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Acute hemodialysis vascular access

Author Section Editor Deputy Editor
Steve J Schwab, MD Jeffrey S Berns, MD Theodore W Post, MD

Last literature review version 18.2: May 2010 | This topic last updated: March 24, 2010
INTRODUCTION — Hemodialysis requires access to blood vessels capable of providing rapid
extracorporeal blood flow. Acute hemodialysis access should be easy to insert, available for
immediate use, and trouble-free in the short-term.

Two currently available classes of device best meet these criteria:

Acute dialysis catheters

Cuffed, tunneled dialysis catheters

The basic aspects of these catheters and the potential complications that can occur will be
reviewed here. The catheters used for chronic vascular access are discussed separately. (See
"Chronic hemodialysis vascular access: Types and placement".)

ACUTE HEMODIALYSIS CATHETERS — Double-lumen, non-cuffed, non-tunneled hemodialysis

catheters have become the preferred method for obtaining acute hemodialysis vascular access.
They are available from many manufacturers and are composed of many different plastics. The
current polymers are rigid at room temperature to facilitate insertion but soften at body
temperature to minimize vessel trauma and blood vessel laceration. The proximal and distal
lumens should be separated by at least 2 cm to minimize recirculation. The continuous blood path
made possible by the dual lumen design allows rapid blood flows and the use of a no
heparin hemodialysis technique. (See "Hemodialysis anticoagulation".) These catheters come in a
series of internal configurations including double D, Coaxial, and shotgun.

The double lumen catheters can be inserted into the jugular, subclavian, and femoral veins [1,2].
They are inserted by a modified Seldinger guide wire technique, thereby minimizing the
insertion-induced hole in the blood vessel wall. These non-cuffed catheters are suitable for
insertion at the bedside and do not require fluoroscopy for placement.

The 2006 National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) guidelines
recommend, after internal jugular or subclavian vein insertion, identifying radiographically any
potential complications and confirming tip placement prior to either anticoagulation or catheter
use [3]. These guidelines also recommend ultrasound vessel identification prior to insertion. In
general, subclavian insertion sites should be avoided because of the risk of subclavian vein
stenosis and thrombosis.

Shorter catheters are usually preferred (9 to 13 cm) so that the tip of these catheters does not
extend beyond the superior vena cava. Right atrial placement of this type of catheter should in
general be avoided due to the more rigid plastic that is used in their construction.

The maximum blood flow with this class of catheters is usually blood pump speeds of 300
mL/min, with an actual blood flow of 250 mL/min or less. Blood flows are consistently higher with
right-sided internal jugular catheters compared with left-sided catheters [4]; this is due in part to
the required bend with left-sided catheters.

Short femoral catheters (9 to 13 cm) have higher recirculation rates than longer femoral
catheters [5]. To minimize recirculation, catheters of at least 18 cm in length are recommended

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for femoral insertion in most average-sized adults.

Ease of insertion and suitability for immediate use are the essential hallmarks of this class of
hemodialysis catheters. The routine use-life of these catheters varies by site of insertion. The
limits on use-life are caused by infection. In general, internal jugular catheters are suitable for 2
to 3 weeks of use, while femoral catheters are usually used for a single treatment (ambulatory
patients) or for 3 to 7 days in bed bound patients [6].

To facilitate blood drawing and diminish the need for additional catheters, an acute triple-lumen
dialysis catheter has been developed. The third lumen is available for blood drawing and the
intravenous administration of drugs and fluid. In a multicenter, prospective study, blood flow
rates and infectious complications were similar with the triple-lumen catheter versus that
observed with a marked dual-lumen catheter [7]. Despite the results of this trial, we do not use
these catheters because of the possibility that non-dialysis personnel will access the catheter via
the third lumen (eg, infusion lumen).

CUFFED, TUNNELED DIALYSIS CATHETERS — Double lumen silastic/silicone and other soft
polymer catheters with felt cuffs and two distinct single lumen catheter pairs are primarily used
for intermediate duration vascular access [8]. These central venous catheters can be inserted into
the subclavian, internal jugular, external jugular, or femoral position, and can be used for six
months and longer because of a decreased incidence of infection [9-11]. The major disadvantage
is that fluoroscopy is typically required during insertion to assure ideal tip location, and some
catheters must be inserted surgically.

