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Vascular and Interventional Radiology |
1 From the Departments of Radiology (T.D.W., S.O.T.), Medicine-Nephrology (M.A.K.), and Medicine-Biostatistics (K.A.L.), Indiana University School of Medicine, Indianapolis. Received June 7, 2002; revision requested August 9; revision received October 25; accepted January 8, 2003. Supported by a grant from Bard Access Systems, Salt Lake City, Utah. Address correspondence to S.O.T., Department of Radiology, Hospital of the University of Pennsylvania, 1 Silverstein, 3400 Spruce St, Philadelphia, PA 19104 (e-mail: streroto@uphs.upenn.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Ultrasonographic (US) evaluation of the right internal jugular vein was performed by interventional radiologists in 143 patients with a history of dialysis catheter placement. The examination focused on the detection of right internal jugular vein thrombosis, with or without occlusion. Total catheter days, catheter type, and catheter-related complications, most notably infection, were evaluated with database analysis for possible association with subsequent development of thrombosis. Statistical analysis of potential risk factors was performed with logistic regression models and 
2 tests.
RESULTS: Evidence of right internal jugular vein thrombosis was present in 25.9% of the patients enrolled in the study. Among the veins with thrombosis, 62% were occluded. Only the mean number of catheters placed in the right internal jugular vein per patient was significant below the level of P = .20; therefore, a multivariate logistic regression model was not used.
CONCLUSION: Prevalence of internal jugular thrombosis, both complete and incomplete, was higher in the study population than previously reported. The risk factors that were analyzed demonstrated no statistically significant association with development of thrombosis.
© RSNA, 2003
Index terms: Catheters and catheterization, complications, 907.442, 9462.442 • Dialysis, 81.42 • Veins, access, 907.1269, 9462.1269 • Veins, thrombosis, 907.442, 9462.442 • Veins, transluminal angioplasty, 907.1269, 9462.1269
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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The purpose of our study was to determine the prevalence of internal jugular vein thrombosis among patients undergoing hemodialysis in whom tunneled dialysis catheters were placed by interventional radiologists and to evaluate the potential risk factors for thrombosis, such as the number of catheters per patient inserted through the right internal jugular vein, catheter type and material, total catheter days, and catheter-associated infection.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Evaluation and Imaging of Patients
Each patient’s involvement in the study was limited to one encounter. Every encounter included a discussion of catheter-related history; a directed physical examination with a specific search for scars from prior catheter insertions, signs of infection, and venous collaterals; and US evaluation of the right internal jugular vein. The same investigator (T.D.W.) performed all patient examinations in the dialysis center, that is, the US examinations in this study were not performed as part of catheter placement but rather specifically for this study. Thirty-six patients were still using a right internal jugular vein catheter for dialysis at the time of examination, though the majority had surgical fistulas or grafts. US was performed with either a 7.5- (128; Acuson Computed Sonography, Mountain View, Calif) or 5.0-MHz (180 Plus; SonoSite, Bothell, Wash) linear transducer. Both gray-scale and color Doppler imaging were included in the sonographic assessment.
The right internal jugular vein was evaluated from the mandibular angle to the clavicle. Thrombosis was defined by (a) visualization of an intravascular filling defect, (b) noncompressibility of the vein, (c) intraluminal defect at color Doppler imaging, or (d) any combination of the above. Thrombosis was considered occlusive if there was nonvisualization of even partial luminal patency and complete absence of color Doppler flow. To improve visualization of a collapsed internal jugular vein, patients were requested to perform a Valsalva-type maneuver (eg, deep cough, bearing down) (11).
