Endovascular Closure of an Acquired Vascular Fistula, an Uncommon Complication of a Tunneled Hemodialysis Catheter: A Case Report.

PURPOSE: The objective of this case is to report an endovascular occlusion of an acquired vascular fistula using an Amplatzer Vascular Plug II. Also, it is to review the available literature on risk factors, pathophysiology, and related management strategies about complications of the tunneled central venous catheter (TCVC). CASE REPORT: The case was a 40-year-old man with a chronic kidney disease (CKD) on dialysis and with a history of several previous TCVC placements, along with recurrent infections. The last TCVC developed a fistula between the superior vena cava and the right pulmonary artery, shown by computed tomography (CT). We decided to remove a long-term TCVC and occluded the fistula applying an endovascular embolic device, an Amplatzer Vascular Plug II, subsequently. The patient was given parenteral treatment during 10 days of hospitalization. Over 9 months of follow-up, the device was appropriately positioned and did not obstruct the vascular flow. CONCLUSION: Tunneled central venous catheters are frequently used for hemodialysis in patients in the last stage of CKD who do not have an arteriovenous fistula. Occasionally, delayed complications such as adherence or catheter migration occur. This case illustrates an endovascular treatment with excellent results and low risk of morbidity and mortality. CLINICAL IMPACT: The purpose of this work is to present an endovascular occlusion by means of an Amplatzer® Vascular Plug II in a residual fistula. The endovascular way is decided in situations, for instance, once the cardiothoracic surgeons argue that the patient is not in general conditions to tolerate surgery, the surgical procedure would be complex, or, in a surgical approach with a difficult-to-resolve hemorrhage. We explain the technique and the materials we used for an excellent result and a low risk of complications. This case is intended to serve as an aid in the treatment of similar events.

A New Procedure for Guidewire Exchange of Tunneled Hemodialysis Catheters in Chronic Hemodialysis Patients: A Pilot Study.

INTRODUCTION: Different techniques of guidewire exchange of tunneled catheters for hemodialysis (HD) have been reported. This study was carried out to assess the feasibility of a new procedure in chronic HD patients who needed catheter exchange because of mechanical dysfunction. METHODS: The guidewire exchange method was based on the creation of a new exit site and a new subcutaneous tunnel while using the same venous insertion site. This was a retrospective study of exchanged tunneled catheters because of mechanical complications in patients on chronic HD between June 1, 2015, and December 31, 2019. The feasibility of the procedure was defined by successful exchange and catheter patency at 6 months. Catheter survival and immediate complications were reported. RESULTS: A total of 49 procedures were performed in 34 HD patients. There was no catheter insertion failure. At 6 months, 6 catheters have lost their patency because of a mechanical complication. Thus, the success rate of the procedure was 43/49 (87.8%). Catheter survival censored on death, transplantation, or vascular access creation was 97.8% at 90 days, 86.2% at 180 days, and 74.5% at 1 year. The median catheter survival was 10.2 months. Among the 49 procedures, there were 9 hematomas at the insertion site that did not require surgical intervention. Discussion/Conlusion: Our study shows that guidewire exchange of a tunneled HD catheter by creating a new exit site and a new subcutaneous tunnel by using the same venous access is a newer method in chronic HD patients. This procedure should not be used in patients with coagulation issues. Additional studies are needed to compare the different methods of HD catheter exchange.

Investigation of risk factors for tunneled hemodialysis catheters dysfunction: competing risk analysis of a tertiary center data.

