Tunneled Femoral Vein Catheterization for Lengthy Time period Hemodialysis: A Single Heart Expertise Al-Hwiesh AK, Abdul-Rahaman IS
Femoral veins have been used for many years to place short-term hemodialysis catheters. Few studies, nonetheless, describe its use for everlasting vascular entry. This examine describes the usage of tunneled femoral vein catheters as everlasting vascular accesses. Fourteen power hemodialysis sufferers (9 males and 5 females) had tunneled central venous catheters positioned within the femoral vein from November 2004 to July 2005. The age of the sufferers ranged from 21 to 68 years with a imply of 49.8 ± 5.9 years. Placement of a catheter through the interior jugular veins was unimaginable in 10 sufferers whose course was difficult by thrombosis or strictures of the superior vena cava. The remaining 4 sufferers had exhausted typical entry websites. The insertion of the femoral catheters concerned a subcutaneous tunnel that was created by retrograde passage of the catheter by way of the cannula to the purpose of exit at a preselected web site within the epsilateral thigh away from the groin. The life span of the tunneled femoral catheter ranged between 32-240 days; median time in place was 182 days. There have been 4 incidences of tunnel an infection with Pseudomonas aeruginosa, E. coli, and Streptococcus epidermidis, which have been handled efficiently with out the necessity for catheter elimination. Different problems reminiscent of bleeding, kinking, migration of the catheter, arterial puncture, retroperitoneal or femoral hematomas weren’t noticed. We conclude that tunneled femoral catheters are appropriate alternate options for long-term hemodialysis entry. Further research with a better pattern dimension are wanted to substantiate this conclusion.
Key phrases: Femoral vein, tunneled, an infection, thrombosis, hemodialysis
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Al-Hwiesh AK, Abdul-Rahaman IS. Tunneled Femoral Vein Catheterization for Lengthy Time period Hemodialysis: A Single Heart Expertise. Saudi J Kidney Dis Transpl 2007;18:37-42
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Al-Hwiesh AK, Abdul-Rahaman IS. Tunneled Femoral Vein Catheterization for Lengthy Time period Hemodialysis: A Single Heart Expertise. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2021 May 5];18:37-42. Out there from: https://www.sjkdt.org/textual content.asp?2007/18/1/37/31843
Blood stream infections are widespread and critical problems of central venous catheters used for hemodialysis. To lower catheter colonization, some physicians advocate tunneling the catheter within the subcutaneous tissue throughout insertion. This system has proved efficient in tunneled central catheters inserted in inside jugular and subclavian veins. ,,
Not too long ago, it has been discovered that the subclavian vein shouldn’t be used as a standard web site for catheter placement, since it’s related to a excessive incidence of vascular stenosis. , Therefore, vascular entry by way of the interior jugular vein is changing into the primary alternative. Nonetheless, repeated makes an attempt at cervical and thoracic vein catheterization have been related in lots of sufferers with a considerably excessive incidence of problems reminiscent of arterial accidents, vascular thrombosis, infections, and hemothorax. In others, these repeated makes an attempt have left the sufferers with no various cervical or thoracic venous entry websites. The percutaneous insertion of a tunneled femoral catheter could also be an appropriate possibility in these chosen sufferers.
This examine describes the expertise of our heart with the usage of tunneled femoral vein catheters as everlasting vascular accesses.
Fourteen power hemodialysis sufferers (9 males and 5 females) had tunneled central venous catheters positioned within the femoral vein from November 2004 to July 2005. The age of the sufferers ranged from 21 to 68 years with a median of 55 years (imply: 49.8 + 5.9). The sufferers’ traits are proven in [Table – 1].
All sufferers had initially obtained central strains through a subclavian vein, which have been eliminated both unintentionally or secondary to catheter obstruction or infectious problems. Placement of a brand new catheter through the interior jugular veins was imdoable in 10 sufferers who suffered from thrombosis or strictures of the superior vena cava. The remaining 4 sufferers had exhausted typical entry websites and no different choices have been left.
Polyurethane twin lumen tunneled catheters, 30 cm lengthy – 7 French with two 16-gauge channels – (Seldiflex, Plastimed, Saint Len, France) have been inserted utilizing the Seldinger methodology. Catheters have been inserted within the minor surgical procedure room beneath strict aseptic circumstances. The insertion web site was ready with povidone iodine or 0.5% chlorhexidine. The subcutaneous tunnel was long-established by retrograde passage of the catheter by way of the cannula to the purpose of exit at a preselected web site within the epsilateral thigh. The gap separating the cutaneous puncture web site from the venous entry needed to be approximately 10 cm. Intravenous tubing and semipermeable clear dressing (Opsite IV 3000, Smith and Nephew Med Ltd.,Hull, United Kingdom), have been modified routinely each 72 hours. Catheter dressings have been inspected by skilled nurses twice per week for the looks of native indicators of an infection. Blood sampling or administration of medicines weren’t permitted by way of the road. Catheter exit web site swabs and blood cultures have been collected on a weekly foundation. Blood move charge (as measured by pump pace), in addition to systolic and diastolic blood pressures have been recorded at half-hourly intervals throughout every hemodialysis session. Drop in blood move by better than or equal to twenty% beneath that prescribed within the absence of hypotension, hypovolemic episode, or affected person/catheter malposition was thought-about to be secondary to catheter malfunction. In all sufferers, blood move was stored at 300 ml/min or extra. A routine intradialytic heparin protocol was used.
