The Journal of Vascular Access

Infectious complications associated with central venous catheters (CVCs) are a major source of morbidity and mortality among hemodialysis (HD) patients. This review aims to discuss prevention, diagnosis criteria and management of CVC-related infections in HD patients.

We searched Medline for articles published in the last 10 years, with the keywords “catheter,” “hemodialysis,” “infection,” “treatment,” “diagnosis,” “prophylaxis” and “adults.” Only English language articles were reviewed. We reviewed prophylaxis and surveillance protocols, diagnosis criteria, including new molecular tools, and the management of catheter-related infections, including antibiotic regimen, empiric and according to causal agents, lock therapy, catheter salvage or removal choice and treatment of complications.

To prevent infectious complications, first of all we need to avoid using catheters. If we need CVC, adoption of prophylaxis and surveillance protocols, and antibiotic ointment at the exit site reduce infectious complications. The diagnosis of CVC-related infections should be made with drainage and/or blood cultures. Empiric systemic antibiotics should cover Gram-positive and -negative microorganisms, and final regimen should be based on culture results. In selected cases, salvage of site, by CVC exchange over wire, or salvage of catheter, using antibiotic lock, under the cover of systemic antibiotics, could be attempted.

The best approach to prevent CVC-related infection would be to avoid the use of CVC. However, in patients for whom it is impossible, the adoption of adequate prophylaxis protocols, early diagnosis and effective treatment of infectious complications are essential to improve outcomes.

There is ongoing debate about the use of transposed basilic vein (TBV) fistula and the choice between it and prosthetic arteriovenous graft (AVG). This paper reviews the available literature relating to TBV fistula in terms of surgical technique, patency rates, complications, access survival and compares it with prosthetic AVG for hemodialysis (HD).

Review of English language publications on TBV during the last two decades.

The rate of fistula maturation was higher in the two-stage group, although the mean diameter of the basilic vein was smaller. Dialysis via central venous catheters at time of surgery was most prevalent in patients undergoing staged procedures—14% in one-stage TBV and 43% in two-stage TBV. Several authors report 1-year cumulative patency rate of 47% to 96% and 59% to 90% for TBV and AVG, respectively. TBV provides a more cost-effective option and should be considered the next choice when primary autogenous fistulae are not possible, whereas AVGs are easier to create, can be punctured earlier and have a greater reintervention rate if the access fails.

This analysis shows that TBV has several advantages over AVG and provides a valuable access for HD but raises the need for a comparative trial between TBV and the newer generation AVGs. There is no clear superiority of the one-stage over the two-stage procedure.

Superficial veins in the upper arm differ according to their relationship to the superficial fascia. We investigated the echographic landmark of the cephalic vein (CV) to correctly distinguish it from the collateral accessory vein (CAV) before hemodialysis angioaccess creation.

Twenty consecutive patients were evaluated by ultrasonographic scan. The echographic features of CV and CAV together with their relationship were described.

Ninety-five percent of patients presented both CV and CAV (75% CAV laterally located, 25% medially located). CV and CAV diameters were 2.9 (±0.65) and 2.0 (±0.70), respectively.

CV differs from CAV for its anatomic location at forearm. Such a difference is clearly evident under ultrasound examination, despite any recommendation in ultrasound guidelines. Whether the exclusive use of CV for angioaccess creation can lead to a better outcome will be ascertained by further studies.

Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related bloodstream infections (CRBSIs), but may be associated with the development of resistant bacteria. Ethanol-based catheter locks may provide a better alternative; however, there are limited data on the long-term integrity of dialysis catheters exposed to ethanol.

We performed in vitro testing of two types of hemodialysis catheters—silicone (SLC) and carbothane (CBT) based—with a 70% ethanol lock (EL) versus heparin lock (HL) for 26 weeks. Lock solutions were changed thrice weekly to mimic a conventional hemodialysis schedule. We tested mechanical properties of the catheters at 0, 13 and 26 weeks by examining stress/strain relationships (SS400%) and modulus of elasticity (ME). Electron microscopy was performed to examine catheter ultrastructure at 0 and 26 weeks.

Catheter integrity for HL versus EL in SLC (SS400%: 4.5 vs. 4.5 MPa, p = NS; ME: 4.6 vs. 4.7 MPa, p = NS) or CBT-based catheters (SS400%: 7.6 vs. 8.9 MPa, p = NS; ME: 9.6 vs. 12.2 MPa, p = NS) were all similar at 13 and 26 weeks. Scanning electron microscopy revealed no structural changes in the central and luminal wall internal surfaces of EL- versus HL-treated catheters.