BACKGROUND: Hemodialysis tunneled catheters are prone to failure due to infection or thrombosis. Prediction of catheter dysfunction chance and finding the predisposing risk factors might help clinicians to prolong proper catheter function. The multidimensional mechanism of failures following infection or thrombosis needs a multivariable and comprehensive analytic approach. METHODS: A longitudinal cross-sectional study was implemented on 1048 patients admitted for the first hemodialysis tunneled catheterization attempt between 2013 and 2019 in Shahid Hasheminejdad hospital, Tehran, Iran. Patients' information was extracted from digital and also paper records. Based on their criteria, single and multiple variable analyses were done separately in patients with catheter dysfunction due to thrombosis and infection. T-test and Chi-square test were performed in quantitative and categorical variables, respectively. Competing risk regression was performed under the assumption of proportionality for infection and thrombosis, and the sub-distributional hazard ratios (SHR) were calculated. All statistical inferences were made with a significance level of 0.05. RESULTS: Four hundred sixty-six patients were enrolled in the analysis based on study criteria. Samples' mean (SD) age was 54(15.54), and 322 (69.1%) patients were female. Three hundred sixty-five catheter dysfunction cases were observed due to thrombosis 123(26.4%) and infection 242(52%). The Median (range) time to catheter dysfunction event was 243(36-1131) days. Single variable analysis showed a statistically significant higher proportion of thrombosis in females (OR = 2.66, 95% CI: 1.77-4.00) and younger patients, respectively. Multivariate competing risk regression showed a statistically significant higher risk of thrombosis in females (Sub-distributional hazard (SHR) = 1.81), hypertensive (SHR = 1.82), and more obese patients (BMI SHR = 1.037). A higher risk of infection was calculated in younger (Age SHR = 0.98) and diabetic (SHR = 1.63) patients using the same method. CONCLUSION: Female and hypertensive patients are considerably at higher risk of catheter thrombosis, whereas diabetes is the most critical risk factor for infectious catheter dysfunction. Competing risk regression analysis showed a comprehensive result in the assessment of risk factors of catheter dysfunction.

Factors Affecting Cuff Extrusion of Tunneled Hemodialysis Catheters.

PURPOSE: To identify patient and procedural factors associated with extrusion of the Dacron cuff from the subcutaneous tunnel of tunneled hemodialysis catheters (THDCs). MATERIALS AND METHODS: Single center 5-year retrospective analysis of 625 catheters in 293 adult patients. Patient data included age, gender, body mass index (BMI), and common comorbidities. Procedural details included type of procedure (new insertion vs. exchange), operator seniority, side of insertion, catheter model and presence of catheter wings skin-sutures. Complications were reported as cumulative risk over time and Cox proportional hazards model was used to evaluate risk factors for cuff extrusion (CE). RESULTS: Median patient follow-up was 503 days (188,913 catheter-days) and median catheter survival 163 days. CE occurred in 23.8% of catheters, at a rate of 0.79 per 1,000 catheter-days and a median time of 64 days. It was more common than infection (14.6%) and inadequate flow (15.5%). The 1-month and 12-month risk of CE was 5.9% and 21.3% respectively. A first episode of CE was a strong predictor of future CE episodes. The only patient factor that affected the risk of CE was BMI (Hazard Ratio 2.36 for obese patients). Procedural factors that affected the risk of CE, adjusted for BMI, were catheter model, type of procedure (lower risk for new insertions) and catheter wings skin-sutures; the latter reduced the 30-day CE risk by 76% without increasing catheter-related infections. CONCLUSION: Cuff extrusion is common in long-term THDCs. The risk increases with obesity, history of previous cuff extrusion, certain catheter models and absence of wing-sutures.

Carotid artery tortuosity may pose a problem during insertion of the tunneled catheter for hemodialysis.

Tortuosity of the carotid artery is usually an asymptomatic vascular abnormality and is discovered accidentally during cerebral angiography. These vascular changes may aggravate surgical procedures in the neck region. We described a technique of permanent catheter insertion in patients with renal graft failure in whom renal replacement therapy was necessary. Severe tortuosity of cervical arteries may make this procedure more difficult, necessitating a special technique, that is, full image monitoring.

Perforation of the ascending colon during implantation of an indwelling peritoneal catheter: a case report.

BACKGROUND: Tunneled peritoneal drainage catheters are described as an effective and relatively safe method in the management of malignant and non-malignant refractory ascites. Therapeutic advantages, linked to their use, are self-management of ascites and palliative care at home. Complications occur rarely. We describe an ascending colon perforation after implantation of a peritoneal drainage in a patient with refractory ascites due to liver cirrhosis. CASE PRESENTATION: The 68-year-old male was admitted to the intensive care unit due to severe community acquired pneumonia. The ascites drainage was inserted in order to reduce the intra-abdominal pressure and enable appropriate ventilation. A few hours later, bowel content could be detected in the tube and an abdominal computed tomography confirmed the intestinal perforation. Notably, there was no pneumoperitoneum and peritonitis had not yet set in. The catheter was removed during an emergency laparotomy and sutured closure of both perforation sites was performed. CONCLUSION: Patients with septated ascites and intraperitoneal adhesions are at potential higher risk of bowel perforation during implantation of an indwelling peritoneal catheter. A mini-laparotomy is, therefore, necessary in order to ensure safe implantation and positioning of the catheter in those cases.

