Hemodialysis Tunneled Catheter Noninfectious Complications
| Category | Keypoints |
|---|---|
| Definition of Catheter Dysfunction | 1. Failure to attain/maintain extracorporeal blood flow (Qb) of ≥300 mL/min at a prepump arterial pressure more negative than −250 mm Hg. 2. Poor Functioning Catheter with Dialysis Ongoing (e.g., Qb > 200 mL/min) but frequent alarms (intradialytic infusion) 3. Nonfunctioning Catheter (Qb < 150/200 mL/min or inability to withdraw) |
| Incidence and Analysis | 1. One-third of tunneled catheter removals due to inadequate blood flow. 2. Almost two-thirds of patients experienced Qb <300 mL/min in at least 1 treatment; 30% had ≥1 session/month of dysfunction. |
| Etiology | Early Dysfunction: Within the first week due to mechanical issues. 1. Malpositioning 2. Kinking 3. Incorrect tip location - Catheter tip should be at the superior vena cava-right atrium junction. 4. Catheter Migration 5.Patient Position |
| Late Dysfunction: Weeks to years post-insertion, due to injury causing turbulent blood flow and stimulating coagulation/inflammatory cascades. | |
| Thrombosis | 1. Occurs in both early and late stages, with late-stage more commonly associated with thrombus formation due to fibrin sheath and vessel injury. 2. Intra-luminal thrombus causes direct obstruction, whereas extra-luminal thrombus results in external compression. |
| Prevention Strategies | 1. Anticoagulant Solutions: Sodium citrate (4%) or concentrated heparin solutions (1000 units/mL) for locking between treatments. 2. Recombinant Tissue Plasminogen Activator (tPA): Pre-CLOT trial showed lower malfunction with tPA versus heparin. 3. Systemic Pharmacologic Therapy: Antiplatelet agents and oral anticoagulants have limited evidence of efficacy and carry bleeding risks. |
| Treatment of Dysfunction | 1. Thrombolytic Agents: Initial steps include saline flushes, repositioning. Alteplase (tPA) (2mg/lumen) is commonly used. 2. Interventional Therapies: Angioplasty for fibrin sheath disruption/stripping, with variable success rates. |
| Central Vein Stenosis (CVS) | 1. Incidence: Up to 40% in hemodialysis patients. Caused by vascular injury from catheters, CIEDs, PICCs. Higher risk with subclavian vein catheters. 2. Symptoms: Often asymptomatic until ipsilateral AV access creation. Symptoms include arm edema, pain, and ipsilateral breast swelling. |
| Management: Percutaneous transluminal angioplasty is the treatment of choice, with variable patency rates. Surgery is a last resort (bypass using graft). | |
| Other Complications | Catheter-Associated Thrombus: Managed with anticoagulation; catheter-related right atrial thrombus requires careful management. |
| Difficult-to-Remove Embedded Catheter: Approaches include surgery, cutting and burying, and endoluminal dilatation. | |
| Last Option Access | For stenosed/occluded central veins, options include transfemoral/translumbar catheters, and the HeRO device. Requires skilled intervention. |