Single‐lumen tunneled catheter: An old but useful option

We report a case of long‐term uneventful catheter use in a patient with previous recurrent vascular access dysfunction and infection. A single‐lumen tunneled catheter was inserted into the left internal jugular vein after a failed attempt of dual‐lumen permanent catheter placement. The follow‐up since device implantation has exceeded 5 years without any complications related to vascular access.     

Can a left internal jugular catheter be used in the hemodialysis of a patient with persistent left superior vena cava?

A patient with a persistent left superior vena cava (PLSVC) was incidentally diagnosed after positioning of a dual lumen catheter for hemodialysis into the left internal jugular vein. Although PLSVC is a relatively rare condition, it is the most common congenital anomaly of thoracic venous circulation. It represents the persistence of the left horn of the embryonic sinus venosus, which normally involutes during embryogenesis to become the coronary sinus. The existence of a PLSVC can cause a significant diagnostic dilemma during catheterization of the left internal jugular vein, pertaining to the positioning of the catheter. It may also be associated with significant clinical implications such as systemic embolization, provocation of arrhythmia, and thrombosis of the vessel. The safety of such catheterization has not been adequately evaluated due to the rarity of this condition. We believe that a diagnostic workup including blood gas analysis, echocardiography, and computed tomography is necessary to confirm a right atrial drainage and a patent innominate vein as prerequisites to maintain the catheter in position.     

Urgent hemodialysis with the use of peripheral veins to avoid catheter insertion

Urgent hemodialysis (HD) in patients with uremia is usually performed using a central vein catheter unless an arteriovenous fistula (AVF) was created in the predialysis period. We present a unique approach, in a patient in whom the first two HD sessions were conducted without implantation of a catheter or AVF. The perfectly developed peripheral veins of a professional bodybuilder served as vascular access allowing catheter insertion to be avoided. The aim of this short case report is to recall a forgotten method for performing urgent HD in patients without a fistula, but with suitably enlarged superficial veins.     

The permanent catheter

An elderly woman receiving hemodialysis via a right brachiocephalic arteriovenous fistula presented to the clinic for elective removal of a tunneled hemodialysis catheter inserted 5 years ago. The catheter had not been removed earlier at the patient's request. Removal was now unsuccessful in the clinic. Exploration in the operating room revealed the innominate vein had fibrosed around the length of the catheter. The procedure was abandoned, catheter cut short and the remnant left in situ. This case serves as a reminder to exercise caution if there is difficulty in removing the catheter even after the cuff is dissected free, and to remove them once a working fistula or graft is available. Failing which, the patient bears an unnecessary risk of line infection, or as in this case, the catheter may unintentionally end up what its common misnomer “perm‐cath” alludes to – becoming truly “permanent.”     

Catheter tip malposition after percutaneous placement of tunneled hemodialysis catheters

The percutaneous catheterization of central veins is increasingly used in nephrological practice as a temporary or permanent vascular access. The aim of our study was to present and to analyze episodes of catheter tip malposition during percutaneous tunneled hemodialysis catheter insertion in the large, unselected group of patients. All patients who underwent the procedure of catheter insertion in our department during year 2012 were analyzed retrospectively. One hundred four tunneled hemodialysis catheters were inserted in 101 patients. In 58 patients, the catheter was inserted at the initiation of hemodialysis therapy as the first access and in 46 the catheter was placed because of the failure of the existing one. In 68 patients, the catheter was inserted into the right internal jugular vein and in 20 patients into the left internal jugular vein (LIJV). Subclavian veins were used in five cases and femoral veins in 11 cases. Malposition of the catheter tips occurred in six patients. In all cases, the LIJV was cannulated. In two cases, the catheter tip malposition was in the right innominate vein and in four cases in the azygos vein. Our data demonstrate that with the blind insertion of tunneled hemodialysis catheters, the risk of catheter tip malposition is significantly higher with the left side insertion. As catheter insertion through the LIJV holds very high (30%) risk of the tip malposition, it should always be performed under the fluoroscopic control.     