Complications From Tunneled Hemodialysis Catheters: A Canadian Observational Cohort Study.

RATIONALE & OBJECTIVE: Clinical practice guidelines discourage the use of central venous catheters (CVCs) for vascular access in dialysis. However, some patients have inadequate vessels for arteriovenous fistula creation or choose to use a dialysis catheter. The risks associated with CVC use and their relationship to patient age are poorly characterized. STUDY DESIGN: Observational retrospective cohort study. SETTING & PARTICIPANTS: Cohort of 1,041 patients older than 18 years from 5 Canadian dialysis programs who initiated outpatient maintenance hemodialysis therapy with a tunneled CVC between 2004 and 2012 and who had no creation of an arteriovenous fistula or arteriovenous graft. EXPOSURES: Age, sex, body size, initiating dialysis therapy in the hospital, and comorbid conditions. OUTCOMES: CVC-related procedures, hospitalization, and death. ANALYTICAL APPROACH: Complications were reported as a cumulative risk at 1 and 2 years. Cox proportional hazards regression for recurrent events was used to evaluate risk factors for study outcomes. RESULTS: At 1 year, risks for CVC-related bacteremia, malfunction, and central stenosis were 9%, 15%, and 2%, respectively. Risks for any CVC-related complication at 1 and 2 years were 30% and 38%, respectively. Death related to CVC complications occurred in 6 of 1,041 (0.5%) patients. Compared with patients younger than 60 years, patients aged 70 to 79 and those 80 years or older experienced lower rates of CVC complications: HRs of 0.67 (95% CI, 0.52-0.85; P = 0.001) and 0.69 (95% CI, 0.52-0.92; P = 0.01), respectively. LIMITATIONS: This Canadian dialysis population may not be representative of populations in other countries. CVC use was not compared with other types of hemodialysis vascular access. CONCLUSIONS: Approximately one-third of hemodialysis patients who used tunneled CVCs during 1 to 2 years experienced complications. Bacteremia occurred in ∼9% of patients at 1 year and were the most common cause of CVC-related hospitalizations. CVC-related death was infrequent. This information could be used to communicate the risk for CVC complications to patients treated with this type of hemodialysis vascular access.

Risk factors for catheter-related infections in patients receiving permanent dialysis catheter.

BACKGROUND: Due to rising vascular comorbidities of patients undergoing dialysis, the prevalence of permanent hemodialysis catheters as hemodialysis access is increasing. However, infection is a major complication of these catheters. Therefore, identification of potential predicting risk factors leading to early infection related complications is valuable, in particular the significance the CRP (C-reactive protein)-value is of interest. METHODS: In this retrospective study 151 permanent hemodialysis catheters implanted in 130 patients were examined. The following data were collected at the time of catheter implantation: CRP-value, history of catheter-related infection, microbiological status, immunosuppression and diabetes mellitus. The primary outcomes were recorded over the 3 months following the implantation: catheter-related infection, days of hospital stay and death. Catheter removal or revision, rehospitalization and use of antibiotics were identified as secondary outcomes. RESULTS: We identified a total of 27 (17.9%) infections (systemic infection: 2.26 episodes/ 1000 catheter days, local infection: 0.6 episodes/ 1000 catheter days). The development of an infection was independent of the CRP-value (p = 0.66) as well as the presence of diabetes mellitus (p = 0.64) or immunosuppression (p = 0.71). Univariate analysis revealed that infection was more frequent in patients with MRSA-carriage (p < 0.001), in case of previous catheter-related infection (p < 0.05) and of bacteremia or bacteriuria in the period of 3 months before catheter implantation (p < 0.001). Catheter removal or revision (p = 0.002), rehospitalization (p = 0.001) and use of antibiotics (p = 0.02) were also more often observed in patients with MRSA-carriage. CONCLUSIONS: The CRP-value at the time of implantation of a permanent hemodialysis catheter is not associated with the development of early catheter related infections, but an individual history of catheter-related infection, MRSA-carriage and bacteremia or bacteriuria in the period of 3 months prior to catheter implantation are significant risk factors.

Comparison of tunneled central venous catheters and native arteriovenous fistulae by evaluating the mortality and morbidity of patients with prevalent hemodialysis.

