- Email: [email protected]
Experience using central venous access for long-term hemodialysis
Experience Using Central Venous Access For Long-Term Hemodialysis A New Concept
Dee J. McGonigle, MD, Spokane, Washington Lawrence G. Schrock, MD, Spokane, Washington Robert 0. Hickman, MD, Seattle, Washington
Central venous catheter access for hemodialysis in the management of patients suffering from acute renal failure has been available and successfully used for a number of years [l-3]. However, this approach has not been utilized for long-term dialysis. We report our experience with the catheter in patients receiving long-term dialysis*. The Catheter and the Technique of Placement The catheter is made of Silastic@. The internal end has a single opening at the tip. The external end has a Luer-Lok connector incorporated into the Silastic tube. Near this latter end of the catheter is incorporated a Dacrona cuff to ultimately provide fibrotic anchorage of the catheter. The lumen has a volume of 1.8 ml, the internal diameter is 2.6 mm, and the external diameter is 4.8 mm. The catheter is placed in the central venous system and positioned in such a way that it irrigates to and fro quite freely. The catheter then ordinarily lies such that its tip is in the superior portion of the right atrium or the adjacent portion of the superior vena cava. A short incision is made over the sternocleidomastoid muscle. The clavicular and sternal heads are separated, exposing the internal jugular vein and a segment of this is mobilized. A stab wound is constructed on the anterior portion of the chest in an appropriate location. A tunnel connecting the exit site and the incision is created and the catheter is drawn through the exit site into the incision. It is placed through an opening on the anteriolateral wall of the internal jugular vein and positioned as just described. The venotomy is then From the Inland Empire Kidney Center, Sacred Heart Medical Center, Spokane, and the Department of Nephrology, University of Washington School of Medicine, Seattle, Washington. Bequests for reprints should be addressed to Dee J. McGonigle, MD. Medical Center Building, #334, Spokane, Washington 99204. Presented at the 69th Annual Meeting of the North Pacific Surgical Association. Spokane, Washington, November 12 and 13. 1962.
Volume 145, May 1963
closed with a previously placed purse-string suture of a knitted Dacron vascular suture material. The incisional wound is closed and a single suture is used to diminish the size of the exit site. The catheter is then filled with undiluted heparin. Our practice is to use 2.5 to 3 ml to be certain that we have amply flushed out the catheter and that its lumen contains pure heparin. It is then capped and clamped using a Quinton Beta clamp, and requires no further care until needed for dialysis. Dialysis is carried out in the usual fashion using the single-needle technique. Our dialysis unit uses the Drake-Willock model 4504SN blood pump. Results Our experience with all patients in whom we have used this catheter for central venous access from April 1981 through October 1982 is reported. Of the 50 patients, the catheter was used for long-term dialysis in 38: in 3 patients for more than 12 months, in 10 patients for 6 to 12 months, in 16 patients for 3 to 6 months, and in 9 patients for 1 to 3 months. The catheter was used in nine patients for acute renal failure. It was placed in an additional three patients for plasmapheresis. Of those 38 patients in whom the catheter was used for long-term hemodialysis, there were 3 patients in whom the catheter was used as their sole or primary access for a period in excess of 1 year. At present, the first patient in whom this catheter was implanted (in April 1981) continues to use it as her only dialysis * This report is a result of our experience wfth a new catheter developed by Robert 0. Hickman, MD and Ever-k&d Products, Medina. Washington. The report encompasses an experience combining 50 patients of the lnfand Empire Kidney Center in whom central venous catheter access was used. Forty-nine of these patients used the new catheter. The remaining patient, a 3 year old child, used a smaller catheter for a total of 7 months for her solitary access site for hemrxfialysis.