CUFFED TUNNELED CATHETER CLASSES — Cuffed, tunneled dialysis catheters are principally
constructed of silastic/silicone and other soft flexible polymers, which are less thrombogenic than
polymers used in acute catheters. Since these catheters are very flexible and are of larger
diameter than acute catheters, a peel-away sheath and a larger hole in the vessel is required for
insertion. Successful techniques for percutaneous, nonsurgical insertion of these tunneled cuffed
catheters, including internal jugular insertions, are now standard practice [12,13]. They come in a
variety of internal configurations including double D, coaxial, shotgun and others. In addition, two
separate distinct catheters are sometimes used.

Cuffed, tunneled dialysis catheters require fluoroscopy for insertion due to their larger size and to
the confirmation of tip location. Many allow right atrial tip location based on their soft polymer
construction. Real time ultrasound guidance is recommended for their insertion. Although these
catheters are most commonly placed in the internal jugular vein and less commonly the
subclavian vein, femoral vein insertion may be necessary, particularly in the setting of bilateral
occlusion of central veins [14,15].

These catheters allow faster blood flows than acute catheters, due to the catheter tip location in
the right atrium and the larger internal diameter lumen. Usually blood pump speeds of 400
mL/min are common for the newer generation of catheters. However, much caution is warranted
in the interpretation of these results (see below). Actual blood flow rates in catheters are almost
always lower than those reported by the blood pump because of tubing deformation due to
elevated inflow negative pressures. In our experience, we have found that catheter blood pump
flows are usually 20 to 30 percent lower than what is recorded by the blood pump when negative
inflow pressure exceeds 200 mmHg.

Double lumen cuffed tunneled catheters — Double lumen catheters vary in internal
configuration and are assembled and marketed by multiple manufacturers. The Prototype was the
Perm Cath TM (Quinton Instrument Co) with a shotgun internal configuration. Others use a
double D internal design (Vas CathTM). All are of sufficient lumen size (diameter) to allow
significantly faster blood flow than acute catheters. These catheters have two lumens with the tip
separated by at least 2 cm to minimize recirculation.

Tesio and ASH catheters — The Tesio catheter is another advancement in catheter design
meant to provide the higher blood flows required for high efficiency dialysis [16]. In this

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procedure, twin 10-French silicone rubber catheters are placed (generally in the internal jugular
position) in the same vessel. The catheter that serves as the venous or blood return port is
inserted 4 cm deeper to prevent recirculation.

The ASH catheter has the two lumens bonded proximally and separated distally; this allows
insertion through a single venipuncture while providing the advantages of the separated tip
design [17]. The OptiFlow catheter is identical to the ASH catheter except that it employs a
conventional step tip.

Comparison of cuffed tunneled catheter efficacy — Compared to matched controls using

fistulas or arteriovenous grafts, most patients required an increase in treatment time of
approximately 20 percent to achieve equivalent urea removal. Thus, as predicted by actual blood
flow (measured by ultrasound dilution). a 20 to 30 percent decrement in flow based upon blood
pump reading should be expected when a catheter is substituted for an AV access.

Cuffed tunneled catheter survival — The overall survival of these catheters is highly variable.
One report found a 74 percent 1-year and a 43 percent 2-year catheter survival [18]. A second
large study of 623 Tesio catheters reported that 78 and 44 percent of catheters survived to one
and three years post-placement, respectively [19]. We found a 50 percent 1-year patency rate
when used as permanent access [20]. Almost all catheter losses were due to bacteremia [20]. We
believe the weight of evidence supports an average one-year-use life.

COMPLICATIONS WITH ACUTE, DOUBLE LUMEN CATHETERS — There are a variety of

complications associated with the acute noncuffed double lumen catheters, including those
associated with insertion, infection, and thrombosis.

Insertion complications — The severity and likelihood of insertion complications varies with the
site of insertion. The complication rate is lowest in the femoral position, and complications when
they occur tend to be minor. The primary problem is perforation of the femoral artery. Bleeding
usually resolves with 10 to 15 minutes of direct digital compression. Large femoral or
retroperitoneal hematomas occur occasionally and usually result from penetration of both walls of
the femoral vein [21].

