European Journal of Cardiovascular Medicine

Nowadays kidney disease is considered as the disease of civilization like cardiovascular disease, arterial hypertension, diabetes or obesity. Patients with end-stage renal disease, either due to acute kidney injury or chronic kidney disease, need dialysis or a kidney transplant apart from conservative care [1]. Some patients with acute renal failure may require temporary (if renal failure is reversible) or permanent dialysis (if kidney injury is chronic or irreversible). Chronic kidney disease (CKD) is attributable to acute kidney injury or a gradual loss of renal function over time associated with diabetic nephropathy, chronic glomerulonephritis or hypertensive nephropathy [2].

Renal replacement therapy

CKD according to WHO affects over 50 million people worldwide including over one million that require renal replacement therapy [3]. Kidney replacement therapy (hemodialysis) is used in patients with acute renal failure and chronic kidney disease. Potential candidates are evaluated based on laboratory parameters and clinical status including glomerular filtration rate (GFR), symptoms of uremia, overhydration, uncontrolled hypertension or malnutrition [4]. To start dialysis a vascular access needs to be created. The gold standard for vascular access for hemodialysis is an arteriovenous fistula most commonly located in the forearm [5]. The main advantage of an AV fistula over a dialysis catheter is a low risk of infection, including systemic infection. The decision to create a fistula depends on such factors as patient age, accompanying diseases, vessel parameters, operator’s experience and patient preferences [6,7,8,9].

Kidney replacement therapy using hemodialysis catheters

Although the AV fistula is the recommended type of hemodialysis vascular access, in the United States alone more than 80% of patients start dialysis with a catheter [10]. Acute dialysis catheters are the gold standard for immediate vascular access, mainly for acute renal failure and in bed-bound patients in Intensive Therapy Units [11]. Permanent catheters have come to be increasingly used in patients in advanced age (shorter life expectancy), with multimorbidity, cancer, awaiting a kidney transplant, before AV fistula creation or with AV fistula failure [5,12]. All these factors affecting the decision to insert a catheter rather than create an AV fistula are also the factors that increase the risk of infections and catheter-related bloodstream infections [13,14,15,16,17]. In such cases we need to choose the most appropriate venous access instead of an AV fistula access site, with all possible consequences of the choice [18].

Complications associated with hemodialysis catheters

There are complications that may occur in patients both with acute and permanent types of dialysis catheters and they include perforation of the superior vena cava and the right atrium, localized and systemic infections and a hematoma at the site of catheter insertion. Additionally, permanent catheters (Permcaths) are likely to adhere to the walls of major veins and right atrium, and may cause venous thrombosis. These complications are associated with higher morbidity and mortality rates [5]. Placement of dialysis catheters requires strict aseptic conditions and should be performed in a standard operating room or a hybrid room under ultrasound and angiography guidance [10]. In patients with symptoms and/or signs of infection (the incidence of catheter-related infections varies considerably depending on the catheter insertion site) or venous obstruction, the catheter needs to be removed, which is often combined with insertion of an acute catheter or exchange of the permanent catheter for a completely new catheter [12,13]. Another common cause of intervention is catheter malfunction (technical problems during hemodialysis), in that case the line should be removed, replaced or moved to another location. It is noteworthy that diabetes may be an additional factor that increases the risk of this complication [14].

The major problem associated with removal of permanent dialysis access catheters is their adherence to the walls of major veins and right atrium, and catheter-related thrombosis. Retaining venous access sites for reinsertion of a new catheter is often challenging. Prompt removal of the existing catheter is recommended for the prevention of catheter-related venous obstruction [18].

Catheter-related right atrial thrombus is an uncommon yet potentially life-threatening complication. At its first sign catheter removal and anticoagulant administration is indicated [19,20,21].

Dialysis catheters – design and placement

Central venous catheters used for chronic hemodialysis have a sleeve and a cuff, and they are tunneled under the skin to secure the catheter within the subcutaneous tissues and to reduce the risk of catheter-related bloodstream infection. This type of catheter is made of silicone, silastic or carbonate elastomer, polyurethane and polycarbonate, i.e. the materials which are softer and more flexible than those used for acute catheters. The catheters are inserted using the Seldinger technique, most frequently in the internal jugular vein, subclavian vein or femoral vein. A larger diameter provides a significantly higher rate of blood flow compared to smaller-diameter acute catheters.