PURPOSE: We examined the association between catheter use for maintenance hemodialysis (HD) and mortality/hospitalization in a cohort of patients with prevalent HD. METHODS: In this study, 70 HD patients with tunneled cuffed central venous catheters (TCVCs) from a Taiwanese HD center during 2014-2016 were enrolled and compared with 70 matched HD patients with native arteriovenous fistulae (AVF). The compared variables included demographic parameters and laboratory and dialysis-related indices. Cox regression analysis was used to assess the risk of mortality/hospitalization within a year. RESULTS: Low baseline serum albumin levels were found in patients with TCVCs (3.64 g/dL vs 3.79 g/dL, p = 0.030). The mortality rates of patients with AVF and TCVCs were 14 per 1000 patients and 171 per 1000 patients, respectively. Infection was the leading cause of mortality/hospitalization in patients with TCVCs. Using multivariate analyses, the risk of death was found to be significantly higher in patients with TCVCs than in those with AVF (Hazard ratio [HR] 12.15, 95% CI 1.16-127.17; p = 0.037). Patients with TCVC also had a higher hospitalization rate (HR 1.33, 95% CI 0.71-2.49; p = 0.369) (not statistically significant). CONCLUSION: Catheter use for maintenance HD was associated with increased all-cause mortality.

Taurolidine-based catheter lock regimen significantly reduces overall costs, infection, and dysfunction rates of tunneled hemodialysis catheters.

Catheter-related infections and dysfunction are the main catheter complications causing morbidity and mortality in hemodialysis patients. However, there are no consistent data for the choice of catheter lock solutions for tunneled hemodialysis lines. In this prospective, multicenter, randomized, controlled trial, two lock regimens using three commercial catheter lock solutions were compared in 106 hemodialysis patients with a newly inserted tunneled central catheter. In the taurolidine group, TauroLock™-Hep500 was used twice per week and TauroLock™-U25,000 once a week. In the citrate group, a four percent citrate solution was used after each dialysis. Both groups were compared regarding catheter-related infections, catheter dysfunction, and costs. Over a period of 15,690 catheter days, six catheter-related infections occurred in six of 52 patients in the taurolidine group, but 18 occurred in 13 of 54 patients in the citrate group, corresponding to 0.67 and 2.7 episodes of catheter-related infections per 1000 catheter days, respectively (Incidence Rate Ratio 0.25, 95% confidence interval, 0.09 to 0.63). Catheter dysfunction rates were significantly lower in the taurolidine group (18.7 vs. 44.3/1000 catheter days) and alteplase rescue significantly more frequent in the citrate group (9.8 vs. 3.8/1000 catheter days). These differences provided significant catheter-related cost savings of 43% in the taurolidine group vs. citrate group when overall expenses per patient and year were compared. Thus, use of taurolidine-based catheter lock solutions containing heparin and urokinase significantly reduced complications related to tunneled hemodialysis catheters when compared to four percent citrate solution and was overall more cost-efficient.

Intraoperative venoplasty to facilitate placement of tunneled catheters for hemodialysis.

Objective With the implementation of the K-DOQI guidelines, more patients are in need of long-term dialysis catheters until maturation of the arteriovenous fistula. However, on occasion, when placing a tunneled cuffed catheter for hemodialysis, we have encountered difficulty with passing the guidewire in spite of demonstration of a patent cervical portion of the internal jugular vein on duplex. Herein, we review our experience with intraoperative venoplasty for placement of Tesio™ catheters (Medcomp Harleysville, PA). Methods Of the 1147 Tesio™ catheters placed since 1997 by our service, 35 venograms were performed due to difficulty encountered with placement of the guidewire. Patent veins were all crossed with the use of angle-guiding catheters, angled glidewires, and a torque vise. If chronically occluded intrathoracic veins were identified, an alternate site was selected for the placement of the Tesio™ catheter. Results Of the 35 cases with difficulty in catheter placement, venogram demonstrated a patent but tortuous vein in 9, chronically occluded intrathoracic veins in 6, and severe stenosis of the intrathoracic veins in 20. In 19 cases with severe stenosis of the intrathoracic veins, balloon angioplasty with an 8-mm balloon was successfully performed, which allowed successful placement of a functional Tesio™ catheter. In the additional one case, the catheter was not able to be placed despite angioplasty. Seven lesions that underwent balloon angioplasty were in the innominate vein, 11 were in the proximal internal jugular vein, and two were in the superior vena cava. Conclusion Venous balloon angioplasty can be used to maintain options for the site of access for tunneled cuffed catheters and may be necessary to assist with placement of long term cuffed dialysis catheters.