Subclavian insertion complications are potentially more serious.

Overinsertion of guidewires can occasionally lead to transient atrial or even ventricular

arrhythmias. The vast majority of these are transient and hemodynamically insignificant [22].

Penetration or cannulation of the subclavian artery can lead to hemothorax, in some cases
requiring a thoracotomy tube. Cases of pericardial rupture and tamponade also have been
described [23-25].

The incidence of pneumothorax varies from less than 1 percent to more than 10 percent of
insertions, reflecting the skill and experience of the physician. The risk of pneumothorax is
greater from the left than right side, since the pleura and dome of the lung are higher on the left
[22].

Given the risk of catheter-induced subclavian stenosis and subsequent loss of the ipsilateral arm
for future hemodialysis access (see below), more centers are relying on internal jugular vein
insertion, particularly the right internal jugular vein. Internal jugular insertions carry a higher
likelihood of carotid artery penetration, but a lower risk of pneumothorax (0.1 percent). The
location of the catheter in subclavian and internal jugular insertion should always be confirmed by
x-ray prior to the initiation of hemodialysis or the administration of anticoagulants.

Hand-held portable ultrasound devices may minimize insertion complications at both internal
jugular and femoral sites. These devices permit ultrasound-guided vein cannulation with a lesser
likelihood of arterial puncture or pneumothorax [26-30]. One prospective study of 190 patients
undergoing percutaneous insertion of a temporary catheter into the internal jugular vein
compared the complication rates among those using ultrasound-guided placement (104 patients)

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to those using landmark-guided insertion (86 patients) [28]. Significantly superior results were
obtained with ultrasound guidance with respect to overall success rate (99 versus 86 percent),
success rate of the first attempt (81 versus 35 percent), puncture trials (1.39 versus 2.58), and
traumatic complication rate (1.9 versus 11.6 percent). The use of such devices may also minimize
the complication rate and maximize the success rate of clinicians inexperienced with placement of
these catheters [29,30].

Catheter thrombosis — Both prevention and treatment of catheter thrombosis are important
clinical issues.

Prevention — To prevent thrombus formation, both lumens of the double lumen catheter are
instilled with heparin following hemodialysis. The amount injected should only fill the catheter
lumen to minimize systemic heparinization. The length of the catheters determines the
appropriate heparin dose. Heparin of either 1 mL = 1000 Units, 1 mL= 5,000 Units, or 1 mL =
10,000 Units can be used. In our experience, the two higher doses are much more effective in
preventing catheter thrombosis. However, the risk of inadvertent anticoagulation has led many
centers to abandon the 1:10,000 concentration.

There is anecdotal evidence suggesting that chronic anticoagulation with warfarin or low
molecular weight heparin may also prevent catheter thrombus, due to either intraluminal clot or
fibrin sheath formation [8]. Well-controlled trials investigating the effectiveness of partial or
systemic anticoagulation are currently underway.

Limited data also suggest that the instillation of alteplase (recombinant tissue-type plasminogen
activator, rtPA), rather than heparin, may improve catheter blood flow and decrease the incidence
of catheter clotting. In a prospective randomized crossover study of 12 patients, the
administration of alteplase (2 mg injected into each lumen) was associated with significantly
higher blood flow rates and better arterial and venous pressures compared with heparin [31]. In
addition, no episode of clotting occurred with alteplase, while 20 percent of patients experienced
clotting with heparin.

Treatment — Lytic agents such as urokinase and alteplase are effective. (See "Thrombosis
associated with chronic hemodialysis vascular access: Catheters".) Alteplase has been approved
for catheter use in the United States. Alteplase has therefore been utilized to treat thrombosis,
with effectiveness rates comparable to that observed with urokinase. As an example, 2 mg of
alteplase was placed into each port of 22 nonfunctional vascular catheters [32]. Adequate blood
flow rates (≥200 mL/min) were established in nearly 90 percent (49 of 56) of cases.

In our experience, many catheters cannot be salvaged with adequate blood flow by the use of
thrombolytic agents alone. Non-cuffed catheters should be exchanged if flow is inadequate.