Upon insertion of a central venous catheter ultrasound or fluoroscopy is used to check the position of the tip. The correct position of the distal catheter tip is the most important factor that determines its long-term function and durability. To aspirate blood with minimal resistance the distal tip should be located in the right atrium or at the junction of the superior vena cava with the right atrium [17]. A slightly lower location is also possible, however the channel that takes the blood should not abut the heart wall or the wall of the vein. Dialysis catheters vary in length depending on whether they are used for acute or chronic hemodialysis, and depending on the manufacturer. In general, they are available in 19,23,28 and 33 cm lengths (length of the implant, total length is greater). The proximal end has two separate channels and an Y-shaped connector. The catheter design determines the implantation technique that is placing the access site under the skin (chest area), and tunneling the catheter to the entry site into the vein (most commonly the jugular vein). The distal end should reach the planned location i.e. the upper or middle part of the right atrium. A polyester felt cuff to fix the catheter in position markedly limits adjustment of catheter insertion depth. Prior to catheter insertion, a substitute of the same length is placed on the chest tracking the expected course. The device can be inserted via the left or right jugular vein (external/internal/common). The length of the catheter depends on the anatomic site meaning that it should be shorter on the right side. Inappropriate catheter length and placement into the body may reduce its durability and promote venous obstruction due to mechanical irritation of the venous wall by the tip (Figure 1).

Figure 1. X-ray images showing types of dialysis catheter malfunction. The tips positioned too high in the superior vena cava (A-D),  the catheters are too deep (E-H), catheters in the orifice (F-G) or the inferior vena cava (H), sometimes even in the right ventricle (E-G).

Catheter types and design differences

Chronologically, PermCath was the first dual lumen tunneled catheter, thick and oval-shaped. Then VasCath was developed, a catheter with a circular cross-section and internal septum dividing the lumen into two parts. The circular cross-section facilitated catheter insertion through the splittable lumen. The third option was the Tesio catheter, a twin-line single-lumen catheter: one line to draw blood from the patient with its tip in the superior vena cava and a second line to return blood. Nowadays, modified Tesio catheters are available: two catheters partially joined along their external surfaces. This design enables catheter insertion with a single puncture through the splittable lumen AshSplit [2] (Figure 2).

Figure 2. Types of catheters removed from patients on dialysis. They share a common feature, i.e. the presence of two channels, as far apart as possible, ending in such a way that light contact between the catheter and the vascular wall does not obstruct blood flow and does not block the suction holes on the catheter. The side holes encourage tissue ingrowth to secure the catheter in place, but in the future it will become an obstacle to simple removal.

Indications for dialysis catheter removal

Nowadays, it is becoming increasingly necessary to remove and replace chronic catheters because of a number of complications. There are many reasons why dialysis catheters (similar to venous ports or permanent pacing leads) should be removed:

1. Catheter-related infection (access site, tunnel and entry-site into the vein or combined with lumen infection and bloodstream infection),
2. Catheter-related endocarditis with (or without) vegetations and symptoms of systemic infection (sepsis) [22],
3. Catheter dysfunction (too high resistance to blood draw or blood flow) most frequently caused by a fibrin sheath at the catheter tip or the tip abutting the heart wall,
4. Catheter no longer required (creation of an AV fistula or stopping dialysis).

About 1/3 of catheter removals are performed due to infection, 1/3 due to alternative venous access site, and 1/3 due to catheter malfunction [23].

In general, no longer needed or infected catheters are removed whereas dysfunctional non-infected catheters are replaced possibly via the same access site.

Figure 3. Preoperative imaging. Fluoroscopy – assessment of catheter position in relation to major vessels, heart, assessment of the tip position (A), Phlebography – subclavian vein drain to superior vena cava (blue arrow) (B), Phlebography – visible collateral vessels (C), assessment of entry site through the skin – signs of local infection i.e. swelling and redness (D).

Organization and technique of dialysis catheter removal – personal experience

Longer catheter dwell times promote fibrous ingrowth and adhesion to the vessel or right atrial wall. The Cardiac Surgery Center in Zamość provides care to patients in the country, often after an attempted catheter removal by for instance vascular surgeons. Our Center has a long tradition of transvenous lead extraction (TLE). Based on our experience a multidisciplinary team for removal of dialysis catheters and venous ports has been formed and includes two operators – a cardiologist and a cardiac surgeon, an echocardiographer, instrument nurses, an anesthesiologist with a nurse anesthetist and a perfusionist.

The removal procedure is performed in the hybrid operating room of the Cardiac Surgery Ward, with cardiac surgical standby in case of an adverse event such as cardiac tamponade or injury to major veins. The patient is prepared as for a cardiac surgery, following an overnight fast, with two peripheral intravenous lines, and an arterial line most frequently placed in the radial artery for continuous blood pressure measurements and arterial blood gas sampling, connected to the cardiac monitor. After scrubbing the surgical field three times – the entire chest and groins (if cutting open the chest and femoral access are required), the patient is covered with a sterile dressing. Depending on expected technical difficulties and procedure-related risk the removal procedure is performed under local or general anesthesia. If the procedure is performed in the patient under general anesthesia, a probe with a transducer is passed into the esophagus for transesophageal echocardiography, allowing for immediate detection of cardiac tamponade, if it happens. The echocardiographer is also able to provide important clues to the possible adhesion of the catheter to veins or right atrium and update on the progress of catheter removal (Figure 3,4).

Figure 4. Fluoroscopy. Transducer for transesophageal echocardiography (A), Dialysis catheter in the patient with a pacemaker (B), Guidewire inserted in the catheter to make it stiffer before proceeding to another stage  – preparation (C), Stents in the venous system, for the management of catheter-associated venous obstruction (D).

