RESUMO
Rationale & Objective: Timely placement of a functional peritoneal dialysis (PD) catheter is crucial to long-term PD success. Advanced image-guided percutaneous and advanced laparoscopic techniques both represent best practice catheter placement options. Advanced image-guided percutaneous is a minimally invasive procedure that does not require general anesthesia. Study Design: Retrospective cohort study comparing time from referral to procedure, complication rate, and 1-year catheter survival between placement techniques. Setting & Participants: Patients who had advanced laparoscopic or advanced image-guided percutaneous PD catheter placement from January 1, 2011 to December 31, 2013 in an integrated Northern California health care delivery system. Exposure: PD catheter placement using advanced laparoscopic or advanced image-guided percutaneous techniques. Outcomes: One-year PD catheter survival; major, minor, and infectious complications; time from referral to PD catheter placement; and procedure time. Analytical Approach: Wilcoxon rank sum tests to compare referral and procedure times; χ2/Fisher exact tests to compare complications; and modified least-squares regression to compare adjusted 1-year catheter survival between PD placement techniques. Results: We identified 191 and 238 PD catheters placed through advanced image-guided percutaneous and advanced laparoscopic techniques, respectively. Adjusted 1-year PD catheter survival was 80% (95% CI, 74%-87%) using advanced image-guided percutaneous technique vs 91% (87%-96%) using advanced laparoscopic technique (P = 0.01). Major complications were <1% in both groups. Minor and infectious complications were 45.6% and 38.7% in advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P = 0.01). Median days from referral to procedure were 12 and 33 for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P < 0.001). Median procedure time was 30 and 44.5 minutes for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P < 0.001). Limitations: Retrospective study with practice preference influenced by timing, local expertise, and resources. Conclusions: Both advanced image-guided percutaneous and advanced laparoscopic techniques reported rare major complications and demonstrated excellent (advanced laparoscopic) and acceptable (advanced image-guided percutaneous) 1-year PD catheter survival. For patients referred for PD catheter placement at centers where advanced laparoscopic resources or expertise remain limited, the advanced image-guided percutaneous technique can provide a complementary and timely option to support the utilization of PD. Plain-Language Summary: Peritoneal dialysis is a preferred dialysis modality for many patients. However, the lack of available skilled surgeons can limit the placement of the peritoneal dialysis catheter in a timely manner. In the past decade, interventional radiology has developed expertise in placing peritoneal dialysis catheters. Using data from an integrated health care system, we compared the outcome of peritoneal dialysis catheters placed using laparoscopic surgery and interventional radiology techniques. Our results showed excellent 1-year patency of peritoneal dialysis catheters placed using laparoscopic surgery, whereas interventional radiology placement of catheters had lower but acceptable 1-year patency survival, based on best practice guideline criteria. Hence, interventional radiology placement of peritoneal dialysis catheters may be a viable alternative when laparoscopic surgery is not available or feasible.
RESUMO
Peritoneal dialysis (PD) catheters can be placed by interventional radiologists, an approach that might offer scheduling efficiencies, cost-effectiveness, and a minimally invasive procedure. In the United States, changes in the dialysis reimbursement structure by the Centers for Medicare and Medicaid Services are expected to result in the increased use of PD, a less costly dialysis modality that offers patients the opportunity to receive dialysis in the home setting and to have more independence for travel and work schedules, and that preserves vascular access for future dialysis options. Placement of PD catheters by interventional radiologists might therefore be increasingly requested by nephrology practices, given that recent publications have demonstrated the favorable impact on PD practices of an interventional radiology PD placement capability. Earlier reports of interventional radiology PD catheter placement came from single-center practices with smaller reported experiences. The need for a larger consensus document that attempts to establish best demonstrated practices for radiologists is evident. The radiologists submitting this consensus document represent a combined experience of more than 1000 PD catheter placements. The authors submit these consensus-proposed best demonstrated practices for placement of PD catheters by interventional radiologists under ultrasonographic and fluoroscopic guidance. This technique might allow for expeditious placement of permanent PD catheters in late-referred patients with end-stage renal disease, thus facilitating urgent-start PD and avoiding the need for temporary vascular access catheters.