Central vein thrombosis and stenosis — There is an association between central venous
cannulation and the development of central vein stenosis [33]. This complication appears to occur
more often with subclavian (40 to 50 percent of cases in some studies) than with internal jugular
insertions (up to 10 percent) [34-36]. It has been proposed that central venous cannulation
creates a nidus of vascular injury and fibrosis. The rapid blood flows associated with the
hemodialysis catheter then create turbulence that can accelerate endothelial proliferation,
eventually leading to venous stenosis [33].

This sequence is more likely with subclavian catheterization, since curving of the catheter
between the clavicle and first rib and as the catheter enters the superior vena cava creates
"pressure" points on the vascular wall [35]. The K/DOQI guidelines therefore recommend avoiding
placement in the subclavian vein, unless no other options are available [37]. In comparison, right
internal jugular catheters have a relatively straight course into the superior vena cava, thereby
minimizing vascular irritation.

An alternative theory suggests a primary role for central venous thrombosis [38,39]. Subsequent
recannulation of the vessel by the thrombolytic system provides the nidus for endothelial

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proliferation and narrowing of the vascular lumen.

Most central venous stenoses are initially asymptomatic. Symptoms, which consist of edema and
raised venous dialysis pressures, primarily occur after a peripheral access has been created in the
ipsilateral arm [33]. In this setting, the high flow through the access exceeds the rate at which
blood can flow at normal pressure across the stenotic lesion.

Central venous thrombosis, if detected early, responds well to directly applied thrombolytic
therapy [33] or to percutaneous transluminal angioplasty when the fibrotic stenosis can be
crossed with a guidewire [40]. Highly elastic lesions that recur following angioplasty can be
treated with metallic wall stents. (See "Thrombosis associated with chronic hemodialysis vascular
access: Catheters".) However, the natural history of even treated central vein stenosis is not
favorable as most vessels ultimately become partially or fully occluded.

Duration of use — The duration of acute double-lumen catheter use varies with the insertion
site. Infectious complications are the principal reason why the catheter must be removed. In one
report of 318 new hemodialysis catheter insertions, the risk of bacteremia with internal jugular
vein and femoral vein hemodialysis catheters was examined during the first four weekly intervals
after placement [41]. During weekly intervals one (which consisted of the time of placement to
the end of week 1), two, three, and four, the incidence of bacteremia for a femoral vein catheter
was 3.1, 10.7, 18.1 and 29.1 percent, respectively, while that for an internal jugular vein
catheter was 1.7, 4.6, 5.4, and 10.3 percent.

Thus, femoral catheters, inserted with sterile technique and meticulously cleaned daily in
bedbound patients, can usually be left in place safely for three to seven days. In comparison,
femoral dialysis catheters must be removed after each use in ambulatory patients. Subclavian
and internal jugular catheters may last for two to three weeks. As noted above, silastic/silicone
cuffed catheters are suitable for long-term use.

Following catheter removal, firm pressure can be applied for at least one to two minutes;
however, the length of time of applied pressure should generally be determined by directly
observed hemostasis.

Infection — The infection risks associated with temporary double lumen catheters include local
exit site infection and systemic bacteremia, both of which require prompt removal of the catheter
and appropriate intravenous antibiotic therapy [3,41,42]. Bacteremia generally results from
either contamination of the catheter lumen or migration of bacteria from the skin through the
entry site, down the hemodialysis catheter into the blood stream [1,2,6,43,44]. As noted in the
previous section, this migration down the catheter wall usually limits the duration of use of these
catheters [43]. Skin flora, Staphylococcus and Streptococcus species, are responsible for the
majority of infections.

In addition to the total duration of use and the presence of an exit site infection, the rate of
infection may vary with the site of catheter insertion. Some feel that the highest risk is with
femoral catheters, followed by jugular and then subclavian vein catheters. However, there is
conflicting evidence concerning the risk of infection based upon the site of insertion.

In the largest prospective randomized study, the risk of infection was not reduced with jugular
versus femoral venous catheterization [45]. In this trial, 750 patients who required renal
replacement therapy were randomly assigned to receive jugular or femoral vein catheterization.
The rate of catheter-related sepsis was the same with both groups (2.3 versus 1.5 per 1000
catheter-days for jugular and femoral venous catheterization, respectively). Among obese
patients (BMI >28.4), the incidence of catheter colonization was significantly lower with jugular
catheterization, but there was no difference in rates of clinical infection. In addition, hematomas
were significantly more common with jugular catheterization (3.6 versus 1.1 percent).