A rare cause of abdominal pain: Catheter in the middle hepatic vein

Hemodialysis catheters are vital for chronic renal failure patients. Permanent tunneled dialysis catheters may be inserted through the jugular, subclavian, and femoral veins. In this paper, we aimed to present the computed tomography findings of a chronic renal failure patient who had referred our clinic with abdominal pain and dyspnea symptoms. This patient had a formerly inserted hemodialysis catheter for chronic renal failure and her catheter was found to be extending towards the middle hepatic vein with the tip leaning onto the parenchyma. Hemodialysis catheters can provide instant vascular access and can also be used for the consecutive procedures. Permanent hemodialysis catheters are ideal for long‐term use when placing an arteriovenous fistula is contraindicated or is no longer possible under conditions like advanced heart failure, peripheral artery disease or short life expectancy. The internal jugular, subclavian, the femoral veins, and the inferior vena cava can be used for catheter insertion. The tip of the catheters inserted in the neck or the thorax must extend to the vena cava superior. Catheter malposition may both lead to fatal outcomes and ineffective dialysis. It is important to obtain chest X‐rays after the procedure, particularly to detect catheter malposition.     

Femoral arteriovenous fistula 3 months after removal of catheter for hemodialysis

A 56‐year‐old Asian woman was admitted to hospital for the consideration of hemodialysis (HD). A right femoral dialysis catheter was inserted for HD. Three months after removal of catheter, she was admitted because of right inguinal swelling. A thrill and bruit were felt and heard at the inguinal area. Color Doppler detected a fistula between right superficial femoral artery and right common femoral vein and subsequently confirmed by contrast enhanced computed tomography scan and 3‐dimensional reconstruction with computed tomography. At surgery, a 4‐mm–diameter fistula was found between the right superficial femoral artery and right common femoral vein. A primary closure of both defects in the artery and vein was then carried out. A follow‐up digital vascular study 3 months after surgical repair was normal. In conclusion, nephrologist should have a heightened awareness to the potential of this complication and should at least document a normal exam following the removal of femoral catheters.     

Real-time, 3-D ultrasound with multiple transducer arrays

Modifications were made to a commercial real-time, three-dimensional (3-D) ultrasound system for near simultaneous 3-D scanning with two matrix array transducers. As a first illustration, a transducer cable assembly was modified to incorporate two independent, 3-D intra-cardiac echo catheters, a 7 Fr (2.3 mm O.D.) side scanning catheter and a 14 Fr (4.7 mm O.D) forward viewing catheter with accessory port, each catheter using 85 channels operating at 5 MHz. For applications in treatment of atrial fibrillation, the goal is to place the sideviewing catheter within the coronary sinus to view the whole left atrium, including a pulmonary vein. Meanwhile, the forward-viewing catheter inserted within the left atrium is directed toward the ostium of a pulmonary vein for therapy using the integrated accessory port. Using preloaded, phasing data, the scanner switches between catheters automatically, at the push of a button, with a delay of about 1 second, so that the clinician can view the therapy catheter with the coronary sinus catheter and vice versa. Preliminary imaging studies in a tissue phantom and in vivo show that our system successfully guided the forward-viewing catheter toward a target while being imaged with the sideviewing catheter. The forward-viewing catheter then was activated to monitor the target while we mimicked therapy delivery. In the future, the system will switch between 3-D probes on a line-by-line basis and display both volumes simultaneously.     

Enterococcus faecalis endophthalmitis as a metastatic complication of hemodialysis vascular access‐related sepsis: A case report and review of the literature

Catheter and/or arteriovenous (A‐V) graft‐related bacteremia is an important cause of morbidity and mortality among hemodialysis (HD) patients. Endocarditis, septic arthritis, epidural abscess, septic embolism, and osteomyelitis are the most common complications of catheter and/or A‐V graft‐related bacteremia; however, endogenous endophthalmitis is rarely seen. To the best of our knowledge, Enterococcus faecalis is the first case report in this population. We hereby report a case of endogenous endophthalmitis caused by E. faecalis as a complication of catheter and/or A‐V graft‐related bacteremia in a diabetic patient, who was undergoing HD for 5 years. We also discuss the etiology, clinical features, and outcomes of endogenous endophthalmitis in HD patients with a brief review of the literature. Although broad‐spectrum parenteral (intravenous and intravitreal) antibiotics were used for 4 weeks, evisceration of the left eye could not be avoided. Endogenous endophthalmitis is a rare but rapidly blinding complication of catheter and/or A‐V graft‐related bacteremia in HD patients. It can develop as a result of silent catheter and/or A‐V graft infections, which may lead to recurrent bacteremia. E. faecalis should be considered as a pathogen in this population who had recent history of catheter or A‐V graft procedure.     

