosis have been implicated in 40% or more catheter failures and subsequent suboptimal flow in the affected vein also renders it useless for later placement of an AVF or AVG. Central venous stenosis may occur in as many as 30 to 50% of patients (subclavian vein placement) with similar consequences. In some patients, a stenosis or occlusion may remain undiagnosed until the high blood flow from a subsequently placed AVF or AVG exposes the stenosis or occlusion and the patient becomes symptomatic. Although balloon angioplasty and stents are used to treat these central venous lesions, the temporary nature of such interventions may minimize the lifespan of the permanent access. Any successful interim access site should therefore make every attempt to curtail long-term complications of central catheters.
Unlike in the control group, catheter placement in the study group was not left to the discretion of the interventional radiologist. No catheter was placed without careful planning and/or vascular screening. When this policy was initially instituted, referring physicians were disturbed that a catheter could not always be placed on the day of request. However, by educating them on the advantages of early screening and careful planning, and by working closely with the vascular laboratory to get patients screened, if not immediately, then within 24 hours, we have been able to maintain this protocol. All patients can now have catheters placed within 24 hours of referral. This practice requires a concerted commitment of all those involved in managing hemodialysis access but it is expected that the long-term benefits to the patient justify the efforts.
In previous studies, preoperative ultrasound screening has been associated with increased AVF placement (14, 27, 28). Similar preoperative screening has been used to identify vessels suitable for AVF placement and to decrease the early failure rates of AVFs (27). Such screening has additionally resulted in decreasing unsuccessful surgical explorations for AVF construction (28). We have extended the utility of the screening program to direct not only the placement of AVF and AVG but also that of interim hemodialysis catheters. This practice has been helpful in two ways: 1) detection of optimal site for permanent access placement, and 2) preservation of that site and diversion of temporary access to the contralateral side so that both near-term and long-term access can be maintained in a logical and more predictive manner. Indeed, this practice resulted in the placement of significantly more central catheters on the left side than was seen prior to pre-catheter screening. We have shown that incorporating ultrasound screening with catheter placement significantly alters the practice of (temporary) catheter placement, without additional investment of cost or time. This practice requires close planning and cooperation between the surgeon, the nephrologist, and interventional radiologist early in the management of patients with anticipated and with ongoing need for hemodialysis and, if instituted, has the potential to increase the duration of successful dialysis. Further studies are needed to evaluate whether a change in policy for catheter placement affected the long-term patency of the subsequently placed dialysis fistulae and grafts in our patients. Additional studies should be performed to demonstrate outcomes benefit with such screening for central veins. Finally, more studies and long-term follow-up are needed to determine if the vascular screening and catheter placement protocol has the intended long-term benefit.
Reprint requests to:
Abigail Falk, MD
Department of Radiology
Box 1234
Mount Sinai-NYU Medical Center
One Gustave Levy Place
New York, NY 10029, USA
e-mail: abigailfalk123@pol.net
REFERENCES
1. US Renal Data System. USRDS 2001 Annual data Report: Atlas of End Stage Renal Disease in the United States. Bethesda, Md. National Institutes of Health, National Institute of Diabetes, Digestive and Kidney Diseases; 2001.
2. Palder SB, Kirkman RL, Whittemore AD, Hakim RM, Lazarus JM, Tilney NL. Vascular access for hemodialysis: patency rates and results of revision. Ann Surg 1985; 202: 235-9.
3. Harland RC. Placement of permanent vascular access devices: surgical considerations. Adv Ren Replace Ther 1994; 1: 99-106.
4. Fan PY, Schwab SJ. Vascular access: concepts for the 1990s. J Am Soc Nephrol 1992; 3: 1-11.
5. Windus DW. Permanent vascular access: a nephrologist's view. Am J Kidney Dis 1993; 21: 457-71.
6. Munda R, First R, Alexander JW, Linnemann CC, Fidler JP, Kittur D. Polytetrafluoroethylene graft survival in hemodialysis. JAMA 1983; 249: 219-22.