571
McGonigleet al
TABLE I
Observed Complications of Central Venous Access for Long-Term Hemodialysis
Complication Outflow obstruction Cuff erosion Infection Limited flow (200-225 ml/min) Subclavian vein thrombosis
Explanation and Number of Patients 8 replacements in 8 patients 4 replacements in 4 patients 2 documented patients, 3 undocumented patients 1 patient received inadequate hemodialysis 1 patient
access. The catheter was used for less than 1 month in the 12 patients in whom it was employed for acute renal failure and plasmapheresis. In most instances the catheter was removed when another manner of managing the renal failure was selected. Thus, the catheter survival figures do not truly reflect the maximal period they might have remained in place and in use. Technical catheter-related problems made it necessary to remove it on 12 occasions. Eight of these replacements occurred as a result of an outflow obstruction phenomenon which caused inadequate flow for dialysis. An additional four replacements were necessitated due to erosion of the Dacron cuff through the exit site. The outflow obstruction phenomenon is either due to coagulation products at the tip of the catheter which cause a ball-valve effect, or due to the position of the tip against the wall of the atrium or vena cava. We have never really identified by roentgenography or with irrigation of the catheter anything that strongly supports clotting as the primary factor. In many instances, repositioning of the patient has relieved this obstruction phenomenon, suggesting that positioning may be the main factor; however, evidence to document this one way or the other is inadequate at the present time. Additionally, 11 catheters were replaced because of modifications made in the management of the patients. Five of these replacements were in patients in whom septicemia had developed and in whom the catheter was suspected to be the source of infection. In two of these five patients the corresponding organism was cultured from unclotted blood present in the tip of the catheter. At no time did we identify vegetations or other evidence of products of coagulation adhering to the tip of the catheter. Four replacements involved a previous catheter that had been used successfully but was removed when the patient’s alternate access site for hemodialysis became available. In all instances these were arteriovenous fistulas that had suitably matured. Subsequently, problems developed with these fistulas that necessitated the use of an alternate dialysis access site. In each of these four patients, we were able to replace the catheter into the same right internal
572
jugular vein, usually several months after the initial catheter had been removed. The final two replacements were necessitated by improper clamping of the catheter which resulted in catheter damage and leakage. This occurred in the 3 year old child in whom the catheter ordinarily used for oncologic purposes was used for hemodialysis. Comments We think it is generally accepted that a wellfunctioning primary arteriovenous fistula of the Cimono-Brescia type [4] atriovenous fistula in the forearm is certainly “the gold-standard” for hemodialysis access; however, many times this choice is not available and so other approaches for hemodialysis need to be developed. This is particularly true in diabetic patients with renal failure in whom radical and ulnar arterial disease is common. Admittedly, the experience that we are reporting is based on an observation period that is relatively short (19 months) and therefore, it represents a preliminary experience with this access approach. We have, however, been sufficiently pleased with this relatively short experience to think that it would be worthwhile to share the results. Potential complications of this procedure are air embolism, thoracic duct injury, thrombosis of the catheter, pulmonary embolic, atrial, or caval perforation, and death; however, there were no deaths or major complications in our experience using this approach. Specifically, we have not encountered any atrial or caval wall injury. No patient has incurred an air embolus, an injury to the thoracic duct, a thrombosis of the catheter, or a pulmonary embolus. The major problem we have encountered with the catheter is one relating to outflow obstruction (Table I). We think that the problem with cuff erosion, which occurred in four patients, can be avoided or at least minimized with some modification in the construction of the catheter. In another patient dialysis was not adequate. He was a very large man with a large muscle mass. With the dialysis equipment that was being used the flow was limited to 200 to 225 ml/min with an 18 percent dead space which results in an effective flow of 164 to 185 ml/min. Infection was present in five patients, two of whom, as previously indicated, had positive cultures on specimens of unclotted blood present in the catheter. Since no vegetations were present on the tips of these catheters, one might question the necessity of removing the catheter to eradicate the septicemia. In one patient with an arteriovenous fistula in the ipsilateral right forearm, a subclavian vein thrombosis developed which produced some swelling. We believe this access method has a number of advantages (Table II). The most important is its availability for long-term dialysis with minimal care. It also provides immediate availability for hemodi-
The American Journal of Surgery
Long-Term Hemodialysis
alysis. The catheter does not require systemic anticoagulation, and it does not require continuous heparin infusion as necessitated by the central venous catheter in which side-holes exist. The access site permits the conservation of other access vessels that could be used for a fistula in the future. We believe the incidence of infection was acceptable. This approach significantly reduces the length of hospital stay for many patients in whom it is used. The access approach itself is economical, both from the standpoint of the materials that are used and the period of hospitalization required. It provides a backup site for early or late fistula problems, but avoids using vessels that would be better used for future arteriovenous fistula access. The catheter’s presence also does not preclude central venous access for other purposes, such as parenteral nutrition. Finally, although this experience focuses principally on patients who needed long-term hemodialysis, it does include a small group of patients in whom the catheter was used for acute renal failure and plasmapheresis. We have also recently used this catheter in one patient who required chemotherapy; the oncologist had indicated that a catheter should be available because the chemotherapy could induce an episode of acute renal failure. It is our belief that using central venous access with this catheter provides a significant new choice among the ways in which hemodialysis can be achieved for either short-or long-term purposes.
