Mini ReviewABSTRACT
End Stage Renal Disease is a rising problem globally. While kidney transplant is the preferred method of treatment, dialysis has the lion share of all kidney failure patients. Arteriovenous fistulas and arteriovenous grafts are used for long term dialysis access. On the other hand, tunneled dialysis catheters have been used for temporary and long term dialysis access. Femoral dialysis catheters have been used for short term access especially in ICUs. However, tunneled femoral dialysis catheters have been used sparingly for longer term dialysis. In this mini review we discuss the importance of early consideration of tunneled femoral dialysis catheters as a method of central thoracic veins preservation.
Keywords: Tunneled Catheter; Femoral; Hemodialysis; Central Vein Occlusion
Mini Review
Type of vascular access influences outcome and mortality in dialysis population. Arteriovenous fistulas are preferred over grafts and catheters [1]. Central venous catheters in contrast have more complications including poor patency, higher infection rates and central venous stenosis [2]. However, in some patients, central venous catheters remain the only options. Some studies showed the type of vascular access does not independently correlate with survival [3]. There has been a recent increasing trend in some European countries in the use of central venous catheters [4]. In this study, data from 10 European renal registries was examined. Whether the trend was due to more individualized treatment based on each patient needs or as a result of loss of venous access, was not determined. Vascular access failure, regardless of the type of access, is a cause of considerable morbidity, inconvenience, readmissions and increase cost [5]. Planning for vascular access early in the process helps avoid placement of catheters. Identifying risk factors for access failure can be used to guide a more directed approach for vascular access preservation. Preservation of peripheral and central veins for placement of arteriovenous fistula in kidney failure patients is of utmost importance especially in younger patients who are expected to require dialysis for longer periods of time [5]. “Save the Vein” initiative has been a campaign to educate health care providers about the importance of practices and guidelines aimed at preserving peripheral veins in chronic kidney disease patients.
While losing peripheral veins in upper arms complicates future dialysis access planning, central thoracic venous occlusion can create even more significant problems in findings suitable sites for dialysis access placement. Central venous stenosis is not an uncommon problem in dialysis patients [6]. It is more prevalent in dialysis patients undergoing venography for access problem and is more associated with subclavian vein catheter placement. Even short-term catheter placement can result in significantly high rates of pericatheter sleeve formation and thrombus formation [7]. The authors of this study strongly recommended avoidance of unnecessary catheter insertion even for short terms. Placement of central venous catheters for dialysis is usually a result of delayed planning for access placement before patients start dialysis. It can also result from having to abandon an existing access due to failure, infection or other forms of complications; a problem that can be significantly reduced by proper access surveillance and maintenance. Tunneled femoral hemodialysis catheters have been historically considered less favorable than internal jugular catheters due to shorter primary patency rates [8]. Another major area of concern is blood stream infection, a cause of increase morbidity and mortality among dialysis patients. Many clinicians refrain from utilizing tunneled femoral hemodialysis catheters in fear of blood stream infections. However, more recent reports suggested that the risk of bloodstream infection is comparable to that of internal jugular catheters [9].
Whether that is due to better catheter maintenance practices, improved catheters by manufactures or stronger antibiotics, remains to be investigated. Long term tunneled femoral hemodialysis catheters have been historically used for patients who exhausted access sites for Tunneled Femoral Hemodialysis Catheters: Villain or Savior their upper extremities and were unsuitable for lower extremity arteriovenous graft placement [10,11]. While tunneled femoral dialysis catheters usage has been reserved for patients who have already lost upper extremity access, mostly due to central thoracic vein stenosis or occlusion, there is no abundance of evidence in the medical literature on their early shortterm use so as to avoid the central venous stenosis problem in the first place [12]. With similar bloodstream infection rates, and lower patency rates, compared to internal jugular catheters, placement of tunneled femoral dialysis catheters seem as an attractive short-term option to avoid central venous stenosis especially in younger patients who are expected to require hemodialysis for longer periods of time. In conclusion, with the increase in number of dialysis patients globally and the improvement of survival on hemodialysis, the problem of central thoracic venous occlusion will continue to exacerbate the complication of dialysis access site loss. Tunneled femoral hemodialysis catheters should be considered an option for early utility to avoid loss of access. In addition, we recommend further investigation of the effectiveness of their use in reducing the problem of central venous stenosis.
Conflict of Interest
The author declares that he has no conflict of interest.
References
- Dhingra RK, Young EW, Hulbert Shearon TE, Leavey SF, Port FK, et al. (2001) Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 60(4): 1443-1451.
- Mc Gee DC, Gould MK (2003) Preventing complications of central venous catheterization. N Engl J Med 348(12): 1123-1133.
- Noordzij M, Jager KJ, Van der Veer SN, Kramar R, Collart F, et al. (2014) Use of vascular access for haemodialysis in Europe: a report from the ERA-EDTA Registry. Nephrol Dial Transplant 29(10): 1956-1964.
- Monroy Cuadros M, Yilmaz S, Salazar Banuelos A, Doig C (2010) Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. CJASN 5(10): 1787-1792.
- Singh NS, Grimes J, Gregg GK, Nau AE, Rivard DC, et al. (2021) "Save the Vein" Initiative in Children With CKD: A Quality Improvement Study. Am J Kidney Dis 78(1): 96-102.e1.
- MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M, et al. (2005) Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 51(1): 77-81.
- Oguzkurt L, Tercan F, Torun D, Yildirim T, Zumrutdal A, et al. (2004) Impact of short-term hemodialysis catheters on the central veins: a catheter venographic study. Eur J Radiol 52(3): 293-299.
- Maya ID, Allon M (2005) Outcomes of tunneled femoral hemodialysis catheters: comparison with internal jugular vein catheters. Kidney Int 68(6): 2886-2889.
- Marik PE, Flemmer M, Harrison W (2012) The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 40(8): 2479-2485.
- Chow KM, Szeto CC, Leung CB, Wong TY, LI KP, et al. (2001) Cuffed-tunneled femoral catheter for long-term hemodialysis. Int J Artif Organs 24(7): 443-446.
- Al Hwiesh AK, Abdul-Rahman IS (2007) Tunneled femoral vein catheterization for long term hemodialysis: a single center experience. Saudi J Kidney Dis Transpl 18(1): 37-42.
- Clerck DT, Bonkain F, Cools W, Van der Niepen P (2020) Vascular access type and mortality in haemodialysis: a retrospective cohort study. BMC Nephrol 21(1): 231.
