Overview of Central Venous Catheters
Central venous catheters (CVCs) for hemodialysis may be non-tunneled (designed for acute episodes and temporary duration) or tunneled (for more chronic use over a longer duration). Acute CVCs are designed to be placed with minimum effort. They generally have double lumens, no subcutaneous cuff or locking device and utilize a short linear tunnel. Tunneled CVCs are dual-lumen, most often composed of silicone, polyurethane, polyethylene or polytetrafluethylene (PTFE) and contain a subcutaneous Dacron cuff for tissue in-growth or a plastic ‘‘grommet’’ to immobilize the catheter below the skin surface1. Central venous catheters are typically placed percutaneously into a large central vein (internal jugular or subclavian vein) through the superior vena cava (SVC) with the goal of placing the tips of the catheter at the junction of the SVC and the right atrium1. Alternative venous access points are external jugular, subclavian, and femoral veins. Right-sided catheters malfunction less often than left-sided catheters, and subclavian catheters should be avoided to help prevent subclavian stenosis2.
Central venous catheters allow immediate access to the circulation without the requirement for cannulation; however, these devices are plagued by their propensity for infection, thrombosis, inadequate blood flow, damage to large central veins, overall cost and increased mortality risk, all of which make their use problematic. Therefore, the Kidney Disease Outcomes Quality Initiative Guidelines (KDOQI) recommend CVC use for short-term and long-term in valid circumstances as follows2:
- AVF or AVG created but not ready for use and dialysis is required
- Acute transplant rejection or other complications requiring dialysis
- PD patient with complications that require time-limited peritoneal rest or resolution of complication (eg, pleural leak)
- Patient has a living donor transplant conﬁrmed with an operation date in the near future (eg, < 90 days) but requires dialysis
- AVF or AVG complication such as major inﬁltration injury or cellulitis that results in temporary nonuse until problem is resolved
Long-term or indefinite duration:
- Multiple prior failed AV accesses with no available options (see anatomic restrictions below)
- Valid patient preference whereby use of an AV access would severely limit QOL or achievement of life goals and after the patient has been properly informed of patient-speciﬁc risks and beneﬁts of other potential and reasonable access options for that patient (if available)
- Limited life expectancy
- Absence of AV access creation options due to a combination of inﬂow artery and outﬂow vein problems (eg, severe arterial occlusive disease, non-correctable central venous outﬂow occlusion) or in infants/children with prohibitively diminutive vessels
- Special medical circumstances
Patients with catheters have a significantly higher mortality risk than patients with arteriovenous fistulas (AVFs) or arteriovenous grafts (AVGs)3. In one study of 616 incident dialysis patients, the adjusted relative hazards of death were 1.5 for catheters (95% CI 1.0-2.2) and 1.2 for grafts (95% CI 0.8-1.8) when compared to AVFs4. Moreover, CVC patients have 2-3 times higher relative risk of infection-related hospitalization and death5. An analysis of the HEMO study, using time-dependent Cox regression adjusted for clinical center and the seven predefined clinical variables, found a significantly higher likelihood of infection-related death among patients dialyzing with CVC compared with those dialyzing with AVF (RR, 2.30 [95% CI, 1.45 to 3.64]; p < 0.001).
Similarly, the likelihood of first infection-related hospitalization or infection-related death was significantly higher for patients dialyzing with CVCs compared with those dialyzing with AVF (RR, 1.85 [95% CI, 1.47, 2.33]; p < 0.001)5. Central venous catheter-related bacteremia averages between 3.4 and 5.5 incidences per 1000 catheter days with the resultant potential for the development of complications including paravertebral abscess, endocarditis and death6. According to Patel et al., bloodstream infection (BSI) rate was highest in patients with temporary (non-tunneled) CVC followed by permanent CVC, AV graft and AV fistula (27.1 events/100 patient-months vs. 4.2 events/100 patient-months vs. 0.9 events/100 patient months vs. 0.5 events/100patient-months)7 CVCs are associated not only with greater mortality and hospitalization rates due to sepsis, but also with greater rates of all-cause hospitalization. Based on this data, KDOQI guidelines considers reasonable for the development of an infection control program to include an infection surveillance team to monitor, track, help prevent, and evaluate outcomes of vascular access infections and, in particular, CVC-related infections. The annual Medicare expenditures for patients with a CVC average approximately $25,000 more than for patients with an AVF8. For these reasons, CVC reduction is one of the primary actionable targets for improving overall hemodialysis patient outcomes.
- Ash SR. The evolution and function of central venous catheters for dialysis. Semin Dial. 2001;14(6):416-424. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11851926.
- Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4, Supplement 2):S1-S164. Available from: http://www.sciencedirect.com/science/article/pii/S0272638619311370.
- Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK. Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int. 2001;60(4):1443-1451. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11576358.
- Astor BC, Eustace JA, Powe NR, Klag MJ, Fink NE, Coresh J. Type of vascular access and survival among incident hemodialysis patients: The choices for healthy outcomes in caring for ESRD (CHOICE) study. J Am Soc Nephrol. 2005;16(5):1449-1455. Available from: https://pubmed.ncbi.nlm.nih.gov/15788468/.
- Allon M, Depner TA, Radeva M, et al. Impact of dialysis dose and membrane on infection-related hospitalization and death: results of the HEMO Study. J Am Soc Nephrol. 2003;14(7):1863-1870. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12819247.
- Nassar GM, Ayus JC. Infectious complications of the hemodialysis access. Kidney Int. 2001;60(1):1-13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11422731.
- Patel PR, Kallen AJ, Arduino MJ. Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients. Am J Kidney Dis. 2010;56(3):566-577. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20554361.
- Nordyke RJ, Reichert H, Bylsma LC, et al. Costs Attributable to Arteriovenous Fistula and Arteriovenous Graft Placements in Hemodialysis Patients with Medicare coverage. Am J Nephrol. 2019;50(4):320-328. Available from: https://pubmed.ncbi.nlm.nih.gov/31434095/.
P/N 101042-01 Rev A 03/2021