TABLE II
Advantages of Central Venous Access for Long-Term Hemodialysis
1. Available for long-term dialysis with minimal care Immediate availability for hemodialysis Systemic anticoagulation unnecessary Continuous heparin infusion of catheter unnecessary Spares access vessels Low incidence of infection Reduces length of hospital stay Economical access approach Provides back-up access site for early or late fistula problem 10. Presence of catheter does not preclude central venous access for other purposes 11. Minimal operation to secure access 12. May be used for other purposes, such as chemotherapy or plasmapheresis
2. 3. 4. 5. 6. 7. 8. 9.
so that the tip lies in the superior portion of the right atrium. After dialysis, I the catheter is filled with heparin. The catheter then requires no additional care between between hemodialysis sessions. We have reported an experience of 50 patients in whom this catheter has been used. The complications have been remarkably few, and none were serious or fatal. At present, the patient using the catheter for the longest period of time has had it in position for approximately 19 months. We believe this technique provides a significant new choice among the ways in which hemodialysis can be achieved for short- or long-term needs.
Summary
References
Central venous access for acute renal failure has been used for a number of years. The femoral vein and, more recently, the subclavian vein have been the routes of access. This technique has many advantages, however, it also has some significant limitations. We have recently been using a catheter for longas well as short-term hemodialysis. The catheter is placed by means of a short incision through an opening in the internal jugular vein, and maneuvered
1. Erben F. Kvasnicka J, Bastecky J, et al. Long-term experience with the technique of subclavian and femoral vein cannulization in hemodialysis. Artif Organs 1979;3:241-7. 2. Erben J, Kvasnicka J, Bastecky J, Vortel V. Experience with routine use of subclavian vein cannulation in hemodialysis. Proc fur Dial Transplant Assoc 1969;8:59-61. 3. FLynn CT. Treatment of acute renal failure. In: Flynn CT, ed. Acute renal failure. Lancaster, England: Medical and Technical Publishing, 1974:113-27. 4. Brescia MJ, Cimono JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arterlovenous fistula. N Engl J Med 1966;275:1089-92.
Volume 145,May 1983
573
Dee J. McGonigle, MD, Spokane, Washington Lawrence G. Schrock, MD, Spokane, Washington Robert 0. Hickman, MD, Seattle, Washington
Central venous catheter access for hemodialysis in the management of patients suffering from acute renal failure has been available and successfully used for a number of years [l-3]. However, this approach has not been utilized for long-term dialysis. We report our experience with the catheter in patients receiving long-term dialysis*. The Catheter and the Technique of Placement The catheter is made of Silastic@. The internal end has a single opening at the tip. The external end has a Luer-Lok connector incorporated into the Silastic tube. Near this latter end of the catheter is incorporated a Dacrona cuff to ultimately provide fibrotic anchorage of the catheter. The lumen has a volume of 1.8 ml, the internal diameter is 2.6 mm, and the external diameter is 4.8 mm. The catheter is placed in the central venous system and positioned in such a way that it irrigates to and fro quite freely. The catheter then ordinarily lies such that its tip is in the superior portion of the right atrium or the adjacent portion of the superior vena cava. A short incision is made over the sternocleidomastoid muscle. The clavicular and sternal heads are separated, exposing the internal jugular vein and a segment of this is mobilized. A stab wound is constructed on the anterior portion of the chest in an appropriate location. A tunnel connecting the exit site and the incision is created and the catheter is drawn through the exit site into the incision. It is placed through an opening on the anteriolateral wall of the internal jugular vein and positioned as just described. The venotomy is then From the Inland Empire Kidney Center, Sacred Heart Medical Center, Spokane, and the Department of Nephrology, University of Washington School of Medicine, Seattle, Washington. Bequests for reprints should be addressed to Dee J. McGonigle, MD. Medical Center Building, #334, Spokane, Washington 99204. Presented at the 69th Annual Meeting of the North Pacific Surgical Association. Spokane, Washington, November 12 and 13. 1962.
