About 23%-41% of the dialysis population uses central venous catheters for access. For some catheter-dependent patients, percutaneous translumbar access has been considered a good alternative when traditional access sites have been exhausted.
To address safety concerns about translumbar catheters, Dr. Gregory J. Nadolski and his colleagues retrospectively studied all translumbar tunneled hemodialysis catheters (TDCs) placed between January 2002 and July 2011 at the Hospital of the University of Pennsylvania in Philadelphia. A total of 33 patients were included – 18 with a normal body mass index and 15 with a BMI greater than 25 kg/m2. All patients had central venous occlusion. The study included 92 catheters (33 initial placements) with a total of 7,825 catheter-days and a mean number of 2.8 exchanges.
Dr. Gregory Nadolski
All catheters were placed successfully, and over-the-wire exchange was never precluded by the presence of retroperitoneal fibrosis around the catheters. The major indications for exchanges or removal were catheter-related infection (n = 39), followed by malposition (n = 14), catheter malfunction secondary to occlusion (n = 11), and mature permanent vascular access (n = 7). Conversion to peritoneal dialysis (n = 3), functioning transplant (n = 2), malfunction and infection (n = 1), and unknown (n = 1) accounted for the rest of the patients, according to Dr. Nadolski, who presented the results at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.
At the time of the review, three translumbar dialysis catheters remained in use. Nine patients had died of non–catheter-related causes, and two were lost to follow-up. The catheter-associated infection rate was 0.51 per 100 catheter-days (n = 40, 19 normal BMI, 19 abnormal BMI, 2 LTFU [long-term follow-up]), Dr. Nadolski said.
The frequency of catheter infection was not significantly different between patients with normal and abnormal BMIs. The frequency of catheter exchange for malposition also was not significantly different. The median time catheter in situ (quartile range) between all patients – those with a normal BMI and those with an abnormal BMI – was not significantly different. The same held true for the median total access site interval (quartile range). There was also no significant difference between the three groups in the primary or secondary device service interval.
"The median time catheter in situ, median total access site interval, median primary device service interval, and median secondary device service interval were not statistically different between normal BMI and overweight patients," Dr. Nadolski noted. "In all, five complications occurred during 92 procedures, for a total complication rate of 5.5%. Two complications occurred in patients with normal BMIs and three in patients with abnormal BMIs, supporting the safety of translumbar TDCs as a whole as well as in overweight patients. Overall, we found the frequency of catheter exchange for infection and malposition to be similar for both normal and abnormal BMI patients. These findings support our hypothesis that translumbar access is no less effective in overweight and obese patients," he said.
"Obtaining durable functioning access for patients with limited central venous access is difficult. We prefer translumbar access over transhepatic access because of their propensity for malposition and migration related to respiratory motion. We found translumbar TDCs to be complicated by catheter migration/malposition in 19% of cases (n = 15). Compared to transfemoral catheters, we prefer to use translumbar access to leave the femoral and iliac veins available for surgical access creation or renal transplant, respectively," he added.