Haemodialysis access via inferior vena cava catheterisation

AGH Assounga*, MA Conrads#, TM Han*, SV Ramdial*. *Renal Unit, Dept of Medicine, Nelson R. Mandela School of Medicine University of KwaZulu Natal; #Dept of Radiology, Entabeni Hospital, Durban, South Africa. Address correspondence to: Prof. Alain Assounga Renal OPD, Inkosi Albert Luthuli Central Hospital Private Bag X03, Mayville 4058, South Africa, FAX: (+27-31) 240 3514 E-mail:[email protected] ABSTRACT Hemodialysis has made significant progress in both dialysis membranes that have become more and more biocompatible and machines that are now much safer and more user friendly. We have recently reported on hemodialysis/ultrafiltration contributing to the progress of non-renal specialties. However, despite such progress, vascular access may limit hemodialysis, especially in patients with poor veins. The lack of vascular access is unfortunately still one of the causes of death in patients with ESRD. We now report our experience with patients lacking conventional vascular accesses and dialyzed via inferior vena cava catheter. Seven patients have benefited from the insertion of 9 IVC catheters following a failure to obtain a functioning arterio-venous fistula or a femoral, subclavian or jugular catheterization. The inferior vena cava was punctured via a translumbar approach with an 18 gauge Cheeba needle. A 14 French dual lumen tunnel dialysis catheter is introduced co-axially over the guide wire following dilatation of soft tissues. The catheter was primed with heparin. Hemodialysis was perfomed 24 h later. IVC catheterization helped prolong the life of our 7 ESRD patients with minimal side effect. It should be considered whenever no other vascular access is possible. A regular review of the state of patients’ veins should be done to assess the development of adequate collateral that could be used for peripheral vein access. I INTRODUCTION Renal replacement therapy prolongs life both in acute and chronic renal failure. Hemodialysis (HD) has made significant progress over many decades. Hemodialysis is more and more accessible to many patients who are able to dialyse themselves. Dialysis membranes have become more and more biocompatible. Dialysis machines are now much safer and user friendly. In a recent review we have reported that Hemodialysis/ultrafiltration contributes to the progress of non-renal specialties including end stage liver disease, bridge to cardiac surgery [1]. However, despite such progress vascular access may limit hemodialysis use especially in patients with poor venous capital. Arterio-venous (AV) fistula the best form of access may be lost following thrombosis. Sub-clavian, jugular or femoral catheters may be used but is often associated with thrombosis, or stenosis. The use Inferior vena cava (IVC) catheter has been reported in hemodialysis [2-4]. IVC catheter use is not widely practiced and the lack of vascular access is unfortunately still one of the causes of death in patients with ESRD. Expertise may be lacking when the need arises. We now report on our experience with patients lacking conventional vascular accesses and are dialyzed via inferior vena cava catheter. The IVC access for haemodialysis may not be the last one as other accesses may become available through development of collaterals or resolution of occlusion. . II Methods A Double lumen IVC catheter set was inserted following a Seldinger Technique as described earlier [5]. Briefly the patient is placed prone or lateral gauge Cheeba needle 1.5-2cm is introduced into midline and just above the right iliac crest at the L3 vertebral level under fluoroscopic guidance (Fig.2). A 14 French dual lumen tunnel dialysis catheter is introduced co-axially over the guide wire following dilatation of soft tissues (Fig. 3, Fig 4). The catheter was primed with heparin. Hemodialysis was performed 24 h later and continued on regular basis 3 times. All patients who underwent the procedure were included in the study. Their files were reviewed retrospectively. The outcome and complications related to IVC catheters were recorded. III. Results Out of 78 patients haemodialysed at Addington hospital’s hemodialysis unit, 7 patients have benefited from the insertion of 9 IVC catheters following a failure to obtain a functioning arterio-venous (AV) fistula or a femoral, subclavian or jugular catheterisation from 