If necessary, phlebography under fluoroscopic guidance is performed to exclude or confirm venous obstruction (Figure 3,4,5). The entire procedure is also performed under X ray control. After administering the general anesthetic, the skin is incised (often at two sites, i.e. the site where the catheter is inserted through the skin and at the closest possible location at which the catheter enters the vein), subcutaneous tissues are prepared and the cuff is removed. In a great majority of patients it is enough to locate the entry site into the vein, prep the skin, free the cuff and remove the catheter by simple traction [24,25]. When vascular access should be retained (which is especially difficult and important in case of venous obstruction) and when the catheter is adhered (it cannot be removed by simple traction) it is necessary to use the technique which we use for transvenous lead extraction (TLE). The procedure involves the use of Byrd telescoping polypropylene dilator sheaths (Cook®), (Figure 3,4) for intraluminal dissection of the catheter from the venous wall under fluoroscopic guidance often combined with transesophageal echocardiography monitoring. Conventional angiographic guide wires are passed through both catheter lumens to stiffen the line and preserve venous site in case of obstruction (Figure 4,5). Dissection through the fibrous tissue requires patience and gradual movement to minimize the risk of vein perforation or right atrial wall perforation. If we want to retain vascular access site (especially if no alternative vascular access sites are available), after catheter removal, we pass a guide wire through the Byrd sheath over which we can insert a new catheter [26]. If the catheter is removed due to local or systemic infection we take swab cultures from the catheter pocket, the catheter and the catheter tip.

We also have patients with venous obstruction who undergo simultaneous angioplasty to open a narrowed vein and stent implantation to reestablish and maintain normal blood flow (Figure 4).

Figure 5. Removal of a dialysis catheter. Polypropylene telescoping catheters Byrd (Cook®) seen in fluoroscopy (green arrow) (A); guide wires advanced into the dialysis catheter (B); red telescoping Byrd sheath passed over the dialysis catheter (C); the removed catheter with fibrous sheath at its distal tip (D).

In most cases no complications occur during or after the procedure and 2-3 days later the patient is discharged or sent back to the referring center. The complications that may arise are most frequently not life-threatening such as hematoma at the preparation site, prolonged bleeding from the entry site of the catheter into the vein. The hematoma (most commonly developing a day or two after the procedure) is evacuated, whereas bleeding is stopped by applying direct pressure or placing a stitch at the bleeding site. Life-threatening complications such as injury to the vein or cardiac tamponade are extremely rare. Cardiac tamponade can be detected immediately on the operating table by an echocardiogram. In such cases it is necessary to apply general anesthetic and make a surgical access incision. Depending on the location of the injury subclavian access, thoracotomy or sternotomy may be required. Sternotomy is performed also in case of cardiac tamponade. The bleeding site is managed with a surgical stitch, often using a felt pad. The anesthesiology team helps stabilize the patient using pressor amines, blood products, hemostatic agents and respiratory therapy. After the complication has been dealt with, the patient is transferred to the Cardiac Intensive Care Unit, and the entire length of hospital stay increases. Sternotomy is used only in extremely rare cases of stenosis, central vein thrombosis or catheter dislodgement (or its broken fragment) [27,28]. Our observations and the literature show that the risk of pulmonary embolism does not increase during the procedure and hospital stay, therefore routine anticoagulant treatment or embolic protection devices seem unnecessary [29].

The experiences of our team and other researchers show that transvenous removal of hemodialysis catheters is a safe procedure and may be recommended as the first-line treatment option [30,31,32]. Patients undergoing transvenous removal procedures avoid trauma of major surgery such as opening the chest, which is often associated with complications. The patient is offered a minimally invasive procedure with a high probability of complete success and a low risk of procedure-related complications. Endovascular approach and smaller injury (wound) favor early mobilization after the procedure and shorten hospital stay. Appropriate patient safety practice (operating room and procedure organization at the Zamość center) decreases the risk of major complications, and facilitates timely and protective intervention if an adverse event such as cardiac tamponade does occur. An important lesson that we have learned is that we should never underestimate the difficulty of a procedure. However, we know that catheter age and venous obstruction are the main determinants of procedure difficulty. To date, several studies have investigated the use of other techniques for removal of adherent hemodialysis catheters such as endoluminal catheter-based balloon dilatation  [33,34,35]. Using this technique fibrin sheath is disrupted and adheres to the catheter, thus creating access to the vessel lumen (ensuring vascular access through placement of a guide wire which may be utilized for insertion of a new catheter), and facilitating safe removal of the embedded catheter (Hong’s technique) [36,37,38,39,40]. As a greater number or rate of catheter insertions is associated with a greater number or rate of complications, tools and techniques will no doubt continue to evolve. Summing up, the factors that determine clinical success include appropriate patient selection for hemodialysis catheter placement (or creation of an AV fistula), the proper way of inserting a catheter, the proper location of the distal end confirmed by fluoroscopy, prevention of catheter-related infections, and timely patient selection for catheter removal.

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