Radiologically Placed Tunneled Hemodialysis Catheters: A Single Pediatric Institutional Experience of 120 Patients

doi:10.1016/j.jvir.2012.01.075

Journal of Vascular and Interventional Radiology

Volume 23, Issue 5, May 2012, Pages 604-612

https://doi.org/10.1016/j.jvir.2012.01.075 Get rights and content

Abstract

Purpose

To report the outcome of tunneled dialysis catheter insertion in 120 patients.

Materials and Methods

A retrospective review of the interventional radiology database and electronic medical records of 120 patients who had tunneled dialysis catheters inserted from April 1997 to July 2010 was performed with institutional review board approval. There were 61 female patients and 59 male patients, with a mean age of 13.3 years (range, 0.2–28.5 y). A total of 193 primary insertions and 330 salvage procedures were performed.

Results

The technical success rate for primary catheter insertions was 100%. Immediate complications included self-limiting tract bleeding and air embolism in two of 193 insertions each (1.03%). Mean indwell duration for primary insertions was 66 catheter-days (range, 1–765 d), compared with a total mean of 159.4 catheter-days (range, 1–1,034 d). Rates of infection and mechanical complications were 0.21 and 0.9 per 100 total catheter-days, respectively. Mechanical and infections complications were increased in children younger than 9 years of age and weighing less than 20 kg. The catheter removal rates for infection and mechanical complications were 0.084 and 0.081 per 100 catheter-days, respectively. Medical salvage procedures, ie, intracatheter thrombolytic agent use or antibiotic therapy (52.1%) and interventional radiologic catheter salvage procedures (47.1%), increased catheter survival by an average of 54.8 days (range, 0–959 d).

Conclusions

Radiologic placement of tunneled hemodialysis catheters is a safe and technically successful procedure in pediatric patients. However, there is a high rate of infectious and mechanical complications, particularly in younger and smaller patients.

Section snippets

Materials and Methods

The study was approved by the institutional review board. A retrospective review of the interventional radiology database was performed to identify all patients who received radiologically placed tunneled hemodialysis catheters from April 1997 to July 2010. The medical records of these patients were reviewed for demographic, clinical, and periprocedural data. There were a total of 120 children in the study (61 female, 59 male), with mean and median patient ages of 13.3 years and 15 years,

Results

A total of 523 procedures were performed in 120 patients during the study period. There were 193 primary catheter insertions, with 84 patients (70%) having only one catheter insertion and 36 patients (30%) having two or more primary catheter insertions. The latter group of patients had repeat insertions, ranging from two to six insertions each, for a total of 58 repeat insertions. The indications for repeat primary insertions included failed salvage for mechanical complications in 23 of 58

Discussion

Placement of hemodialysis and central venous catheters in pediatric subjects has been shown to be technically challenging and associated with higher rates of complications compared with their placement in the adult population (1, 24, 25). Higher success rates and lower complication rates have been reported for radiologically placed catheters in adult and pediatric populations (1, 3, 8, 9, 11, 12, 13, 14, 15). The 100% technical success rate reported in the present retrospective series further