2002-2007. Their ages spun from 20 to 41 years old. The mean age was 33 years. There were 3 males and 1 female. The indication was occlusion of all conventional accesses (Fig 1). Two patients had their catheter replaced for being torn. Infection of the catheters was encountered in 4 out of 7 patients Staphylococcus aureus was found in 2 patients and pseudomonas aerugenosa was cultured in one patient. Three patients died: one died after 16 months from a cerebral bleed probably related to ADPKD, one died from catheter related sepsis after 14 months, and one died from further catheter occlusion after 9 months. The average duration of IVC catheters was 11.1 ±1.5 months (range 2-19 months). Three selected cases below highlight the course of the patients following the catheter insertion. Patient 1. N.S. A 41-Year-old female patient with a diagnosis of end stage renal disease secondary to autosomal dominant polycystic kidney disease treated by dialysis since 1994, she received CAPD for one year then was on hemodialysis. Fashioning of AV fistula in September 2000; and June 2002, were not successful. Patient was subsequently hemodialysed via subclavian and femoral catheters in January 2001 and July 2002 respectively. Patient was subsequently haemodialysed 3 times per week via IVC catheter inserted under fluoroscopy in September 2002, after having obstruction of most veins usually used for vascular access. An IVC catheter placed worked well for 2 months then cracked at the external tip and was successfully replaced by another that performed very well for 14 months until the patient died suddenly following a massive cerebral bleed. Patient 2. R.R. A 28-year-old male patient with End stage renal disease (ESRD) was treated by chronic dialysis for 3 years. The aetiology of chronic renal failure was unknown. On past history, patient had insertion of Tenckhoff catheter for Continuous ambulatory peritoneal dialysis (CAPD) on 2 previous occasions in early 2001 and removed in July 2001 and the abdomen was found to be frozen. An arterio-venous fistula fashioned in 01/2001 failed. A renal transplant scheduled in October 2001 was abandoned because the dissection was found to be hazardous due to extensive fibrosis. The patient was being treated by haemodialysis via IVC permanent catheter inserted on 03/2002 after diagnosing the occlusion of all great venous vessels was confirmed by Doppler and venogram. The IVC catheter functioned very well for 8 months, and then was torn at exit site. The IVC catheter was successfully replaced and is functioning well. A review of venous Doppler of upper body done revealed a good venous flow. A radio-radial arterio-venous fistula was subsequently fashioned and is functioning well. Patient 3. B.B. A 40-Year-old patient with End stage renal disease of unknown etiology was treated by haemodialysis since June 1999 at Addington Hospital following a failure of CAPD. In his past history hypertension and diabetes mellitus were diagnosed 5 years earlier and were well controlled. Ultrasound done in October 2002 revealed that the left kidney was not clearly visualized while the right kidney measured 7.2 cm and echogenic. An AV fistula fashioned in November 2001 was ligated in May 2002 due to obstruction. A venogram confirmed blockage of major venous vessels (Fig. 1). Femoral catheterization attempts were unsuccessful as it was impossible unable to advance guide wire due to occlusion. Patient commenced on PD on 9/10/2002 lack of vascular access pending IVC catheterization. Permanent HD catheter (IVC) was inserted by Seldinger technique on 21/10/2002, an infection of IVC catheter with staphylococcus aureus was recorded and was successfully treated with Vancomycin. All the patients’ characteristics and outcome of IVC catheters are summarized in Table 1. IV. Discussion IVC catheterisation helped prolong the life of our 7 ESRD patients. As in previous studies IVC catheterisation was offered when all other HD accesses failed [6,7]. Expertise to perform the technique needs to be developed to improve success and reduce the risk of injury [8]. It must be stressed that a regular review on complications are comparable to other studies [2,3]. Ideally, patients should have arterio-venous fistulas fashioned before reaching end stage renal failure. This should be part of the preparation for hemodialysis. This will avoid the risk of using