Vascular Access Placement Order and Outcomes in Hemodialysis Patients: A Longitudinal Study.

BACKGROUND: Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled "permanent" for AV fistulas (AVF) or grafts (AVG) and "temporary" for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement. METHODS: All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age. RESULTS: In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments. CONCLUSIONS: HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a "permanent" vascular access and used an AVA for the majority of HD treatments.

Clinical presentation and outcome of hemodialysis tunneled catheter-related bloodstream infection in older persons.

BACKGROUND: The use of a tunneled catheter as the primary vascular access among old hemodialysis patients is frequent. Catheter-related bloodstream infection (CRBSI) is a common complication, associated with increased mortality. Data regarding the clinical presentation and outcomes of CRBSI among old hemodialysis patients is limited. METHODS: All chronic hemodialysis patients hospitalized between 2010 and 2022 with CRBSI were included. Patients were classified into two groups: old adults (≥ 75) and younger patients. Clinical, microbiological, and outcome data were collected and analyzed. RESULTS: One hundred and fifty-four patients with CRBSI were identified. Fifty-seven were aged ≥ 75 years. Mean age in the older and younger groups was 81.2 ± 5 and 59.7 ± 12.7, respectively. Male gender was predominant (64%). Charlson comorbidity score and Pitt bacteremia score were comparable among both groups. Norton score < 14 was more common among old persons (n = 24, 67% versus n = 21, 31%, p < 0.001), as well as nursing-home residence. Gram-negative pathogens and Staphylococcus aureus were common in both groups. The frequency of inappropriate empirical antimicrobial treatment was higher among older persons. Overall, in-hospital and 90-day mortality was high (age ≥ 75, 36.8%, age < 75, 24.7%, p = 0.14). Age was not significantly associated with mortality after adjustment for low Norton score, residence, and inappropriate antimicrobial therapy as well as resistance patterns of bloodstream isolates [OR = 1.2 (95% CI 0.4-3.3), p = 0.76]. CONCLUSIONS: Clinical characteristics and outcomes of CRBSI were comparable among old and young hemodialysis patients. However, the high mortality rate in this cohort suggests that the use of tunneled catheters as a permanent vascular access should be discouraged in both patient groups.

A Tunneled Catheter Placement Program for Community Hospices.

CONTEXT: The symptoms associated with the excessive fluid accumulation of ascites or pleural effusions can be intractable to medical management and can have a significant negative impact on quality of life of hospice patients. Hospice of the Valley, a community-based, nonprofit hospice agency has historically referred patients to outpatient providers for paracentesis, thoracentesis, and placement of tunneled drainage catheters. OBJECTIVES: To describe an in-house pilot program of tunneled catheter placement to provide immediate and longer-term symptom relief for selected hospice patients. METHODS: The logistics and cost of the pilot program are described. Key data elements, including select demographics, patient eligibility screening, and incidence of procedure-related or late complications are reported. RESULTS: A total of 135 drainage procedures completed on 127 unique hospice patients over 27 months (2020-2023) were reviewed. The rate of procedure-related complications (<4%) and late complications (<3%) are low. The average cost per procedure ($1030) compares favorably with outpatient providers' fees. The program was well-accepted by the interdisciplinary hospice team, patients, and families. CONCLUSIONS: An in-house program of tunneled catheter placement is a feasible option for hospice providers with low-cost exposure and high potential for improved quality of life and symptom relief for selected patients.

A Modified Switching Procedure from Temporary to Tunneled Central Venous Dialysis Catheters.