Volume 145, May 1963
closed with a previously placed purse-string suture of a knitted Dacron vascular suture material. The incisional wound is closed and a single suture is used to diminish the size of the exit site. The catheter is then filled with undiluted heparin. Our practice is to use 2.5 to 3 ml to be certain that we have amply flushed out the catheter and that its lumen contains pure heparin. It is then capped and clamped using a Quinton Beta clamp, and requires no further care until needed for dialysis. Dialysis is carried out in the usual fashion using the single-needle technique. Our dialysis unit uses the Drake-Willock model 4504SN blood pump. Results Our experience with all patients in whom we have used this catheter for central venous access from April 1981 through October 1982 is reported. Of the 50 patients, the catheter was used for long-term dialysis in 38: in 3 patients for more than 12 months, in 10 patients for 6 to 12 months, in 16 patients for 3 to 6 months, and in 9 patients for 1 to 3 months. The catheter was used in nine patients for acute renal failure. It was placed in an additional three patients for plasmapheresis. Of those 38 patients in whom the catheter was used for long-term hemodialysis, there were 3 patients in whom the catheter was used as their sole or primary access for a period in excess of 1 year. At present, the first patient in whom this catheter was implanted (in April 1981) continues to use it as her only dialysis * This report is a result of our experience wfth a new catheter developed by Robert 0. Hickman, MD and Ever-k&d Products, Medina. Washington. The report encompasses an experience combining 50 patients of the lnfand Empire Kidney Center in whom central venous catheter access was used. Forty-nine of these patients used the new catheter. The remaining patient, a 3 year old child, used a smaller catheter for a total of 7 months for her solitary access site for hemrxfialysis.
571
McGonigleet al
TABLE I
Observed Complications of Central Venous Access for Long-Term Hemodialysis
Complication Outflow obstruction Cuff erosion Infection Limited flow (200-225 ml/min) Subclavian vein thrombosis
Explanation and Number of Patients 8 replacements in 8 patients 4 replacements in 4 patients 2 documented patients, 3 undocumented patients 1 patient received inadequate hemodialysis 1 patient
access. The catheter was used for less than 1 month in the 12 patients in whom it was employed for acute renal failure and plasmapheresis. In most instances the catheter was removed when another manner of managing the renal failure was selected. Thus, the catheter survival figures do not truly reflect the maximal period they might have remained in place and in use. Technical catheter-related problems made it necessary to remove it on 12 occasions. Eight of these replacements occurred as a result of an outflow obstruction phenomenon which caused inadequate flow for dialysis. An additional four replacements were necessitated due to erosion of the Dacron cuff through the exit site. The outflow obstruction phenomenon is either due to coagulation products at the tip of the catheter which cause a ball-valve effect, or due to the position of the tip against the wall of the atrium or vena cava. We have never really identified by roentgenography or with irrigation of the catheter anything that strongly supports clotting as the primary factor. In many instances, repositioning of the patient has relieved this obstruction phenomenon, suggesting that positioning may be the main factor; however, evidence to document this one way or the other is inadequate at the present time. Additionally, 11 catheters were replaced because of modifications made in the management of the patients. Five of these replacements were in patients in whom septicemia had developed and in whom the catheter was suspected to be the source of infection. In two of these five patients the corresponding organism was cultured from unclotted blood present in the tip of the catheter. At no time did we identify vegetations or other evidence of products of coagulation adhering to the tip of the catheter. Four replacements involved a previous catheter that had been used successfully but was removed when the patient’s alternate access site for hemodialysis became available. In all instances these were arteriovenous fistulas that had suitably matured. Subsequently, problems developed with these fistulas that necessitated the use of an alternate dialysis access site. In each of these four patients, we were able to replace the catheter into the same right internal
572
jugular vein, usually several months after the initial catheter had been removed. The final two replacements were necessitated by improper clamping of the catheter which resulted in catheter damage and leakage. This occurred in the 3 year old child in whom the catheter ordinarily used for oncologic purposes was used for hemodialysis. Comments We think it is generally accepted that a wellfunctioning primary arteriovenous fistula of the Cimono-Brescia type [4] atriovenous fistula in the forearm is certainly “the gold-standard” for hemodialysis access; however, many times this choice is not available and so other approaches for hemodialysis need to be developed. This is particularly true in diabetic patients with renal failure in whom radical and ulnar arterial disease is common. Admittedly, the experience that we are reporting is based on an observation period that is relatively short (19 months) and therefore, it represents a preliminary experience with this access approach. We have, however, been sufficiently pleased with this relatively short experience to