There were no significant differences in catheter integrity between SLC or CBT catheters exposed to a 70% EL for 26 weeks. Given its low cost, potential to avoid antibiotic resistance and structural integrity after 6 months of high-dose ethanol, ELs should be studied prospectively against antibiotic locks to assess the efficacy and safety in hemodialysis patients.

Arteriovenous fistula (AVF) surgery affords an excellent opportunity for junior surgeons to learn key vascular techniques. However, implementation of the European Working Time Directive has reduced trainee surgeon's working hours, leading to concerns regarding a possible effect on patient outcomes. Given high early postoperative failure rates and limited AVF sites, it has been proposed that AVF surgery should be performed by Consultants and senior trainees only. This prospective observational study aimed to establish how seniority impacts upon AVF surgery outcomes.

All patients referred for AVF formation were considered for inclusion. Demographic data, comorbidities, medications and previous access history were recorded. Surgery was performed by a Consultant Vascular Surgeon or a junior surgeon. Clinical review was undertaken 30 days postoperatively to assess patency and record any complications.

Seventy-seven patients underwent AVF formation. About 63.6% procedures were carried out by a junior surgeon. The groups were well matched for demographics, comorbidities and medications. There was no difference in anatomical site of formation between groups operated on by consultant versus juniors (p = 0.373). More general anaesthetic procedures were undertaken by Consultant surgeons, for example basilic vein transposition when compared with juniors (p = 0.039). There was no significant difference in terms of early AVF failure (p = 0.710), complication rates (p = 0.139) or requirement for re-intervention (p = 0.256) between the groups. Patency rates were also equivocal between the groups.

The seniority of the operating surgeon does not appear to impact on outcomes following AVF formation. A greater proportion of general anaesthetic cases were undertaken by a Consultant, which may introduce bias. Junior surgeons with appropriate training and modest experience can perform access surgery without detriment to patients patient detriment.

Vascular access (VA) devices may contribute to chronic inflammation in hemodialysis (HD). Pentraxin 3 (PTX3) is a recently discovered acute phase protein that responds more rapidly than other inflammatory markers. This study compared PTX3 and other markers between HD patients and healthy controls.

The study population included 30 patients with tunneled permanent catheter (TPC), 30 patients with arteriovenous fistula (AVF) and 30 healthy controls. Hemogram, biochemical assays, ferritin, high sensitive C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α) and PTX3 were evaluated in all groups.

PTX levels were highest in HD patients with TPC, intermediated in HD patients with AVF and lowest in healthy controls (5.2 + 2.4 vs. 3.1 + 1.3 vs. 1.8 + 0.7, p<0.001 for all comparisons). PTX3 levels correlated strongly to hs-CRP (r = 0.857) and moderately to TNF-α, NLR, ferritin and total neutrophil count. PTX3 and albumin levels had a negative correlation. PTX3 levels were higher in patients with 8 months of TPC than those with 7 months or less.

PTX3 levels are significantly elevated in all patients on HD, but presence and extended duration of TPC are associated with incrementally higher levels of PTX3 and other inflammatory markers. PTX3 and NLR may be useful in assessing chronic inflammatory states in HD.

Even though early transplantation is still the first-line therapy in paediatric patients with end-stage renal disease (ESRD), up to 30% of these patients still require haemodialysis (HD). Creating an arteriovenous fistula (AVF) is quite challenging, particularly in children, leading to disproportional use of catheters. In this paper, we describe our experience in the creation of AVF with currently no in-dwelling catheters in children and adolescents on HD.

From January 2009 to December 2013, there were 34 patients rated as unfit for transplantation for at least the next 6 months or who had already been on HD through a central venous catheter (CVC). Three patients aged between 12 months and 3 years and weighing 9-12 kg were not suitable for AVF. Finally 31 patients, from 6 to 19 years of age with a mean weight of 43.3 ± 14.5 kg (19-80 kg), were assigned to the alternative of AVF.

During the above-mentioned time period, 31 patients were provided with 32 AVFs; 26 received a distal radiocephalic fistula, five a Gracz-type fistula and one a brachio-basilic fistula. All but two fistulae matured primarily, within an average time of 45 (range: 16-191) days until the first dialysis. The fistula's 1-year primary and primary assisted patency rates were 78% and 94%, respectively.

The creation of a native vascular access is an effective and durable procedure in paediatric and adolescent patients. It reduces using of CVCs and is appropriate both for long-term treatment and as a bridging procedure until renal transplantation.