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Procedures requiring a return visit to IR (eg, catheter exchanges, contrast evaluations, cuff adjustments, resuturing) were called IR-maintenance procedures. Technical success, device service intervals, access site intervals, and complication categorization were defined using SIR guidelines (16–19). Catheter-related infections were analyzed if they met Society of International Radiology (SIR) definitions of catheter-related sepsis/bacteremia, with no alternative source of infection, and resulted in catheter removal (16).
Evaluate technical aspects and outcomes of insertion/maintenance of hemodialysis (HD) central venous catheter (CVC) during infancy.
Single-center retrospective study of 29 infants who underwent 49 HD-CVC insertions between 2002 and 2016. Demographics, procedural, and post-procedural details, interventional radiology (IR) maintenance procedures, technical modifications, complications, and outcomes were evaluated. Technical adjustments during HD-CVC placement to adapt catheter length to patient size were labeled “modifications.” CVCs requiring return visit to IR were called IR-maintenance procedures. Mean age and weight at HD-CVC insertion were 117 days and 4.9 kg.
Of the 29 patients, 13 (45%) required renal-replacement-therapy (RRT) as neonates, 10 (34%) commenced RRT with peritoneal dialysis (PD), and 19 (66%) with HD. Fifteen nontunneled and 34 tunneled HD-CVCs were inserted while patients were ≤1 year. Technical modifications were required placing 25/49 (51%) HD-CVCs: 5/15 (33%) nontunneled and 20/34 (59%) tunneled catheters (P = .08). Patients underwent ≤6 dialysis-cycles/patient during infancy (mean 2.3), and a mean of 4.1 and 49 HD-sessions/catheter for nontunneled and tunneled HD-CVCs, respectively. Mean primary and secondary device service, and total access site intervals for tunneled HD-CVCs were 75, 115, and 201 days, respectively. A total of 26 of 49 (53%) patients required IR-maintenance procedures. Nontunneled lines had greater catheter-related bloodstream infections per 1,000 catheter-days than tunneled HD-CVCs (9.25 vs. 0.85/1,000 catheter days; P = .02). Nineteen patients (65%) survived over 1 year. At final evaluation (December 2017): 8/19 survived transplantation, 5/19 remained on RRT, 2/19 completely recovered, 1/19 lost to follow-up, and 3 died at 1.3, 2, and 10 years.
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Consequently, if a patient is severely oliguric or anuric at the time of dialysis, anticoagulation may no longer be required. CVC occlusion and thrombosis, not always amenable to local installation of fibrinolytic agents or systemic anticoagulation, may result in interruption of treatment, repeated CVC insertions (with potential acute insertion related complications [11,58,59,96]) and stenosis of the central vessels, potentially compromising future vascular access [53,73,74]. Central vein stenosis, affecting the major intrathoracic veins (subclavian vein, brachiocephalic vein, and SVC), is often asymptomatic, especially if the stenosis is not critical, or there is development of adequate collateral flow and is usually diagnosed at times of newly attempted CVC insertion or following the construction of an AVF in the ipsilateral extremity.
Despite the high rate of central venous catheter (CVC)-related venous thromboembolic (VTE) complications and long-term sequelae, CVCs remain a vital component of patient care in children with complex underlying diseases. In this review, we focus on CVC-related VTE in children with end-stage renal disease (ESRD) undergoing hemodialysis, a population in whom the provision of renal replacement therapy is a lifelong undertaking. Occlusion of the CVC and thrombosis underlie most instances of access malfunction and failure in children on chronic hemodialysis. Frequent CVC replacements are required, resulting in increased risk of central vein thrombosis and stenosis, precluding adequate hemodialysis in years to come. As recurrent CVC malfunction may constitute the sole sign of CVC-related VTE, a high index of suspicion is required for its investigation and the consequent institution of anticoagulation treatment, attempting to salvage the CVC and minimize recurrent line exchanges and venous cannulations and their sequelae. Hemodialysis access planning should take into account potentially modifiable prothrombotic risk factors in order to preserve vascular access. Effective strategies for maintenance of catheter patency and survival are needed for the conservation of future hemodialysis access. Further investigation aiming for identification of predictors of CVC-related VTE in children undergoing hemodialysis will aid in the design and application of much needed multicenter prospective studies examining the benefit and the safety of thromboprophylaxis.
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: None of the authors have identified a conflict of interest.

: The authors thank Dr. Berhanu G. Michael for his technical support during the statistical analysis of the results of the study.

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Clinical studyRadiologically Placed Tunneled Hemodialysis Catheters: A Single Pediatric Institutional Experience of 120 Patients

Abstract

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

J Vasc Interv Radiol

J Vasc Interv Radiol

Kidney Int

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

Am J Kidney Dis

Am J Kidney Dis

Am J Kidney Dis

J Vasc Interv Radiol

J Pediatr Surg

J Vasc Interv Radiol

J Vasc Interv Radiol

Tunneled internal jugular catheters in adult patients: comparison of outcomes in hemodialysis versus infusion catheters

Acta Radiol

Clinical study
Radiologically Placed Tunneled Hemodialysis Catheters: A Single Pediatric Institutional Experience of 120 Patients