think that it would be worthwhile to share the results. Potential complications of this procedure are air embolism, thoracic duct injury, thrombosis of the catheter, pulmonary embolic, atrial, or caval perforation, and death; however, there were no deaths or major complications in our experience using this approach. Specifically, we have not encountered any atrial or caval wall injury. No patient has incurred an air embolus, an injury to the thoracic duct, a thrombosis of the catheter, or a pulmonary embolus. The major problem we have encountered with the catheter is one relating to outflow obstruction (Table I). We think that the problem with cuff erosion, which occurred in four patients, can be avoided or at least minimized with some modification in the construction of the catheter. In another patient dialysis was not adequate. He was a very large man with a large muscle mass. With the dialysis equipment that was being used the flow was limited to 200 to 225 ml/min with an 18 percent dead space which results in an effective flow of 164 to 185 ml/min. Infection was present in five patients, two of whom, as previously indicated, had positive cultures on specimens of unclotted blood present in the catheter. Since no vegetations were present on the tips of these catheters, one might question the necessity of removing the catheter to eradicate the septicemia. In one patient with an arteriovenous fistula in the ipsilateral right forearm, a subclavian vein thrombosis developed which produced some swelling. We believe this access method has a number of advantages (Table II). The most important is its availability for long-term dialysis with minimal care. It also provides immediate availability for hemodi-
The American Journal of Surgery
Long-Term Hemodialysis
alysis. The catheter does not require systemic anticoagulation, and it does not require continuous heparin infusion as necessitated by the central venous catheter in which side-holes exist. The access site permits the conservation of other access vessels that could be used for a fistula in the future. We believe the incidence of infection was acceptable. This approach significantly reduces the length of hospital stay for many patients in whom it is used. The access approach itself is economical, both from the standpoint of the materials that are used and the period of hospitalization required. It provides a backup site for early or late fistula problems, but avoids using vessels that would be better used for future arteriovenous fistula access. The catheter’s presence also does not preclude central venous access for other purposes, such as parenteral nutrition. Finally, although this experience focuses principally on patients who needed long-term hemodialysis, it does include a small group of patients in whom the catheter was used for acute renal failure and plasmapheresis. We have also recently used this catheter in one patient who required chemotherapy; the oncologist had indicated that a catheter should be available because the chemotherapy could induce an episode of acute renal failure. It is our belief that using central venous access with this catheter provides a significant new choice among the ways in which hemodialysis can be achieved for either short-or long-term purposes.
TABLE II
Advantages of Central Venous Access for Long-Term Hemodialysis
1. Available for long-term dialysis with minimal care Immediate availability for hemodialysis Systemic anticoagulation unnecessary Continuous heparin infusion of catheter unnecessary Spares access vessels Low incidence of infection Reduces length of hospital stay Economical access approach Provides back-up access site for early or late fistula problem 10. Presence of catheter does not preclude central venous access for other purposes 11. Minimal operation to secure access 12. May be used for other purposes, such as chemotherapy or plasmapheresis
2. 3. 4. 5. 6. 7. 8. 9.
so that the tip lies in the superior portion of the right atrium. After dialysis, I the catheter is filled with heparin. The catheter then requires no additional care between between hemodialysis sessions. We have reported an experience of 50 patients in whom this catheter has been used. The complications have been remarkably few, and none were serious or fatal. At present, the patient using the catheter for the longest period of time has had it in position for approximately 19 months. We believe this technique provides a significant new choice among the ways in which hemodialysis can be achieved for short- or long-term needs.
Summary
References
Central venous access for acute renal failure has been used for a number of years. The femoral vein and, more recently, the subclavian vein have been the routes of access. This technique has many advantages, however, it also has some significant limitations. We have recently been using a catheter for longas well as short-term hemodialysis. The catheter is placed by means of a short incision through an opening in the internal jugular vein, and maneuvered
1. Erben F. Kvasnicka J, Bastecky J, et al. Long-term experience with the technique of subclavian and femoral vein cannulization in hemodialysis. Artif Organs 1979;3:241-7. 2. Erben J, Kvasnicka J, Bastecky J, Vortel V. Experience with routine use of subclavian vein cannulation in hemodialysis. Proc fur Dial Transplant Assoc 1969;8:59-61. 3. FLynn CT. Treatment of acute renal failure. In: Flynn CT, ed. Acute renal failure. Lancaster, England: Medical and Technical Publishing, 1974:113-27. 4. Brescia MJ, Cimono JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arterlovenous fistula. N Engl J Med 1966;275:1089-92.
Volume 145,May 1983
573