Background: Tunneled central venous catheters are commonly used for dialysis in patients without a functional permanent vascular access. In an emergent setting, a non-tunneled, temporary central venous catheter is often placed for immediate dialysis. The most critical step in the catheter insertion is venipuncture, which is often a major cause for longer intervention times and procedure-related adverse events. To avoid this critical step when placing a more permanent tunneled catheter, an exchange over a previously placed temporary one can be considered. In this paper, we present a modified switching approach with a separate access site. Methods: In this retrospective analysis of a prospective database, we examined whether this modified technique is non-inferior to a de novo application. Therefore, we included all 396 patients who received their first tunneled dialysis catheter at our site from March 2018 to March 2023. Out of these, 143 patients received the modified approach and 253 the standard de novo ultrasound-guided puncture and insertion. Then, the outcomes of the two groups, including adverse events and infections, were compared by nonparametric tests and multivariable logistic regression. Results: In both groups, the implantations were 100% successful. Catheter explantation due to infection according to CDC criteria was necessary in 18 cases, with no difference between the groups (5.0% vs. 4.4% p = 0.80). The infection rate per 100 days was 0.113 vs. 0.106 in the control group, with a comparable spectrum of bacteria. A total of 12 catheters (3 vs. 9) had to be removed due to a periinterventional complication. An early-onset infection was the reason in two cases (1.3%) in the study group and five in the control group (1.9%). A total misplacement of the catheter occurred in two cases only in the control group. After adjustment for potential confounders via multivariable logistic regression there was not a significant difference in the complication rate (adjusted odds ratio, aOR = 0.53, 95% CI = 0.14-2.03, p = 0.351) but an estimated decreased risk overall based on the average treatment effect of -1.7% in favor of the study group. Conclusions: The present study shows that a catheter exchange leads to no more infections than a de novo placement; hence, it is a feasible method. Moreover, misplacements and control chest X-rays to exclude pneumothorax after venipuncture were completely avoided by exchanging. This approach yields a much lower infection rate than previous reports: 1.3% compared to 2.7% in all existing aggregated studies. The presented approach seems to be superior to existing switching methods. Overall, an exchange can also help to preserve veins for future access, since the same jugular vein is used.

Etiological Factors Affecting Single Versus Multiple Tunneled Hemodialysis Catheter Cuff Extrusions in the Saudi Population.

OBJECTIVE: To identify underlying factors associated with single versus multiple expulsions of tunneled hemodialysis catheter cuffs and their associated complications. MATERIALS AND METHODS: A multicenter, five-year retrospective data analysis was conducted on hemodialysis patients with tunneled catheters. Patient data included age, gender, BMI, and associated comorbidities. The type of procedure (new tunnel insertion vs. exchange), exit site infection, and catheter-related bloodstream infection (CRBSI) were also included. RESULTS: The data of 122 patients was analyzed. Seventy-eight patients had diabetes mellitus, 102 patients had hypertension, and 24 had ischemic heart disease. Fifty-one patients were on antiplatelet therapy, and nine patients were on oral steroids. The access site for 98 patients was the right internal jugular; for 19 patients, it was the left internal jugular; five patients had a femoral dialysis catheter. Patients were grouped into two categories: those with single cuff extrusion episodes and those with multiple cuff-out episodes. Sixty-three patients had one cuff extrusion, and 59 had multiple cuff-out episodes during the study period. Patients who had CRBSI and hypertension and were aged between 61 and 95 had multiple episodes of cuff extrusion and reached statistical significance. Exit-site infection, diabetes mellitus, antiplatelet therapy, gender, catheter site, and BMI had no statistical significance between the two groups. CONCLUSION: Tunneled catheter cuff extrusion is a frequent phenomenon. Catheter-related bloodstream infection, hypertension, and age of 61 to 95 years are high-risk factors for multiple episodes of cuff extrusion.

Variables Leading to Usage of Alteplase Versus Heparin Lock in Patients With Tunneled Catheters in Hemodialysis Care Project Centers, Saudi Arabia.

INTRODUCTION: A hemodialysis tunneled catheter is one option for vascular access used with hemodialysis patients; however, catheter complications such as thrombosis are still inevitable. To prevent thrombosis formation, a catheter-locking solution is instilled between dialysis sessions. Heparin is used as a default locking solution in our Hemodialysis Care Project centers, while a recombinant tissue plasminogen activator (rt-PA) such as alteplase is used to treat suspected catheter thrombosis. This study aimed to identify the clinical factors, catheter brands, and hemodialysis variables that influence the choice of use for alteplase versus heparin, for those patients with tunneled catheters, and reduce overprescribing of high-alert medication alteplase. METHODS: A retrospective medical chart review study was conducted involving 230 patients with tunneled catheters; the first group of 133 patients used alteplase regularly three times a week, while the second group of 97 patients completed at least one year using the same catheter access with heparin lock only. RESULTS: Multivariate logistic regression and logistic regression analysis showed a significant association (p < 0.05) between different variables. Results suggest that overweight and hyperlipidemia patients are more likely to use alteplase. Patients using brand-name catheters such as Hemostar/Vas-cath (BD, Franklin Lakes, NJ) are less likely to use heparin than those using Medcomp catheters (Medcomp, Yuma, AZ). In addition, patients having a history of angioplasty would be less likely to have heparin than no angioplasty. Moreover, if the patient's fluid removal were equal to or less than 2 kg, they would be more likely to use heparin and vice versa. CONCLUSION: The study postulates that identified variables affect whether alteplase or heparin is used in hemodialysis tunneled catheters, and may be useful to increase awareness, improve practices, or judiciously control the use of alteplase within Saudi Arabia and globally.

