European Journal of Radiology j our nal homepage: www. el sevi er . com/ l ocat e/ ej r ad Insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations Kotsikoris Ioannis a,1 , Zygomalas Apollon b, , Papas Theofanis a,2 , Maras Dimitris a,3 , Pavlidis Polyvios a,4 , Andrikopoulou Maria a,6 , Tsanis Antonis c,5 , Alivizatos Vasileios d,7 , Bessias Nikolaos a,8 a Department of Vascular Surgery, Erythros Stauros General Hospital, Greece b Department of General Surgery, University Hospital of Patras, Greece c Department of Interventional Radiology, Erythros Stauros General Hospital, Greece d Department of General Surgery and Articial Nutrition Unit, Agios Andreas General Hospital of Patras, Greece a r t i c l e i n f o Article history: Received 14 March 2011 Received in revised form 4 June 2011 Accepted 7 June 2011 Keywords: Central venous catheter Angiographic technique Venography Hemodialysis Multiple catheterizations a b s t r a c t Introduction: Central venous catheter placement is an effective alternative vascular access for dialysis in patients with chronic renal failure. The purpose of this study was to evaluate the insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations in terms of efcacy of the procedure and early complications. Materials and methods: Between 2008 and 2010, the vascular access team of our hospital placed 409 central venous catheters in patients with chronic renal failure. The procedure was performed using the Seldinger blind technique. In 18 (4.4%) cases it was impossible to advance the guidewire, and so the patients were transported to the angiography suite. Results: Using the angiographic technique, the guidewire was advanced in order to position the central venous catheter. The latter was inserted into the subclavian vein in 12 (66.6%) cases, into the internal jugular vein in 4 (22.2%) and into the femoral vein in 2 (11.1%) cases. There was only one complicated case with severe arrhythmia in 1 (5.5%) patient. Conclusion: Our results suggest that insertion of central venous catheters using angiographic techniques in hemodialysis patients with previous multiple catheterizations is a safe and effective procedure with few complications and high success rates. 2011 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Adequate treatment for uremic patients on hemodialysis requires valid and lasting access to their vessels. Arteriovenous stulas (AVF) represent the main access option used for chronic stable patients, while central venous catheters (CVCs) are an
Corresponding author at: University Hospital of Patras, 26504, Rio, Patras,
Greece. Tel.: +30 6979326000. E-mail addresses: gkotsikoris@gmail.com(I. Kotsikoris), azygomalas@upatras.gr (A. Zygomalas), pfanis@otenet.gr (T. Papas), dimmaras@gmail.com (D. Maras), polpavlidis@yahoo.gr (P. Pavlidis), madric@gmail.com (M. Andrikopoulou), atsanis@gmail.com (A. Tsanis), valiviz@hol.gr (V. Alivizatos), bessias@otenet.gr (N. Bessias). 1 Red Cross Hospital, Athens, Greece. Tel.: +30 6932344686. 2 Red Cross Hospital, Athens, Greece. Tel.: +30 6945269717. 3 Red Cross Hospital, Athens, Greece. Tel.: +30 6977200553. 4 Red Cross Hospital, Athens, Greece. Tel.: +30 6973023916. 5 Red Cross Hospital, Athens, Greece. Tel.: +30 6979000005. 6 Red Cross Hospital, Athens, Greece. Tel.: +30 6934563456. 7 Agios Andreas General Hospital, Patras, Greece. Tel: +30 2613603888. 8 Red Cross Hospital Athens, Greece. Tel.: +30 6932375692. effective alternative for dialysis [1]. Importantly, CVCs should be placed when AVFs cannot be used (due to poor vascular status with previous AVF failure and/or while waiting for a newAVF to develop vessels that can be punctured), and the insertion should be carried out by experienced surgical teams in order to avoid complications [2,3]. Central vein stenosis is commonly associated with chronic CVC use. Placement of multiple catheters, longer duration, location in subclavian vein, and placement on the left-hand side of neck seem to predispose to the development of central vein stenosis [4]. The purpose of this study was toevaluate the insertionof central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations in terms of ef- cacy of the procedure and early complications. 2. Materials and methods FromJanuary 2008 to December 2010, the vascular access team of our hospital placed 409 central venous catheters for hemodial- ysis. CVCs were inserted at the bedside using the Seldinger blind technique. In 18 (4.4%) cases, it was impossible to advance the 0720-048X/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2011.06.025 I. Kotsikoris et al. / European Journal of Radiology 81 (2012) 22702272 2271 Fig. 1. (A) Venipuncture of the right subclavian vein, the arrow shows the needle. (B) The contrast is injected and a stenosis (arrow) in the right subclavian vein is revealed. (C) The guidewire (arrow) has been properly advanced. (D) Positioning of the central vein catheter (arrow) where the catheter tip should be adjusted to the level of the caval atrial junction or into the right atrium to ensure optimal blood ow. guidewire after at least 3 consecutive efforts and therefore these patients