7. Kinnaert P, Vereerstraeten P, Toussaint C, Van Geertruyden J. Nine years' experience with internal arteriovenous fistulas for hemodialysis: study of some factors influencing results. Br J Surg 1977; 64: 242-6.
8. Kherlakian GM, Roedersheimer LR, Arbaugh JJ, Newmark KJ, King LR. Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis. Am J Surg 1986; 152: 238-43.
9. Dunlop MG, Mackinlay JY, Jenkins AM. Vascular access: experience with the brachiocephalic fistula. Ann R Coll Surg Engl 1986; 68: 203-6.
10. Ryan JJ, Dennis MJS. Radiocephalic fistula in vascular access. Br J Surg 1990;77:1321-1322.
11. Albers F. Causes of hemodialysis access failure. Adv Ren Replace Ther 1994; 1: 107-18.
12. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000. Am J Kidney Dis 2001; 37 (suppl 1): S137-81.
13. Teodorescu V, Frasier K, Falk A, et al. Early vascular lab screening can increase the number of arteriovenous fistulae and reduce the need for catheters to initiate dialysis. J Surg Res 2000; 93 (2): 367-8.
14. Falk A, Teodorescu V, Uribarri J, Mitty H, Lautin J, Moore F. A new screening and management protocol to increase the number of functioning renal dialysis arteriovenous fistulae. J Vasc Interv Radiol 2000; 2: 229.
15. Sedlecek M, Teodorescu V, Falk A, Vassalotti J, Uribarri J. Hemodialysis access placement with preoperative noninvasive vascular mapping: comparison between patients with and without diabetes. Am J Kidney Dis 2001; 38: 560-4.
16. Gordon AC, Saliken JC, Johns D, Owen R, Gray RR. US-guided puncture of the internal jugular vein: complications and anatomic considerations. J Vasc Interv Radiol 1998; 9: 333-8.
17. Caridi JG, Hawkins IF Jr., Wiechmann BN, Pevarski DJ, Tonkin JC. Sonographic guidance when using the right internal jugular vein for central venous access. Am J Roentgenol 1998; 171: 1259-63.
18. Docktor BL, Sadler DJ, Gray RR, Saliken JC, So CB. Radiologic placement of tunneled central catheters: Rates of success and of immediate complications in a large series. Am J Roentgenol 1999; 173: 457-60.
19. Mauro MA, Jaques PF. Radiological placement of long-term central venous catheters: a review. J Vasc Interv Radiol 1993; 4: 127-37.
20. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodyalisis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant 1991; 6: 722-4.
21. Macdonald S, Watt AJB, McNally D, Edwards RD, Moss JG. Comparison of technical success and outcome of tunneled catheters inserted via the jugular and subclavian approaches. J Vasc Interv Radiol 2000; 11: 225-31.
22. Trerotola SO. Hemodialysis catheter placement and management. Radiology 2000; 215: 651-8.
23. DeCicco M, Matovic M, Balestreri L, et al. Central venous thrombosis: an early and frequent complication in cancer patients bearing long-term silastic catheter–a prospective study. Thromb Res 1997; 86: 101-13.
24. Haire WD, Lieberman RP, Lund GB, Edney JA, Kessinger A, Armitage JO. Thrombotic complications of silicone rubber catheters during autologous marrow and peripheral stem cell transplantation: prospective comparison of Hickman and Groshong catheters. Bone Marrow Transplant 1991; 7: 57-9.
25. Lokich JJ, Becker B. Subclavian vein thrombosis in patients treated with infusion chemotherapy for advanced malignancy. Cancer 1983; 52: 1586-9.
26. DeBona R. Thrombotic complications of central venous catheters in cancer patients. Semin Thromb Hemost 1999; 25: 147: 55.
27. Silva MB, Hobson II RW, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg 1998; 27: 302-8.
28. Robbin ML, Gallichio MH, Deierhoi MH, Young CJ, Weber TM, Allon M. US vascular mapping before hemodialysis access placement. Radiology 2000; 217: 83-8.
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