Association between tunneled catheter placement and catheter-associated deep venous thrombosis in adults with inflammatory bowel disease receiving home parenteral nutrition: A retrospective cohort study.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk of thrombosis. They often need parenteral nutrition (PN) requiring intravenous access for prolonged periods. We assessed the risk of deep vein thrombosis (DVT) associated with peripherally inserted central catheters (PICCs) and tunneled catheters for patients with IBD receiving home PN (HPN). METHODS: Using the Cleveland Clinic HPN Registry, we retrospectively studied a cohort of adults with IBD who received HPN between June 30, 2019 and January 1, 2023. We collected demographics, catheter type, and catheter-associated DVT (CADVT) data. We performed descriptive statistics and Poisson tests to compare CADVT rates among parameters of interest. We generated Kaplan-Meier graphs to illustrate longevity of CADVT-free survival and a Cox proportional hazard model to calculate the hazard ratio associated with CADVT. RESULTS: We collected data on 407 patients, of which, 276 (68%) received tunneled catheters and 131 (32%) received PICCs as their initial catheter. There were 17 CADVTs with an overall rate of 0.08 per 1000 catheter days, whereas individual rates of DVT for PICCs and tunneled catheters were 0.16 and 0.05 per 1000 catheter days, respectively (P = 0.03). After adjusting for age, sex, and comorbidity, CADVT risk was significantly higher for PICCs compared with tunneled catheters, with an adjusted hazard ratio of 2.962 (95% CI=1.140-7.698; P = 0.025) and adjusted incidence rate ratio of 3.66 (95% CI=2.637-4.696; P = 0.013). CONCLUSION: Our study shows that CADVT risk is nearly three times higher with PICCs compared with tunneled catheters. We recommend tunneled catheter placement for patients with IBD who require HPN infusion greater than 30 days.

Tunneled catheter-related bacteremia in hemodialysis patients: incidence, risk factors and outcomes. A 14-year observational study.

BACKGROUND: Tunneled catheter-related bacteremia represents one of the major complications in patients on hemodialysis, and is associated with increased morbidity and mortality. This study aimed to evaluate the incidence of tunneled catheter-related bacteremia and, secondly, to identify possible factors involved in the first episode of bacteremia. METHODS: This is a retrospective study of all tunneled catheters inserted between 1 January, 2005 and 31 December, 2019. Data on patients with a tunneled catheter were analyzed for comorbidities, catheter characteristics, microbiological culture results and variables related to the first episode of bacteremia. Patient outcomes were also assessed. RESULTS: In the 14-year period under study, 406 tunneled catheters were implanted in 325 patients. A total of 85 cases of tunneled catheter-related bacteremia were diagnosed, resulting in an incidence of 0.40 per 1000 catheter days (81.1% after 6 months of implantation). The predominant microorganisms isolated were Gram-positive organisms: Staphylococcus epidermidis (48.4%); Staphylococcus aureus (28.0%). We found no significant differences in time to catheter removal for infections or non-infection-related reasons. The jugular vein, the Palindrome® catheter, and being the first vascular access were protective factors for the first episode of bacteremia. The 30-day mortality rate from the first tunneled catheter-related bacteremia was 8.7%. CONCLUSIONS: The incidence of bacteremia in our study was low and did not seem to have a relevant impact on catheter survival. S. epidermidis was the most frequently isolated microorganism, followed by S. aureus. We identified Palindrome® catheter, jugular vein, and being the first vascular access as significant protective factors against tunneled catheter-related bacteremia.

Challenges with tunneled dialysis catheter placement with subcutaneous emphysema.

Central vein catheter is a convenient and preferred vascular access for blood purification therapy in intensive care unit. Utilizing ultrasound to access the central vein is considered standard of care. However, critically ill patients can pose challenges while acquiring an optimal ultrasound image. The presence of subcutaneous air pockets, concerns for air embolism, and excessive bleeding from the exit site is one such clinical situation. We describe our experience with a unique situation while placing a tunneled dialysis catheter in a COVID-19 patient with acute respiratory failure and subcutaneous emphysema.