To assess the effect of the Medtronic paclitaxel drug-eluting balloon (DEB) on re-intervention to in-stent stenoses in autogenous dialysis arteriovenous fistulas (AVFs).

AVF is the optimum haemodialysis access. The commonest problem is stenosis, preventing maturation, causing inadequate dialysis or precipitating occlusion. Conventional angioplasty has a high recurrence rate. Successful drug elution in the coronary circulation led us to use DEBs in recurrent AVF stenoses since 2010.

This is a retrospective study, based on prospective audit data, using DEBs on recurrent in-stent stenotic lesions in the AVF circuit of our haemodialysis population. To analyse the effect of DEBs on re-intervention, we created two Kaplan–Meier curves. The first curve compares the last “disease-free-interval” pre-DEB intervention to the first “disease-free interval” post-DEB, giving us “re-intervention-free percentage at 12 months” pre- and post-DEB. The second curve takes into account the multiple pre- and post-DEB interventions to the index lesion, and uses a marginal proportional hazards model to estimate the hazard ratio for “DEBpresent vs. DEBabsent”.

From 1 September 2010 to 1 December 2013, we treated 625 AVF stenoses with endovascular techniques. In 86 of these stenoses, DEBs were used. Of the 86 DEB interventions, 37 were included for this study, 49 were excluded. In the study group, there was a significant difference in “re-intervention-free percentage at 12 months” before and after DEB: 19% vs. 69%. The hazard ratio for “DEBpresent” vs. “DEBabsent” was 0.23 (95% CI 0.14 to 0.36, p<0.001).

This retrospective study suggests that DEBs significantly reduce re-intervention on recurrent in-stent AVF stenoses.

The purpose of this study is to verify as early as possible the correct positioning of the peripherally inserted central catheter (PICC) tip in order to reduce complications due to possible malpositioning. The ECG-guided technique proved to be reliable, easy to carry out, straightforward, low-cost and allows us to recognize an incorrect or a suboptimal positioning throughout the procedure. The purpose of this study is to compare two methods used during the PICC insertion so as to prevent catheter malpositioning; the first study estimates the catheter length by the landmark method (based on cutaneous anatomical landmarks, CALs) with the addition of the postprocedural verification of tip location by chest X-Ray (CxR), whereas the second method of intraprocedural tip location is based on the observation of the morphological variations of the P wave (ECG-guided technique) with the addition of the postprocedural verification by CxR.

From 2010 to 2012, 90 PICCs were positioned, 48 using the anatomical landmarks and 42 using the ECG technique.

Twenty-five percent of the catheters positioned with the anatomical landmark technique did not reach the correct position of the tip in SVC; of these, 6.25% were placed in an aberrant position and others in a suboptimal position.

Of the 42 PICCs positioned with the ECG technique, only in three cases (equal to 7.14%), a suboptimal position of the tip was observed, whereas there was no case of aberrant positioning.

The ECG technique represents an accurate, low-cost and safe technique to verify the correct positioning of the tip. The use of the ECG allowed a more correct positioning in terms of catheter tip-carina distance and catheter tip-tracheobronchial angle, and in no patient was it necessary to place a catheter again.

In this study, we analyzed the thin-section pulmonary computed tomographic (CT) angiogram scans of pediatric patients to determine the normative length of superior vena cava (SVC) and the distance between carina and cephalad of SVC or cavocatrial junction.

Consecutive child patients, under 13 years of age in whom the central catheters were inserted under ultrasound guidance from December 2004 to April 2005 were evaluated retrospectively.

In the 14 cases, the mean age was 7.2 ± 4.21 years. The mean length and diameter of the SVC in the pediatric patients were 45.6 ± 23.03 and 13.7 ± 3.62 mm, respectively. The distance from the carina to the cavoatrial junction was 22.0 ± 9.98 mm. The mean distance from the superior margin of the SVC to the carina was 23.7 ± 16.70 mm. The mean distance from the carina to the catheter tip was 38.9 ± 18.60 mm. In no case was the cavoatrial junction cephalad with respect to the carina. Carina to cavoatrial junction junction was significantly associated with age, height, and weight, respecitively (r = 0.750; p = 0.005, r = 0.763; p = 0.004; r = 0.777; p = 0.003).

The carina is a good landmark for the upper border of the cavoatrial junction. Length of carina to cavoaterial juction was associated with age. The rates of malposition and re-intervention and the patient's exposure to radiation can be reduced by using ultrasound during the catheter insertion.

