Hintergrund und Fragestellung: Subkutan implantierte Dialysekatheter werden zunehmend als Gefäßzugang für
Patienten mit dialysepflichtiger Niereninsuffizienz verwendet. Ursächlich liegen
höheres Alter der Patienten sowie zunehmende frustrane Fistelanlagen zugrunde.
Wir berichten über unsere Erfahrungen mit der Implantation und Anwendung von „gecufften”
Vorhofkathetern als Alternative zur arteriovenösen Fistel.
Patienten und Methodik: Vom 1.5.2001 bis zum 28.2.2003 wurden konsekutiv 258 Dialysekatheter bei 203
Patienten (122 Männer, mittleres Alter 70 ± 12 Jahre), entsprechend 1,3 Katheter/Patient,
implantiert. Nach Aufklärung und schriftlichem Einverständnis erfolgte in Lokalanästhesie
unter Durchleuchtung die Implantation der Dialysekatheter über die Vena jugularis
interna, subclavia oder femoralis. Sämtliche Ereignisse und Komplikationen wurden
in einem Follow-up von mindestens 6 Monaten nach Implantation verfolgt.
Ergebnisse: Die mittlere Zeitdauer der Katheterimplantation lag bei 38 ± 12 min mit einer
primären Erfolgsrate von 100 % und einer Häufigkeit relevanter periprozeduraler
Komplikationen von 6 %. Bei 147 Patienten (72 %) waren im Follow-up bei einer
medianen Verweildauer der Katheter von 9 Monaten keine korrigierenden Interventionen
erforderlich. Ein Katheterfluss < 200 ml/min trat mit einer Häufigkeit von
einer Episode pro 41 Patientenmonate auf. In der Hälfte dieser Fälle konnte jedoch
ein ausreichender Blutfluss durch nicht oder wenig invasive Interventionen wiederhergestellt
werden. Die Häufigkeit infektiöser Komplikationen lag bei einer Episode pro 16
Patientenmonate. Eine infektionsbedingte Katheterexplantation war in einem Fall
pro 73 Patientenmonate erforderlich. Bakterielle Endokarditiden traten im
Studienverlauf nicht auf.
Folgerungen: Subkutan-implantierte Dialysekatheter stellen insbesondere bei älteren Patienten
mit limitierter Lebenserwartung und schlechten Gefäßverhältnissen, bei fraglicher
Indikation zur chronischen Hämodialyse sowie als Überbrückung vor elektiver Shuntanlage
bzw. bei Shuntdysfunktion einen alternativen Gefäßzugang zur Nierenersatztherapie
mit hoher primärer Erfolgs- und niedriger peri- und postprozeduraler Komplikationsrate
dar.
Background: Silastic cuffed catheters play an increasing role in providing long-term vascular
access for hemodialysis. The reasons for this were related to increased patient
age and an increased number of patients who had exhausted sites for vascular access.
We report our experience with subcutaneously tunnelled cuffed hemodialysis catheters.
Method: From May 1, 2001 to February 28, 2003, 258 consecutive hemodialysis catheters
were placed in 203 patients (122 men, mean age 70 ± 12 years) as access for hemodialysis
(1.3 catheters/patient). Catheter implantation was explained to all patients and
a protocol consent form was signed. The catheter was implanted via the internal
jugular, subclavian or femoral vein and the correct final catheter position was
determined fluoroscopically. Short and long-term catheter-associated complications
were collected from the time of catheter insertion until a follow up of at least
6 months after implantation.
Results: The mean duration of implantation procedure was 38 ± 12 minutes with an initial
clinical success rate of 100 % and a periprocedural complication rate of 6
%. The median catheter indwell time was 9 months with a primary patency rate of
72 % at the end of the follow-up. Inadequate flow rate < 200 ml/min was noted
at one per 41 patient-months but sufficient blood flow was restored in 50 % of
these patients with non- or semi-invasive interventions. Bacteremic episodes
occurred at a rate of one episode per 16 patient-months. Catheter removal due
to severe exit site infections or bacteremic episodes were necessary at one per
73 patient-months. There were no cases of bacterial endocarditis.
Conclusion: Subcutaneously tunnelled cuffed venous hemodialysis catheters are a safe und
highly feasible vascular access with a low complication rate and a long use-life
especially for elder patients with limited life expectancy, exhausted sites for
vascular access or in case of failing hemodialysis arteriovenous fistulas.
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Dr. med. Martin Brueck
Medizinische Klinik I, Klinikum Wetzlar-Braunfels
Forsthausstraße 1
35578 Wetzlar
Phone: 06441/792327
Fax: 06441/792328
Email: Martin.Brueck@hkw.med.uni-giessen.de