of catheters with their associated complications. Unfortunately in our setting, the majority of patients are diagnosed at the end stage of renal failure requiring urgent dialysis. With early detection and screening for renal disease and better education of the public as vascular access has could be fashioned timeously and avoid unnecessary use of catheters leading to numerous complications. Other unconventional venous accesses such as catheterisation of common femoral vein have been reported [4]. However the site is prone to infection. Recanalization of occluded, should be considered whenever no other conventional vascular access is possible [9-11]. A regular review of the state of patients’ veins should be done to assess the development of adequate collaterals that may allow use peripheral vein access. The replacement of IVC catheter can safely be performed [12]. IVC catheter complications have been reported. Thrombosis of IVC may be treated using a wallstent [13,14]. Although IVC catheterisation seems to be the ultimate vascular access for hemodialysis, Thrombosis of IVC may still occur. Other options may become available and need to be considered in patients [15]. IVC catheter has been used for indications other than hemodialysis. Haire et al., reported their experience in peripheral stem cell apheresis and transplantation [16]. As a life saving technique, IVC catheterisation is not well known. It should be included into nephrology/hemodialysis textbooks and be taught to nephrologists/intervention radiologists placing hemodialysis catheters to avoid unnecessary death of patients for lack of vascular access. A regular exam of venous vasculature needs to be pursued to reveal other simpler vascular accesses that may become usable for hemodialysis. REFERENCES 1. Han TM, Nankissor, Pearce A, Assounga AG. Hemodialysis and ultrafiltration. A bridge to cardiac surgery. Saudi Med J. 2004; 25:1301-1303. 2. Matsagas MI, Gouva CD, Charissis C, Katopodis KP, Fatouros M, Kappas AM. Vascular access for haemodialysis in extreme situations: surgically placed inferior vena cava catheter. Nephrol Dial Transplant. 2004; 19: 752. 3. Bonomini V, Mioli V, Albertazzi A, Vangelista A. Percutaneous aorta-inferior vena cava catheterization with external shunt for recurrent hemodialysis in organic acute renal insufficiency. Arch Ital Urol Nefrol. 1968; 40: 279-288. 4. 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Am J Kidney Dis. 1988; 11: 515-518. 15. Jean G, Chazot C, Vanel T, Charra B, Terrat JC, Calemard E, Laurent G. Central venous catheters for haemodialysis : looking for optimal blood flow. Nephrol Dial Transplant. 1997; 12: 1689-1691. 16. Haire WD, Stephens LC, Kotulak GD, Schmit-Pokorny K, Kessinger A Double-lumen inferior vena cava catheters for peripheral stem cell apheresis and transplantations. Transfus Sci. 1995; 16: 79-84. Table 1: Profile of patients haemodialyzed via IVC catheter ----------------------------------------------------------------------------- ---------------------------------------------------- Patient Age/Sex Nephropathy Indication Durat. IVC cath. Complication Outcome --------------------------------------------------------------------------------------------------------------------------------- # 1 41/F ADPKD Occlusive veins 2;14 months torn; Nil Functioning cath. Death(cerebral bleed) # 2 28/M Unk Vein thrombosis 8;10 months torn; Nil Resolved, AV fistula # 3 40/M Unk Occlusive veins 19 months infection Functioning cath. # 4 20/M CGN Vein thrombosis 9 months occlusion Replaced, by Cath. in collateral femoral vein # 5 30/M CGN Vein thrombosis 11 months recurrent Functioning infection # 6 27/F CIN Vein occlusion 13 months infection Functioning # 7 32/F Unk Vein occlusion 14 months infection Death --------------------------------------------------------------------------------------------------------------------------------- ADPKD: autosomal dominant polycystic kidney disease Unk: unknown CGN: chronic glomerulonephritis CIN: chronic interstitial nephritis Fig1: X-ray fluoroscopy of a patient showing the obstruction of right internal jugular vein. Fig 2: X-ray Fluoroscopy of a patient showing puncture of inferior vena cava. Fig 3: X-ray Fluoroscopy of a patient showing puncture of a guide wire inserted in the vena cava. Fig 4: X-ray Fluoroscopy of a patient showing puncture of a guide wire inserted in the vena cava