End-stage renal disease has a high cost burden to the public. Surgical procedures such as hemodialysis (HD) access creation and transplant have high rates of vascular access complications, infections, and readmissions. Cost of HD care has increased to $19.4 billion in 2011; 30-day readmission rates are as high as 36%. There is a continuing need to preserve the route of vascular access for patients, given frequent thrombosis at a rate of 0.8 episodes per patient year at risk. We describe a novel method of thrombolysis using ultrasound-accelerated thrombolysis (USAT) technology for large caliber clotted vascular access.

Consecutive patients with thrombosis of their dialysis vascular access that involved large caliber conduits or those that extended into large and/or central veins (axillary, subclavian, innominate) were chosen to undergo catheter-directed thrombolysis with the EKOS EndoWave system.

Twelve patients underwent a total of 14 procedures. Complete thrombolysis was achieved after seven procedures at the time of repeat fistulogram. Four patients required percutaneous balloon thombectomy to resolve remaining clot at the arterial anastomosis, and three required rheolytic thrombectomy in the aneurysmal segment of the arteriovenous fistula (AVF). All patients had an associated procedure (percutaneous transluminal angioplasty and/or stent placement) to treat the cause of thrombosis.

USAT is a safe and effective percutaneous method of thrombolysis in patients who have large clot burden.

This pre-trial qualitative research study was carried out to explore patient and clinical staff attitudes to central venous access devices (CVADs). In addition, views about participation in a randomised controlled trial (RCT) were explored with the aim of maximising recruitment to an imminent RCT of three CVADs.

Three patient focus groups (each comprising three patients) and 23 interviews with clinical staff were conducted. Interviews and focus group discussions were digitally recorded, transcribed verbatim, anonymised, uploaded to the QSR NVivo10 qualitative software programme and thematically analysed.

Analysis of focus group interviews revealed the added challenges that a CVAD poses to patients with cancer. Four key themes emerged: continuity of daily life, pain and discomfort, stigma (a mark of disgrace associated with certain conditions) and self-preservation. The findings show the impact of a CVAD on patients’ ability to manage their condition. Clinical staff interviews highlighted several potential barriers to recruitment; a lack of equipoise (genuine clinical uncertainty as to which intervention is the most beneficial), concerns about the logistics of device insertion and a perceived requirement for education and training.

This qualitative study raises awareness of key areas of concern to patients who need a CVAD for chemotherapy delivery. It was identified that there is a need for clearer patient information around CVADs. Additionally it allows investigators to identify barriers to recruitment in a timely manner in order to minimise the potential for conflict between the roles of carer and researcher and consequently, maximise recruitment to the RCT.

There is an ongoing struggle to understand the potential economic benefits that radial access may offer. Cost savings are thought to primarily occur after the procedure. The aim of our study was to analyze cath lab expenses resulting from transradial (TRA) and transfemoral approaches (TFA).

A total of n = 1890 matched pairs of patients were analyzed. A traditional Judkins catheter strategy was pursued for coronary angiography. Three large databases were merged to collect and compare procedural data as material, medication costs and fluoroscopy time.

Compared to TFA diagnostic catheterization from TRA was associated with significantly lower procedural costs (€181.0 versus €167.5; p<0.001). Extra costs in TFA were primarily produced by frequent use of vascular closure devices (VCDs) in 86% of patients. However, the potential saving amount related to VCD use was only partly realized due to the higher number of extra catheters (0.53 ± 0.9 versus 0.23 ± 0.6; p<0.001) and hydrophilic guidewires (0.088 ± 0.3 versus 0.014 ± 0.1; p<0.001) used in TRA. Weak correlations were observed between the total number of cases and fluoroscopy time (r = −0.13; p<0.001) as well as material costs (r = 0.31; p<0.001).

Significant cost savings can be realized by TRA at the procedural level even when adhering to a conventional Judkins catheter strategy. Hydrophilic guidewires and additional catheters are the main cost drivers in TRA. In contrast to fluoroscopy time material costs steadily increase during the early stage of the TRA learning curve.

The objective of this study was to investigate variables that may affect sonographic cannulation of great saphenous vein and determine the ideal location for ultrasound-guided saphenous vein cannulation in adult emergency department (ED) patients.

A prospective observational study at an academic ED. The great saphenous vein was identified in adult subjects at three distinct sites after placing the tourniquet proximal to the vein: the ankle, mid-calf, and below the knee using a 10-5 MHz linear transducer. The depth of the saphenous vein from the skin surface and its diameter were measured in supine and reverse trendelenburg positions in both extremities.