One patient,two malpositioned hemodialysis catheters, (hepatic vein and ascending lumbar vein), no fluoroscopy

Cuffed-tunneled hemodialysis catheter (CTHC) application via the femoral vein is a safe and effective alternative when peripheral vascular routes are exhausted for hemodialysis in patients with end-stage renal disease. Also, imaging methods have become more important for the diagnosis or prevention of the possible complications that may develop during or after catheter placements. Here, we present a case of hemodialysis catheter dysfunction due to the insertion of a CTHC tip into the hepatic vein, and into the left ascending lumbar vein at the next attempt. We think that the use of fluoroscopy, whether in the first catheter intervention or catheter change, is extremely important in preventing possible complications that may develop, or detecting them as soon as possible.     

Tunneled-cuffed catheter implanted into the accessory hemiazygos vein because of occlusion of the left innominate vein

Hemodialyzed patients are at risk of multiple catheterizations. Nephrologists performing such procedures need to be familiar with congenital and acquired vascular abnormalities. We describe a successful insertion and use of a cuffed-tunneled catheter in a patient with unusual anatomy of the central venous system. Computed tomography angiography revealed thrombosis of the right subclavian vein and bilateral occlusion of innominate veins. The left internal jugular and subclavian veins joined to form a large vessel that drained through the accessory hemiazygos and azygos veins into the superior vena cava. The catheter was implanted through the left internal jugular vein into the accessory hemiazygos vein. The presented case demonstrates that the catheter can be implanted into distended collateral, especially when no other location is possible.     

Heparin‐induced thrombocytopenia due to heparin lock in a hemodialysis patient: A case report

Heparin‐induced thrombocytopenia (HIT) is a potentially fatal clinical condition which can develop after exposure to unfractionated or low‐molecular‐weight heparins. Even small doses of heparin such as heparin flushes in hemodialysis catheter can induce the development of HIT. However, the true incidence of heparin lock‐related HIT is unknown. We report a 58‐year‐old woman with acute kidney injury because of obstructive uropathy who developed HIT after heparin‐free hemodialysis. She was found to have severe thrombocytopenia with deep vein thrombosis of left lower limb and arterial thrombosis of the right anterior and middle cerebral arteries. The heparin‐platelet factor 4 antibody was positive and she was put on plasmapharesis. However, her condition further deteriorated and succumbed shortly. Heparin lock solution in the hemodialysis catheter was believed to be the cause of HIT in our patient.     

Asymmetric breast enlargement minus central venous thrombosis in a hemodialysis patient

A 76-year-old woman hemodialysis patient was hospitalized for community-acquired pneumonia complicating chronic obstructive pulmonary disease. End-stage renal disease secondary to hypertension had been diagnosed at the age of 64 for which the patient was initiated on maintenance hemodialysis. Then, she received a deceased donor kidney transplant at the age of 68 that succumbed to chronic rejection 4 years later when she was restarted on hemodialysis. Hemodialysis was performed via a right subclavian vein double lumen catheter for 2 months when a right brachio-axillary graft was inserted. Severe venous congestion, swelling, and nipple tenderness of her right breast noted on admission had been increasing for 6 weeks before hospital admission. No arm swelling was evident. Initial management of the patient's pneumonia and chronic obstructive pulmonary disease consisted of intravenous ceftriaxone and albuterol inhaler to which intravenous oxacillin (1 g q 6 hr) was added for presumed right mastitis. Radiological work-up for masses and malignancies was negative. An angiogram of the right upper extremity detected stenosis of the dialysis access graft at its anastomosis with the axillary vein. Angioplasty of the stenosis was performed without incident or evidence of central vein stenosis. Rapid resolution over 10 days of the unilateral breast congestion followed without complication.     

