Acute Hemodialysis Catheters: How Safe are They?

Double-lumen dialysis catheters are widely used for temporary access in patients who require acute hemodialysis (HD), continuous venovenous hemofiltration (CVVH), plasmapheresis, and during the maturation period of recently created or revised permanent arteriovenous fistulas. As these procedures require access to blood vessels capable of providing high extracorporeal blood flow, the femoral (1), subclavian (2) and internal jugular (3) veins are the sites most commonly chosen. Although they provide rapid angioaccess, these catheters can cause some serious complications, such as trauma to vital structures, infection, thrombosis, and central venous stenosis. The severity and rate of insertion-associated traumatic complications are lowest with femoral catheters. The wider use of such catheters, however, is precluded by interference with ambulation, concern over bleeding, infection, and deep venous thrombosis (4). The subclavian vein (SCV) route has therefore emerged as the most commonly used site. However, reports of complications, associated with SCV catheters both short and long-term, raised concern (5, 6). Short-term complications include trauma to central structures (7, 8, 9), infection (10), and venous thrombosis (11). Traumatic complications include arterial puncture (7, 8), venous laceration (7, 8), hematoma formation (7, 8), pneumothorax (7, 8), superior vena cava syndrome (12), cardiac perforation (9), pericardial tamponade (13), and even death (14). Preexisting congenital vascular anomalies increase the risk of complications associated with central venous cannulation. A persistent left superior vena cava may result in difficulty of catheter placement, vascular wall trauma, internal bleeding, large hematomas and other complications (15). In addition, compression of the brachiocephalic vein by the innominate artery (16) may result in massive arm edema. Another well recognized long-term complication of dwelling catethers is SCV sterosis (3, 6). This usually becomes apparent months after the establishment of an ipsilateral AV fistula. The associated increase in venous pressure can be manifested as edema of the access extremity (17), or more rarely of the ipsilateral breast (18), pleural effusion (19), prolonged bleeding from puncture sites, aneurysm and pseudoaneurysm formation, and increased recirculation leading to decreased dialysis efficiency (3, 6). Cimochowski et al (3) suggested that compared to the internal jugular vein (IJV) route the long-term stricture rate of SCV catheters was unacceptably high. The IJV route was therefore suggested as a safer alternative to SCV cannulation (3, 4). However, complications, both short and long-term, associated with the use of the IJV catheters include Horner's sydrome, ascribed to damage of the sympathetic chain (20), vocal cord paralysis (21), laceration of the vertebral artery with hemorrhage into the pleural space (22), venous perforation (23), hematoma formation (24), carotid artery puncture (25), arteriovenous fistula (26, 27, 28) thoracic duct injury (29), pneumothorax (30), cardiac tamponade (31), and cardiac arrest (32). Furthermore, IJV catheters have recently been reported to be associated with superior vena cava stenosis (33). It should be emphasized that central venous cannulation will continue to be a widely-used approach to gain rapid access to the circulation, with a very low overall incidence of complications. Serious sequelae, including death, may however occur. Measures to safeguard against the occurence of such complications should therefore be instituted. The use of central venous catheters for HD should be avoided whenever possible. Elective placement of the permanent access should be planned early enough to allow its maturation before the need for "acute" dialysis arises. Catheter insertion should be attempted only by operators who have received adequate training; and physicians and nursing staff need to exercise vigilance. Any neck swelling, new carotid bruit, chest pain, dyspnea, cardiac arrhythmia, and/or unexplained or refractory hypotension should be regarded as a potential traumatic complication of the catheter until proven otherwise. The safety of the procedure may be enhanced by the introduction of newer techniques of venous cannulation. Denys et al (34) has reported that ultrasound-guided cannulation of the IJV significantly improves the success rate, decreases access time, and reduces the complication rate when compared to the use of the external landmark-guided technique. Finally, limiting the duration of use of the acute doublelumen catheter should prevent infectious complications. Femoral catheters in bedbound patients can usually be left in place safely for several days, if meticulously maintained. In ambulatory patients, however, the femoral catheter should be removed after each use. Subclavian and internal jugular catheters may last for 2 to 3 weeks, provided