A total of 60 subjects (male 30, female 30) were enrolled in the study. The median age of the patients was 50.5 years [interquartile range (IQR) 34.5-67.5]. The median body mass index (BMI) was 27.3 (IQR, 24.2-31.8). The great saphenous vein was significantly superficial in location at the ankle level compared with the calf (p<0.001), knee (p<0.001), and left side compared with the right (p<0.001). The subject position was not significantly related to saphenous vein depth (p = 0.68). The saphenous vein diameter was significantly larger in the left lower extremity than the right side (p = 0.007), and at the ankle level compared with the calf (p<0.001) and knee (p<0.001). The diameter of the vein increased significantly when patient's position changed from supine to reverse Trendelenburg (p<0.001).

Our results support ultrasound evaluation of the course of great saphenous vein from the ankle to the knee for the selection of appropriate venipuncture site and cannulation.

This paper describes a simple and inexpensive method to make high-fidelity simulators for use in ultrasound-guided vascular access teaching. The phantoms can be created to reflect the ultrasound appearance and feel of central or peripheral arteries and veins. Different clinical states such as hypovolaemia may be readily displayed using the phantoms.

The article and associated videos describe the production, appearance and use of phantoms for central vascular access, for peripheral venous access and for peripheral arterial access. Key ingredients are readily accessible and include chicken breasts, modelling balloons and thin walled latex or silicone tubing.

The phantoms are easily and rapidly constructed and may be used repeatedly in a training session. As the needle passes through the phantom and vessel wall, the ultrasound appearance and tactile sensation is very similar to that of human tissue and vessels.

Using this method, simple and inexpensive phantoms can be created. These are ideal for use in training for ultrasound-guided vascular access. Links to videos describing the phantom construction process, their appearance and the teaching techniques utilised by the authors are found in the text.

The purpose of this study is to report a case of Hemodialysis Reliable Outflow (HeRO) device malfunction in the subclavian position secondary to costoclavicular impingement.

The electronic medical record was reviewed for the patient in question and pertinent imaging was collected and photographs were taken with the patient's consent. The patient presented with signs of outflow obstruction after a period of HeRO venous outflow component function. The outflow component was found to be crushed between the first rib and the clavicle at the costoclavicular junction.

This case suggests that costoclavicular impingement should be considered as a mode of outflow failure with the HeRO outflow component in the subclavian position. Other central venous access points should be considered first, and the central veins accessed through the lower extremities are possible alternatives if this failure mode was to arise. First rib resection would also be a viable strategy to relieve impingement at this site.

Central venous catheters are often required in oncologic patients for long-term safe administration of chemotherapeutic agents, antibiotics, and parenteral nutrition. Rupture of these devices and intracardiac migration is a rare complication.

We report one spontaneous rupture and embolization of a totally implantable vascular access device (TIVAD) in an asymptomatic patient.

A 50-year-old woman received a TIVAD silicone catheter 8 FR for adjuvant chemotherapy. After 3 years of port time in situ, during a follow-up control, a catheter malfunction was found and radiologic investigations showed a rupture and migration of the catheter to the right ventricle. The attempt to remove the fragment under fluoroscopic control using the femoral route was unsuccessful. We did not try a surgical approach because of the complete absence of symptomatology and hemodynamic impairment.

The catheter rupture and intracardiac embolization is a rare complication associated with totally implantable or tunneled central venous catheters. When such an event happens, the patient should be managed by expert hemodynamists or interventional radiologists making an effort to remove the fragment without surgical measures. When the intravascular percutaneous route fails, the possibility to leave the fragmented catheter in heart chambers should be evaluated, being surgery questionable in asymptomatic patients.

Superior vena cava (SVC) syndrome owing to benign etiology is rare and endovascular techniques have been advocated as the treatment of choice. We report a case of endovascular revascularization of a port catheter-associated complete occlusion of the SVC with reversed flow in the azygos vein.

In this setting using a sheath in combination with its dilatator to pass the occlusion of the SVC after neither a diagnostic catheter nor a PTA balloon would pass the lesion may be a valid option. A dual venous approach was established using the right common femoral vein and an indwelling port catheter in the right cephalic vein to dilate and stent the lesion. Finally, a port may be implanted after the revascularization had been successful.

Passage through the port catheter-associated occlusion of the SVC was only possible by use of the sheath in combination with its dilatator. A dual venous access by the femoral approach and the indwelling central catheter is helpful in treating a SVC occlusion.

Long-term central venous catheters may cause SVC syndrome, especially with a catheter tip located too far cranially. An endovascular revascularization of a complete occlusion of the SVC represents the therapy of choice.