Date Published: March 27, 2017
Publisher: Public Library of Science
Author(s): Hari Talreja, Stephen Edward Ryan, Janet Graham, Manish M. Sood, Adnan Hadziomerovic, Edward Clark, Swapnil Hiremath, Vivekanand Jha.
With the increasing frequency of tunneled hemodialysis catheter use there is a parallel increase in the need for removal and/or exchange. A small but significant minority of catheters become embedded or ‘stuck’ and cannot be removed by traditional means. Management of embedded catheters involves cutting the catheter, burying the retained fragment with a subsequent increased risk of infections and thrombosis. Endoluminal dilatation may provide a potential safe and effective technique for removing embedded catheters, however, to date, there is a paucity of data.
1) To determine factors associated with catheters becoming embedded and 2) to determine outcomes associated with endoluminal dilatation
All patients with endoluminal dilatation for embedded catheters at our institution since Jan. 2010 were included. Patients who had an embedded catheter were matched 1:3 with patients with uncomplicated catheter removal. Baseline patient and catheter characteristics were compared. Outcomes included procedural success and procedure-related infection. Logistic regression models were used to determine factors associated with embedded catheters.
We matched 15 cases of embedded tunneled catheters with 45 controls. Among patients with embedded catheters, there were no complications with endoluminal dilatation. Factors independently associated with embedded catheters included catheter dwell time (> 2 years) and history of central venous stenosis.
Embedded catheters can be successfully managed by endoluminal dilatation with minimal complications and factors associated with embedding include dwell times > 2 years and/or with a history of central venous stenosis.
Access to the vasculature, afforded since the advent of the Quinton-Scribner shunt and the cannulation of the central venous system, has made hemodialysis possible for the last half century. Given the problems with infectious and mechanical complications, as well as the higher mortality associated with them, central venous catheters (CVC) are reserved only for patients who are unable to start hemodialysis with a permanent access, i.e. an arteriovenous fistula or graft. The realities of patient co-morbidity, however, result in a substantial proportion of hemodialysis patients with a CVC at any given time as their vascular access, which makes the issue of preventing and treating complications with CVCs, as they occur, of paramount importance.
We identified 15 patients who had tethered CVCs and had required endoluminal balloon dilatation for catheter removal (‘cases’) who were matched 1: 3 with 45 patients who had undergone uncomplicated CVC removal at the bedside using the standard method (‘controls’). The demographic characteristics of cases and controls are presented in Table 1.
In the largest case series to date involving endoluminal dilatation for embedded catheter removal, we found the procedure was well tolerated and with no discernable complications. All cases attempted were successful. Factors associated with embedded catheters included longer duration of CVC in situ and a previous history of central venous stenosis. These findings illustrate that endoluminal dilatation provides a safe potential alternative to traditional management strategies.