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.
Literatur
- 1
Astor B C, Eustace J A, Powe N R. et al .
Timing of nephrologist referral and arteriovenous access use: the CHOICE Study.
Am J Kidney Dis.
2001;
38
494-501
- 2
Brescia M J, Cimino J E, Appell K, Hurwich B J, Scribner B H.
Chronic hemodialysis using venipuncture and a surgically created arteriovenous
fistula.
J Am Soc Nephrol.
1999;
10
193-199
- 3
Brismar B, Hardtstedt C, Jacobson S.
Diagnosis of thrombosis by catheter phlebography after prolonged central venous
catheterization.
Ann Surg.
1981;
194
779-783
- 4
Capdevila J, Segarra A, Planes A M. et al .
Successful treatment of hemodialysis catheter-related sepsis without catheter
removal.
Nephrol Dial Transplant.
1993;
8
231-234
- 5
Cassidy F P, Zajko A B, Bron K M, Reilly J J, Peitzman A B, Steed D L.
Noninfectious complications of long-term central venous catheters: radiologic
evaluation and management.
Am J Roentgenol.
1987;
149
671-675
- 6
Churchill D N, Taylor D W, Cook R J. et al .
Canadian Hemodialysis Morbidity Study.
Am J Kidney Dis.
1992;
19
214-234
- 7
Cimochowski G E, Worley E, Rutherford W E, Sartain J, Blondin J, Harter H.
Superiority of the internal jugular over the subclavian access for temporary
dialysis.
Nephron.
1990;
54
154-161
- 8
Clase C M, Crowther M A, Ingram A J, Cina C S.
Thrombolysis for restoration of patency to hemodialysis central venous catheters:
a systematic review.
J Thromb Thrombolysis.
2001;
11
127-136
- 9
Deitel M, McIntyre J A.
Radiographic confirmation of site of central venous pressure catheters.
Can J Surg.
1971;
14
42-52
- 10
Fan P Y.
Acute vascular access: new advances.
Adv Ren Replace Ther.
1994;
1
90-98
- 11
Fant G F, Dennis V W, Quarles L D.
Late vascular complications of the subclavian dialysis catheter.
Am J Kidney Dis.
1986;
7
225-228
- 12
Gibson S P, Mosquera D.
Five years experience with the Quinton Permcath for vascular access.
Nephrol Dial Transplant.
1991;
6
269-274
- 13
Hinkelmann J.
Diagnostik und Therapie dialysebedingter Durchblutungsstörungen der oberen Extremitäten.
Dtsch Med Wochenschr.
2003;
128
2543-2546
- 14
Hoshal V L, Ause R G, Hoskins P A.
Fibrin sleeve formation on indwelling subclavian central venous catheters.
Arch Surg.
1971;
102
253-258
- 15
Johnson D W, Mac Ginley R, Kay T D. et al .
A randomized controlled trial of topical exit site mupirocin application in
patients with tunnelled, cuffed hemodialysis catheter.
Nephrol Dial Transplant.
2002;
17
1802-1807
- 16
Kherlakian G M, Roedersheimer L R, Arbaugh J J, Newmark K J, King L R.
Comparison of autogenous fistula versus expanded polytetrafluorethylene graft
fistula for angioaccess in hemodialysis.
Am J Surg.
1986;
152
238-243
- 17
Lay J P, Ashleigh R J, Tranconi L, Ackrill P, Al-Khaffaf H.
Result of angioplasty of Brescia-Cimino hemodialysis fistulae: medium-term follow-up.
Clin Radiol.
1998;
53
608-611
- 18
Malovrh M.
Approach to patients with end-stage renal disease who need an arteriovenous
fistula.
Nephrol Dial Transplant.
2003;
18
50-52
(Suppl 5)
- 19
Malovrh M.
Native arteriovenous fistula: preoperative evaluation.
Am J Kidney Dis.
2002;
39
1218-1225
- 20
Malovrh M.
Non-invasive evaluation of vessels by duplex sonography prior to construction
of arteriovenous fistulas for hemodialysis.
Nephrol Dial Transplant.
1998;
13
125-129
- 21
National Kidney Foundation .
NKF-DOQI clinical practice guidelines for vascular access 2000.
Am J Kidney Dis.
2001;
37
137-181
((suppl 1))
- 22
Overbosch E H, Pattynama P M, Aarts H J, Schultze Kool L J, Hermans J, Reekers J A.
Occluded hemodialysis shunts: Dutch multicenter experience with the hydrolyser
catheter.
Radiology.
1996;
201
485-488
- 23
Pisoni R L, Young E W, Dykstra D M. et al .
Vascular access use in Europe and the United States: Results from the DOPPS.
Kidney Int.
2002;
61
305-316
- 24
Prabhu P N, Kerns S R, Sabatelli F W, Hawkins I F, Ross E A.
Long-term performance and complications of the Tesio twin catheter system for
hemodialysis access.
Am J Kidney Dis.
1997;
30
213-218
- 25
Rodriquez J A, Armadans L, Ferrer E. et al .
The function of permanent vascular access.
Nephrol Dial Transplant.
2000;
15
402-408
- 26 Schwab S J, Butterly D. Hemodialysis vascular access,. Flagstaff, AZ in Henry
M, Ferguson R (eds): Vascular Access for Hemodialysis IV 1995: 27-35
- 27
Seddon P A, Hrinya M K, Gaynord M A, Lion C M, Mangold B M, Bruns F J.
Effectiveness of low dose urokinase on dialysis catheter thrombolysis.
ASAIO.
1998;
44
M559-M561
- 28
Shusterman N H, Kloss K, Mullen J L.
Successful use of double-lumen, silicone rubber catheters for permanent hemodialysis
access.
Kidney Int.
1989;
35
887-890
- 29
Suhocki P V, Conlon P J, Knelson M H, Harland R, Schwab S J.
Silastic catheters for hemodialysis vascular access: thrombolytic and mechanical
correction of malfunction.
Am J Kidney Dis.
1996;
28
379-386
- 30
Turmel-Rodrigues L, Pengloan J, Blanchier D. et al .
Insufficient dialysis shunts: improved long-term patency rates with close hemodynamic
monitoring, repeated percutaneous balloon angioplasty, and stent placement.
Radiology.
1993;
187
273-278
- 31
Uldall R, Besley M E, Thomas A, Salter T, Nuezca L A, Vas M.
Maintaining the patency of double-lumen silastic jugular catheters for hemodialysis.
Int J Artif Organs.
1993;
16
37-40
- 32
Vanherweghem J L, Cabolet P, Dhaene M. et al .
Complications related to subclavian catheters for hemodialysis.
Am J Nephrol.
1986;
6
339-345
- 33
Windus D W, Jendrisak M D, Delmez J A.
Prosthetic fistula survival and complications in hemodialysis patients: effects
of diabetes and age.
Am J Kidney Dis.
1992;
20
448-452
- 34
Woods J D, Turenne M N, Strawderman R L. et al .
Vascular access survival among incident hemodialysis patients in the United
States.
Am J Kidney Dis.
1997;
30
50-57
- 35
Zaleski G X, Funaki B, Kenney S, Lorenz J M, Garofalo R.
Angioplasy and bolus urokinase infusion for the restoration of function in thrombosed
Brescia-Cimino dialysis fistulas.
J Vasc Interv Radiol.
1999;
10
129-136
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