By comparison, prospective nonrandomized studies suggest that the infection risk appears to
sequentially increase for hemodialysis catheters inserted into the subclavian, internal jugular, and

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femoral veins, respectively. In one prospective study of 105 hemodialysis catheters (79
subclavian and 26 jugular), a significantly higher risk of catheter-related bacteremia was
associated with insertion into the internal jugular vein (hazard ratio of 4, P = 0.02) [46]. In a
second prospective study of 318 new hemodialysis catheter insertions, there was a higher risk of
bacteremia after insertion into the femoral vein compared to that associated with internal jugular
vein placement (relative risk of three) [41].

Overall, compared with the subclavian vein, the internal jugular vein remains the preferred
access site in ambulatory patients because of the high rate of central vein stenosis associated
with subclavian vein catheterization (see above). In the Intensive Care Unit, either femoral or
internal jugular vein placement is satisfactory, with the use of ultrasound making internal jugular
vein placement safer.

Prevention — Prevention of infection principally involves strict adherence to proper placement

technique (including the use of maximal barrier precautions), and optimal exit site care and
management of the catheter within the hemodialysis facility [8,47]. After placement, the direct
application of mupirocin ointment (an antibiotic with high antistaphylococcal activity) to the
insertion site may significantly decrease the incidence of local and/or systemic Staphylococcal
aureus infection [48]. (See "Tunneled, cuffed hemodialysis catheter-related bacteremia".)

Trials of antiseptic or antibiotic-bonded hemodialysis catheters or different flush solutions have

reported a decreased incidence of catheter-related infections when these devices are used
[49,50]. In one study, for example, 130 patients were randomly assigned to a
minocycline-rifampin coated catheter or an unimpregnated catheter [49]. At a mean period of
catheter use of eight days, infections were markedly reduced in the group that received the
antibiotic-coated catheter (0 versus 7).

Such coated catheters have also proven effective in preventing intravascular catheter infections
in the non-dialysis setting. In addition, sterile nonocclusive gauze dressings have been found to
be superior to occlusive transparent dressings. (See "Prevention of intravascular catheter-related
infections", section on 'Antimicrobial impregnated catheters' and "Prevention of intravascular
catheter-related infections", section on 'Insertion site preparation'.)

COMPLICATIONS WITH CUFFED, TUNNELED DIALYSIS CATHETERS — Thrombosis and

infection are the major complications associated with cuffed catheters. The management of
thrombosis is discussed in detailed separately. (See "Thrombosis associated with chronic
hemodialysis vascular access: Catheters".)

Anticoagulants (usually heparin) are also instilled in these catheters between dialysis sessions.
The exact lumen size is labeled on the catheter to allow exact instillation [9]. Although heparin is
the current standard of care, some centers have also successfully used sodium citrate 4 percent
locking solution to prevent thrombosis [51,52].

Insertion complications are similar to that described for acute catheters. Complications with these
cuffed tunneled catheters are dealt with in more detail in other topic reviews.

Infection — The infection risk with cuffed silastic catheters is significantly reduced, because the
cuff within the tunnel serves as a barrier to the migration of bacteria down the external surface of
the catheter. Exit site infections can usually be treated locally with oral or intravenous antibiotics
and local wound care.

Antibiotic salvage of silastic cuffed catheters as an alternative to catheter removal has been
proposed. Limited data from a prospective trial at Duke University suggests that only 30 percent
of catheters can be salvaged with antibiotic therapy alone [53]. However, antibiotic therapy with
simultaneous guidewire exchange may be more successful than prolonged antibiotic therapy
alone if the tunnel exit site is not infected [54]. (See "Tunneled, cuffed hemodialysis
catheter-related bacteremia".)

Thrombosis and fibrin sheath formation — The use of lytic therapy with alteplase and

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urokinase as described for acute hemodialysis catheters has been found to be very successful in
treating catheter thrombosis (see above). On the other hand, when lytic therapy is unsuccessful
other techniques other than catheter removal are routinely used. This is discussed separately.
(See "Thrombosis associated with chronic hemodialysis vascular access: Catheters".)

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