#3438 OUTCOME OF HEMODIALYSIS TUNNELED CUFFED CATHETER PLACEMENT BY THE NEPHROLOGIST AT THE DIALYSIS UNIT
Authors: Camp Sander , De Clerck Dieter , Cools Wilfried , Van Der Niepen Patricia 
Published: June 2023

Background and Aims

A large proportion of patients starts dialysis treatment with a temporary catheter which is afterwards replaced by a tunneled cuffed catheter (TCC) by the surgeon or interventional radiologist. This implies a certain dependency on the availability of the surgeon or radiologist. During this waiting time, the patient is exposed to a temporary catheter, which is accompanied by a higher risk of infection. At the UZ Brussel, until 2017 TCC's were placed at the operating room by the surgeon. In September 2017 nephrologists at the UZ Brussel started to place TCC's at the dialysis unit, without the use of fluoroscopy, to lower the time of exposure to a temporary catheter.

Method

We did a retrospective analysis of 100 patients who got a TCC placed at the dialysis unit from September 2017 until February 2021 (nephrologist group); as a control group we evaluated the last 100 patients who got a TCC by the surgeon before this period. We evaluated complications (during procedure and within the first month), catheter function during the second week and after three months, and waiting time to get a TCC. Logistic regression analysis was performed to detect differences in complication rate and catheter function. Two-way analysis of variance was performed on the log transformed waiting times.

Results

In both groups, comorbidities such as diabetes mellitus, history of cardiac surgery and presence of a pacemaker or port-a-cath at the time of catheter insertion were comparable. In both groups almost half of the patients were taking antiplatelet therapy. In the nephrologist group more patients got a catheter because of AKI (32% versus 15%) and less patients had a planned admission (19% versus 42%). More patients had a TCC placement after an ICU admission (33% versus 18%) and only few of the catheter placements were replacements of in situ TCC's (3% versus 35%). In the nephrologist group, catheters were inserted in the right (93%) and left jugular vein (7%). In the surgeon group, catheters were inserted in the right (71%) and left jugular vein (23%) and in the subclavian vein (6%). In the nephrologist group there were no failed procedures, but 2 left jugular vein catheters were not in the correct position (turning upwards in the superior vena cava). In 3 patients the carotid artery was punctured and 3 patients had a significant exit site bleeding. In the surgeon group, 3 patients had a failed procedure and 2 patients had a carotid puncture. Analysis of late complications in the nephrologist group showed a bleeding from the exit site in 8 patients, development of bacteremia in 2 patients and the neck wound opened up in 2 patients. In the surgeon group 9 patients had an exit site bleeding, 4 patients had an exit site infection, 2 patients had a bacteremia, 1 patient had a catheter cuff becoming visual at the exit site, 1 patient had a catheter dislocation, 1 patient had a vena cava superior syndrome and 1 patient had a large hematoma. The presence of AKI and the use of antiplatelet therapy were found to be risk factors of getting a late complication. Getting a catheter placed by the nephrologist lowered the risk, even after correction for AKI and antiplatelet therapy, with an odds ratio of 0.414 (p = 0.044). In the nephrologist group, 92% of catheters had a good early function, compared to 84% in the surgeon group. At three months, about half of the catheters were still in use. Catheter function was correct in 87% in the nephrologist group versus 77% in the surgeon group. In patients who first started with a temporary catheter, the mean waiting time to get a TCC in the nephrologist group was 1.6 days compared to 4.5 days in the surgeon group (p &lt; 0.001). In patients who got immediately a TCC the mean waiting time was 0.6 days in the nephrologist group compared to 2.4 days in the surgeon group (p &lt; 0.001).

Conclusion

In patients who have to start dialysis urgently, TCC's can be placed without fluoroscopy by the nephrologist at the dialysis unit in a safe and efficient manner. This lowers the need for temporary catheters, and shortens the waiting time for getting a TCC.