Hemothorax caused by replacement of hemodialysis catheter: A case report

Central venous catheters (CVC) are widely used in clinics to gain vascular access, but the risk and prevalence of catheter‐related complications remains a serious issue. We report a long‐term dialysis catheter accidentally inserted into the mediastinum via the right jugular vein in a hemodialysis patient. We also review complications associated with vascular catheterization and propose immediate therapeutic interventions for such cases.     

A complication of double lumen hemocatheter guide wire entrapment in a hemodialysis patient

Double lumen hemocatheter is commonly used for temporary hemodialysis patient and various complications have been documented but few reports of guide wire‐related complications. We report a complication of double lumen hemocatheter guide wire entrapment in a 43‐year‐old female of type 1 diabetes mellitus and hemodialysis patient. She was admitted for left arteriovenous shunt dysfunction and right internal jugular vein hemocatheter chamber clotting was found while on hemodialysis, so a new hemocatheter was changed over guide wire. Guide wire was introduced without any resistance and the clotting hemocatheter was removed. During the procedure, the J‐tipped guide wire could not be withdrawn and portable chest radiography revealed the J‐tip of the guide wire was in the right ventricle near the region of tricuspid valve. Fluoroscopy was arranged and it also confirmed the J‐tip was lying in the ventricle near the tricuspid valve where it was stuck. Snare catheter kit was inserted through the 10 Fr sheath and the cardiologist untied the knot by endovascular snare and removed the guide wire smoothly. This report emphasizes the importance of awareness on guide wire entrapment while inserting double lumen hemocatheter. When a guide wire became hard to withdraw, extracting an entrapped guide wire with fluoroscopy guide and snare catheter is a preferable and minimal invasive approach.     

Use of an alteplase algorithm for the management of hemodialysis catheter dysfunction

Hemodialysis (HD) catheter dysfunction compromises HD adequacy and increases the cost of patient care. Repeated administration of alteplase in HD catheters typically produces only short-term benefits. The purpose of this study was to design, implement, and evaluate the efficacy of an experimental alteplase algorithm to manage HD catheter dysfunction. This was a two-part prospective nonrandomized study. Baseline data of alteplase use and catheter exchange were collected during part 1 of the study. Part 2 consisted of the alteplase algorithm implementation and repeat collection of catheter data. Rates of alteplase use and catheter exchange per 1000 catheter-days were the primary and secondary outcomes of the study. One hundred and seventy-two catheters in 131 patients were followed prospectively during the course of the study. The adjusted relative rate (RR) of alteplase use showed no significant difference between both parts of the study, adjusted RR: 1.10, 95% confidence interval (CI) (0.73-1.65). Similarly, catheter exchange rates were not significantly different over the duration of the study (1.12 vs. 1.03 per 1000 catheter-days). However, waiting time for catheter exchange increased from 20.36 ± 14 days in part 1 to 38.42 ± 28 days in part 2 (P < 0.05). The alteplase algorithm did not significantly reduce alteplase use. This may be partially explained by repeated use of alteplase in part 2, due to longer waiting times for catheter exchange procedures.     

Hemodialysis access-related survival and morbidity in an elderly population in South West Thames, UK

Elderly patients form the most rapidly expanding group of hemodialysis (HD) patients in Europe and the United States. There are initiatives to promote an increase in arteriovenous fistula (AVF) formation. There are concerns that elderly patients may have lower rates of surgical vascular access compared with younger patients due to risks of higher co-morbidities, surgical complications, and higher AVF nonuse rates. The aim of this study was to compare access-related survival and morbidity for dialysis catheters and AVFs and to evaluate the AVF nonuse rate in an elderly population. We have performed a retrospective analysis of access survival and morbidity in patients > or = 70 years of age, either on maintenance HD or predialysis with preemptive formation of surgical access. One hundred and forty-six patients had permanent HD access created during the 18-month study period, from 1 January 2006 to June 2007. There were 89 male and 57 female patients in whom 78 AVFs and 137 tunneled venous catheters were inserted. There was a significantly greater loss of vascular access due to infection in the catheter group compared with the AVF group (P<0.016). Access survival was also significantly prolonged in the AVF group (446 days, 95% confidence interval 405-487) compared with the catheter group (276 days, 95% confidence interval 240-313), P=0.001. The rate of nonuse of AVFs was low (16%). We conclude that an AVF is the preferred form of vascular access in elderly HD patients.     