Results of the physical and US examinations, as well as key elements of the history, were recorded on data sheets designed to preserve anonymity. Individual results were not disclosed, nor treatment offered. More detailed information regarding catheter history such as number of catheters per right internal jugular vein per patient, total catheter days, catheter type, and catheter-related infections was incorporated from a comprehensive quality-assurance database and review of medical records. The catheter database includes the following information: reason for catheter placement (eg, hemodialysis, chemotherapy), access site, catheter type, periprocedural and late complications, imaging modality for access, dates of catheter placement and removal, and total catheter days. All follow-up information not in the database, all US information, and clinical information at the time of US were obtained by one investigator (T.D.W.) and reviewed by other investigators (M.A.K., S.O.T.). The catheters used during the 7 years preceding the study included 14.5-F polyurethane (AshSplit, MedComp, Harleysville, Pa; Optiflow, Bard Access Systems, Salt Lake City, Utah), 13.5-F silicone (Hickman; Bard Access Systems), and 12.5-F silicone (MedComp) catheters.
Statistical Analysis
Descriptive statistics were calculated for all variables. For continuous data, these included means, SDs, medians, and ranges. Descriptive statistics included proportions for the binary data and the number in each category for the categoric variables. 2 tests were used to identify categoric variables that may have an association with thrombosis, including catheter type, catheter material (polyurethane or silicone), and the presence of documented catheter-related infection. Logistic regression was used to identify simple associations between thrombosis and continuous independent variables, including total catheter days and total number of catheters. Stepwise logistic regression was performed for multivariate model selection by using P 
.20 for entry and P .15 for exit.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Patients had had between one and six catheters, with an average of 2.1 catheters ± 1.2 (SD) and a median of 2.0 catheters. Nine types of 13.5–14.5-F dialysis catheters were placed among this group of patients. However, 86 (60.1%) of the 143 patients had only one type of catheter. In regard to the material of the catheters, 78 (54.5%) of 143 patients had polyurethane catheters, 33 (23.1%) had silicone catheters, and 32 (22.4%) had both types of catheters. The totals and percentages of thrombosis for the various materials were as follows: polyurethane, 15 of 78 (19%); silicone, 11 of 33 (33%); and both materials, 11 of 32 (34%).
The exact total catheter days were known for all but 14 patients. For 12 of the 14 patients, the actual usage could be determined with review of the medical records to within a several-week estimation of accuracy. This variable was examined with both inclusion and exclusion of patients whose total catheter days were estimated by providing average total catheter usage time of 10.0 months ± 8.6 (range, 10 days to 51.0 months) and 10.3 months ± 8.7 (range, 10 days to 51.0 months), respectively. Included in these calculations was one outlier, a patient who used a catheter for 51.0 months (the next closest actual usage was 28.3 months). By excluding this outlier, the average usage was 9.6 months ± 8.6, which is based on exact values only, and 10.0 months ± 8.7, when estimated values were also included. Further analyses regarding catheter usage were performed both with and without this patient.
Fifty (35.0%) of 143 patients had a documented infection; 16 of the 50 (32%) also had thrombosis. However, the infection and thrombosis did not necessarily occur synchronously or even with the same catheter. Of the 93 patients without a documented infection, 21 (23%) had thrombosis.
The Table shows the results from the univariate logistic regression models and 2 tests. Only the mean number of catheters placed in the right internal jugular vein per patient was significant below the P = .20 level; therefore, a multivariate logistic regression model was not utilized.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Past research in which subclavian and internal jugular access outcomes were compared has led to the usage of the right internal jugular vein as the preferred site for hemodialysis catheter placement. Cimochowski et al (15) detected a 50% stenosis rate of the subclavian and a 0% stenosis rate of the internal jugular vein following insertion of temporary dialysis catheters. The percentage of stenosis of the subclavian and internal jugular vein was reported as 42% and 10%, respectively, among a hemodialysis population in a study of Schillinger et al (16). Authors of a retrospective study (17) in which the two approaches were compared found a higher overall complication rate for subclavian access versus access with the internal jugular vein, with infection as the predominant complication of both. It has been demonstrated with venographic follow-up that the incidence of central venous stenosis associated with tunneled dialysis catheters placed by interventional radiologists is low (18).