The length of practical lifetime of the tunneled femoral catheter ranged between 32-240 days; median time and imply have been 182 and 149.3 + 13.8 days, respectively.
No problems occurred through the insertion process. One catheter needed to be eliminated after 86 days due to a profitable institution of an A-V fistula. One other catheter needed to be eliminated after 160 days due to catheter obstruction. The remaining 12 catheters functioned with out issues with a blood move of 300-350 ml/min throughout dialysis. There have been 4 incidences of tunnel an infection with Pseudomonas aeruginosa, E. coli, and Streptococcus epidermidis which have been handled efficiently with out the necessity for catheter elimination. In a single case, the process was difficult by femoral vein thrombosis related to E. coli bacteremia. Within the different 11 sufferers there have been no catheterassociated infectious problems. Different problems reminiscent of bleeding, kinking, migration of the catheter, arterial puncture, retroperitoneal or femoral hematomas weren’t noticed [Table – 2].
The femoral vein is the hemodialysis short-term entry web site of alternative by most nephrologists. Catheterization of the femoral vein is comparatively straightforward to carry out, protected and handy. In distinction to entry through the subclavian or inside jugular veins, which can contain life-threatening problems, there’s a comparatively low threat of insertion-related problems through the use of the femoral route. The heart beat of the femoral artery serves as a landmark for the vein; within the case of bleeding, the vessel could be immediately compressed towards the arduous surfaces of the femur and the pelvis. Thrombosis or constructions of the superior vena cava could preclude placement of a central catheter through the interior jugular route. In such sufferers, insertion of tunneled femoral vein catheters would appear to be a rational various. Lazrus et al  reported on 5 grownup sufferers present process transplantation of autologous bone marrow in whom tunneled femoral central venous catheters have been positioned and remained in place for a median of 35 days. There have been two infectious problems that resolved with antibiotic remedy with out elimination of the catheter.  One other report was revealed regarding an grownup affected person who obtained high-dose chemotherapy and allogeneic peripheral blood stem cell transplantation through a femoral Hickman catheter for recurrent high-grade nonHodgkin’s lymphoma; this catheter was efficiently used for 3 months.  Typical femoral vein catheterization has been ceaselessly related to infections due to fecal contamination.  An infection primarily originates from the pores and skin catheter junction,  particularly in catheters used for the quick time period; ,, that’s the reason it has been prompt that subcutaneous tunneling of the catheter may scale back the transmission of pathogens by growing the gap between the skin-catheter junction and the vein. In the meantime, the usage of tunneled catheters proved to be related to a three-fold lower in catheter-related sepsis.  An analogous conclusion has been reported by Timsit et al  in critically unwell sufferers. Though studies are conflicting, long-term cannulation of the femoral vessels for the aim of hemodialysis was believed to hold a better threat of an infection in comparison with non-femoral cannulation. , ,,,, Nonetheless, in a latest examine by Daniel, the incidence of catheterassociated infections with femoral catheters have been just like these beforehand reported with jugular catheters.  Within the current examine, the incidence of catheter-related web site infections and catheter -related bacteremia with tunneled femoral catheters was solely 28.6%, and seven.1%, respectively. Using subcutaneous tunneling to take away the exit web site of the catheter from the perineal space could have considerably decreased the danger of an infection. One other rationalization is the low incidence of thrombosis in our sufferers, as there’s an affiliation of thrombosis and sepsis. ,, As well as the comparatively quick length of the catheter in place (imply 149.3 + 13.8 days) could have contributed to the low incidence of catheter-related thrombosis in our collection, as earlier research,, have proven that thrombosis often happens after a median of seven weeks. For a few years, insufficient supply of blood move for dialysis has been a constant concern. Insufficient blood move could be divided into acute and power phases: acutely diminished move could also be because of systemic hypotension, catheter malpositioning, or different mechanical issues. Whereas diminished move occurring later could also be because of thrombosis or formation of a fibrin sheath, along with mechanical issues. 
Till not too long ago, blood move charges beneath 200 ml/min have been usually thought-about insufficient; nonetheless, the DOQI tips raised the usual for blood move charges by suggesting a minimal move charge of 300 ml/min. In our examine we didn’t encounter difficulties in reaching this purpose. We conclude that tunneled femoral catheters are appropriate alternate options for long-term hemodialysis entry. Further research with bigger pattern sizes are wanted to substantiate this conclusion.
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Correspondence Deal with:
Abdulla Ok Al-Hwiesh
King Fahd Hospital of the College P.O. Field 40246, Al-Khobar, 31952
[Table – 1], [Table – 2]