were transported to the angiography suite. There was no difference between patients with successful guidewire placement and those in whom the guidewire could not be safely advanced in terms of age, presence of diabetes, hyperlipidaemia, hypertension, and number of previous AVFs/CVCs. The present study included the 18 patients in whom the guidewire could not be advanced. Patient median age was 59.3 years (range 3978). Patients had multiple previous CVC with a median total indwelling time of 36 months. Each patient had a CVC (permanent or temporary) placement at least 6 times in the last 5 years. In all cases, written informed con- sent was obtained by the patient before the procedure. Using the angiographic technique, the contrast substance was injected into the central vein and the guidewire was appropriately advanced in order to position the CVC (Fig. 1). The placement of the CVC was in the subclavian vein in 12 (66.6%) cases, internal jugular in4 (22.2%) andinthe femoral veinin2 (11.1%) cases. We evaluated the efcacy of the procedure and the early complications. 3. Results In all patients in whom the bedside procedure failed, a steno- sis in the central vein (subclavian in 15 cases or internal jugular in 3 cases) developed. Dilatation of the stenotic vein was avoided to minimize risk of trauma and because of our teams poor experience in dilatation. Thus, the CVC was successfully inserted by the angio- graphic technique in 5 (27.7%) cases, while an alternative central vein was used in all other cases. However, in 2 (11.1%) patients, both the subclavian and the internal jugular vein developed steno- sis, and so the CVC had to be inserted into the femoral vein. In all cases, positioning of the CVCwas completedusing the angiographic technique. There was only one complication with atrial brillation in one (5.5%) patient. This was due to close contact between the heart and theCVCandoccurredduringtheprocedure. Thepatient was treated with amiodarone by the cardiologists and the arrhythmia resolved after 1h. 2272 I. Kotsikoris et al. / European Journal of Radiology 81 (2012) 22702272 4. Discussion Central vein stenosis is associated with placement of CVC and multiple catheters, longer duration, locationinsubclavianvein, and placement on the left-hand side of neck seem to predispose to the development of central vein stenosis [2]. In our study, we observed central vein stenosis in all the patients in whom the bedside pro- cedure failed. The National Kidney Foundation Kidney Disease Outcomes QualityInitiative (NKF KDOQI) guidelines for vascular access clearly determine the indications and the type of CVC that should be used inhemodialysis patients. The use of angiographic techniques is pro- posed for the insertion of both permanent and temporary CVCs [5]. Venography, color Doppler sonography and digital subtrac- tion angiography have been used to display the anatomy of the vascular region involved [5,6]. More recently, however, magnetic resonance venography (MRV) is being established as the most reli- able modality [7]. The latter was not used in our centre, as it was not available. Importantly, radiologic CVC insertion is generally safe, with complication rates lower than 5% [810]. This is conrmed in the present study, although the small number of patients prevents drawing rm conclusions. The radiologic technique allowed the identication of veins suitable for access in all the patients and the safe CVC positioning. 5. Conclusion Our results suggest that insertion of central venous catheters using angiographic techniques in hemodialysis patients with previous multiple catheterizations appears to be safe and effec- tive with few complications and high success rate. However, it must be borne in mind that our series is rather small, and so further conrmation in a larger patient population is needed. Conict of interest The authors and authors institutions have no conicts of inter- est. References [1] Desmeules S, Canaud B. Venous access for chronic hemodialysis: undesirable yet unavoidable. Artif Organs 2004;28:6116. [2] David A, Risitano DC, Mazzeo G, Sinardi L, Venuti FS, Sinardi AU. Central venous catheters and infections. Minerva Anestesiol 2005; 71:5614. [3] Niyyar VD. Anterior chest wall arteriovenous grafts: an underutilized form of hemodialysis access. Semin Dial 2008;21:57880. [4] Agarwal AK, Patel BM, Haddad NJ. Central vein stenosis: a nephrologists per- spective. Semin Dial 2007;20:5362. [5] Anonymous. NKF-K/DOQI clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis 2001;37:S13781. [6] Trerotola SO. Hemodialysis catheter placement management. Radiology 2000;215:6518. [7] Spritzer CE. Progress in MR imaging of the venous system. Perspect Vasc Surg Endovasc Ther 2009;21:10516. [8] RobertsonLJ, MauroMA, Jaques PF. Radiologic placement of Hickmancatheters. Radiology 1989;170:10079. [9] Mauro MA, Jaques PF. Radiologic placement of long-term central venous catheters: a review. J Vasc Interv Radiol 1993;4:12737. [10] Lyon SM, Given M, Marshall NL. Interventional radiology in the provision and maintenance of long-term central venous access. J Med Imaging Radiat Oncol 2008;52:107.