While most research has concentrated on venous stenosis and thrombosis in the central veins (ie, subclavian, innominate, and superior vena cava), authors of very few studies have focused more exclusively on the long-term complications of internal jugular hemodialysis access. Agraharkar et al (8) reported a 2% incidence of thrombosis among 101 veins cannulated with a silicone rubber catheter (Cook). However, more recent literature, and our own experience, indicate higher rates of thrombosis. Forauer and Glockner (10) found 18 patients with total occlusion and 11 patients with nonocclusive thrombus among 79 patients scheduled for dialysis catheter placement. Our results, with 16% complete thrombosis and 26% thrombosis of the internal jugular vein overall, appear similar to those of Forauer and Glockner, although they did not establish the prevalence of jugular thrombosis in their entire dialysis population. By examining a hemodialysis population in whom catheters were placed radiologically during a short period of time, we were able to estimate the prevalence of the right internal jugular vein thrombosis in this population. This does not establish the incidence of right internal jugular vein thrombosis for one or multiple catheter placements; to determine that, patients would need to be followed up longitudinally with serial US examinations after catheter placement. Jassal et al (19), in a retrospective case series, concluded that the long-term safety of the internal jugular approach (vs subclavian) may be misleading, and they emphasized the importance of primarily using arteriovenous grafts and fistulas. This mirrors the National Kidney Foundation Dialysis Outcomes Quality Initiative, or DOQI, (20) recommendations that "less than 10% of chronic maintenance hemodialysis patients should be maintained on catheters as their permanent chronic dialysis access."
In contrast to thrombosis of the subclavian or innominate vein, internal jugular thrombosis or stenosis is often clinically occult. This is owing to the development of extensive venous collaterals and the isolation of internal jugular thrombosis from the high outflow drainage from the upper extremities. However, internal jugular thrombosis can become symptomatic when there is central propagation of a clot into the innominate vein and/or superior vena cava, impairment of hemodialysis catheter function, or a thromboembolic phenomenon (ie, pulmonary embolism) (21,22). In our study, clinical signs such as jugular venous distention or edema at the time of examination were uncommon and did not consistently correlate with the presence of internal jugular thrombosis.
Despite being clinically occult, internal jugular thrombosis results in loss of the preferred access site for temporary and tunneled catheters, and in keeping with the spirit of vein preservation extolled by the DOQI guidelines, it must be considered a serious complication. When bilateral, jugular thrombosis may lead to the use of far less desirable access sites for catheterization, including the subclavian and femoral veins. The progressive loss of access sites secondary to thrombosis must be avoided if at all possible. Our results reinforce the concept that hemodialysis catheters, even when inserted through the internal jugular vein, are not a benign form of venous access for dialysis.
The main limitation of our study is that only the prevalence, not incidence, of internal jugular thrombosis was investigated. With baseline assessment of the parent vein routinely performed as part of the preprocedural work-up, future studies in which the focus is on incidence of thrombosis could be readily implemented on a large scale. Although we have complete data regarding the catheters placed by interventional radiologists, it is possible that patients might have had catheters placed before they entered our system or had nontunneled catheters placed by nephrologists or other practitioners. In our institution, this is unlikely, however, because all tunneled catheters and virtually all jugular nontunneled catheters are placed by interventional radiologists. Since this had been the case for 7 years preceding this study, we believe this represents a fairly homogeneous population and that the results are valid. We acknowledge that in this patient population, history may not always be reliable; however, the detailed quality assurance database had all insertion and nearly all removal data, and by virtue of detailed patient records kept in the dialysis center, episodes of infection or symptomatic thrombosis were, we believe, accurately captured.
Though no specific risk factors for the development of thrombosis were identified in our study, such variables merit further evaluation in subsequent investigations. Future investigations of internal jugular catheters should probably include an assessment of the incidence of internal jugular vein thrombosis. These studies may help guide strategies for the reduction of thrombotic and other complications. Until such a reduction is achieved, however, we must adhere to the guidelines set forth by DOQI and limit catheter use in favor of surgically created fistulas and grafts.
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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  M. Allon Current Management of Vascular Access Clin. J. Am. Soc. Nephrol., July 1, 2007; 2(4): 786 - 800. [Abstract] [Full Text] [PDF]
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