The level of C‐reactive protein in chronic hemodialysis patients: A comparative study between patients with noninfected catheters and arteriovenous fistula in two large Gulf hemodialysis centers

Hemodialysis (HD) patients have greater morbidity and mortality when they have a central venous catheter (CVC) rather than an arteriovenous fistula (AVF) access. Inflammation associated with dialysis catheter use and resultant higher C‐reactive protein (CRP) levels could have an independent adverse effect on patient outcomes. In this prospective study, we investigated whether HD catheters induce inflammation independent of infection. We compared the mean levels of the inflammatory marker (CRP) in 67 patients on maintenance HD using noninfected catheters with 86 HD patients using AVFs at Prince Salman Center for Kidney Diseases, Saudi Arabia (KSA), and Jahra Hospital, Kuwait, who met our inclusion criteria. C‐reactive protein levels were measured every 2 months over a period of 6 months using immunoturbidimetric assay. One hundred fifty‐three patients on maintenance HD for more than 6 months were included in the study, with mean age of 52.19 ± 16.06 years; 66% were males and 34% were females. Serial levels of mean CRP were statistically and significantly higher in group with noninfected catheters (1.33, 1.24, and 1.10 mg/dL) compared to those with AVFs (0.65, 0.59, and 0.68 mg/dL) with P value of 0.000. In our study, we found no relation between CRP level and age, sex, hemoglobin, albumin, calcium, phosphorus, and iPTH level in both groups. Hemodialysis patients with a catheter have a heightened state of inflammation independent of infection, and thus our study supports the avoidance of catheters and a timely conversion to AVFs with catheter removal.     

Hemodialysis does not impair ventricular functions over 2 years

We aimed to evaluate the long-term effect of hemodialysis (HD) treatment on left and right ventricular (LV and RV) functions in patients with end-stage renal disease. The study population consisted of 22 patients with newly diagnosed end-stage renal disease. Before an arteriovenous fistula was surgically created for HD, the patients were evaluated by echocardiography for systolic and diastolic functions. After the first HD session (mean 24.22 ± 2.14 months), the second echocardiographic evaluations were performed. Left ventricular and RV functions before and after long-term HD treatment were compared. The mean age was 55 ± 13 years and 10 (45%) of the patients were female. After long-term HD treatment, the isovolumic relaxation time was significantly decreased; however, the peak early (E) and late (A) diastolic mitral inflow velocities, E/A ratio, and deceleration time of E wave were not significantly different from the baseline measurements. Also, there was no significantly change in the early diastolic velocity (Ea) of the lateral mitral anulus and the E/Ea ratio. Pulmonary vein peak diastolic velocity, peak atrial reversal velocity, and peak atrial reversal velocity duration remained almost unchanged even though the pulmonary vein peak systolic velocity and the pulmonary vein peak systolic velocity/pulmonary vein peak diastolic velocity ratio were significantly lower after long-term HD treatment. In addition, LV systolic functions, LV diameters, LV mass index, left atrium size, and RV diastolic functions were not statistically different after long-term HD treatment. The myocardium is exposed to hemodynamic, metabolic, and neuro-humoral abnormalities during HD treatment; however, the long-term effects of HD on ventricular functions are not clearly known. The present study showed that the long-term effects of HD on LV and RV functions were insignificant in patients with end-stage renal disease. We have demonstrated that the LV and RV functions did not change significantly after long-term HD treatment. We suggest that this result may be due to regulated blood pressure levels of the patients, treatment of anemia and other metabolic disorders during the HD period and the prevention of weight gain and hypervolemia.     

Multiple metastatic infections in a hemodialysis patient with untunneled internal jugular catheter

We present an end‐stage renal disease patient on dialysis with fever. The primary source was right internal jugular vein catheter which had metastatic infections in the body probably via an arteriovenous communication in a cavity in left lung. Patient had right psoas muscle abscess and a left kidney abscess. An ¹⁸F‐fluorodeoxyglucose‐positron emission spectroscopy scan was done to find out left kidney abscess. A search of literature did not reveal many patients of psoas abscess secondary to infection of hemodialysis access.