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Vascular and Interventional Radiology |
1 From the Department of Radiology, Division of Interventional Radiology (T.P.S., J.M.R.), and Department of Medicine, Division of Nephrology (D.N.R.), Duke University Medical Center, Room 1502, Durham, NC 27710. From the 2003 RSNA scientific assembly. Received May 1, 2003; revision requested July 1; final revision received October 12; accepted November 18. Address correspondence to T.P.S. (e-mail: smith146@mc.duke.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONADDENDUMREFERENCES |
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MATERIALS AND METHODS: Sixteen patients (seven men and nine women aged 21–77 years; mean age, 51.6 years) underwent placement of 21 transhepatic hemodialysis catheters. Transhepatic catheters were placed in the absence of an available peripheral venous site (11 patients) or for preservation of a single remaining venous site to achieve permanent vascular access. Safety was assessed by means of complications encountered, and catheter functionality was assessed by means of total access site service interval. Catheter patency was described by using a Kaplan-Meier survival curve, and number of catheter days were compared according to patient sex by using a two-sample t test.
RESULTS: Technical success was achieved in all patients. The mean total access site service interval was 138 catheter days (range, 0–599 days), and there was no significant difference according to patient sex (P = .869). Of the 16 catheters placed initially, five became dislodged and required an additional access procedure to be performed. These 21 catheters required 30 exchanges in 10 patients (48%) (range, 1–6 exchanges per patient). The most common reason for catheter exchange was device failure. There were six complications among 21 catheters placed (29%), including one death from massive intraperitoneal hemorrhage on the day after catheter placement.
CONCLUSION: Transhepatic hemodialysis catheters offer a viable option to patients with limited options; however, there are maintenance issues and complications.
© RSNA, 2004
Index terms: Catheters and catheterization, central venous access • Catheters and catheterization, complications • Dialysis • Liver, interventional procedures, 761.459
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONADDENDUMREFERENCES |
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Transhepatic venous access for dialysis was described by Po et al in a case report in 1994 (7). Since that time, case reports and one small series of three children have been reported (8–10). Although considered a viable approach, the transhepatic dialysis catheter is believed to carry substantial risks, including bleeding, biliary tract communication, infection, hepatic dysfunction, and dislodgment (11). The purpose of our study was to retrospectively review our experience regarding the safety and functionality of transhepatic hemodialysis catheters.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONADDENDUMREFERENCES |
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Technique
Thirteen patients required a single transhepatic access procedure. Because of catheter dislodgment, one patient required a second access placement procedure, and two patients required three access procedures, which resulted in a total of 21 separate transhepatic access sites in 16 patients. Five radiologists, whose experience as attending interventional radiologists ranged from 4 to 18 years, performed the 21 access procedures: Two radiologists placed four catheters each, and the other three radiologists each placed six, five, and two catheters.
Thirteen patients received the Ash Split Cath (Medcomp, Harleyville, Pa): Two patients received a 24-cm catheter, three patients received a 28-cm catheter, five patients received a 32-cm catheter, and three patients received a 36-cm catheter. Eight patients received the Hickman Hemodialysis/Apheresis 13.5-F round dual-lumen catheter (Bard Access Systems, Salt Lake City, Utah): Two patients received a 40-cm catheter, one patient received a 42-cm catheter, four patients received a 45-cm catheter, and one patient received a 50-cm catheter. Of the 21 catheter placements, 16 tips were positioned in the right atrium, four in the inferior vena cava (two directed inferiorly to just above the renal veins, and two in the proximal cava just below the right atrial junction), and one in the superior vena cava.
All patients underwent routine laboratory studies to evaluate biochemical, hematologic, and coagulation parameters. Prior imaging to determine patency of the hepatic veins or suprahepatic inferior vena cava was not performed routinely. All procedures were performed by using conscious sedation (intravenous fentanyl [Abbott Laboratories, North Chicago, Ill] and midazolam [Baxter Healthcare, Deerfield, Ill]) administered by dedicated interventional radiology nurses. The right upper lateral abdominal quadrant was prepared; with fluoroscopy, a 15-cm 21-gauge needle was placed approximately halfway through the liver in a direction parallel to the right and middle hepatic veins and directed toward the expected confluence of the hepatic veins (Fig 1a).
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All catheters were sutured in place. All patients were kept overnight for observation unless additional hospitalization was required for medical concerns unrelated to catheter placement or for complications of catheter placement. Complications were defined by the three authors in consensus as the necessity for any additional treatment or observational period.
Catheters were exchanged because of device failure or bacteremia without tract infection. The time from catheter placement to exchange constituted the initial device service interval. Exchange was performed in all cases as described previously (12) for more traditional catheter access sites. With regard to decreased function, the use of intracatheter thrombolytic agents was not included in the calculation of device revision rates (13).
Data and Statistical Analysis
Patient follow-up was performed by means of reviewing the hospital and dialysis records, as well as maintaining communication between the radiologists and the patients. No patients were lost to follow-up. Safety of catheter placement was empirically based on number and severity of complications encountered. Catheter functionality was based on access service interval in catheter days and was described by using the Kaplan-Meier survival curve. Catheters were censored if they were functioning at the time of patient death, if vascular access was placed at a different site while the current access site was still functioning, or if follow-up was complete. Such censored catheters were therefore included in the analysis while they were at risk but were not considered to have failed when they were censored. Catheter patency days were compared according to patient sex by using the two-sample t test. A P value of .05 was considered to indicate a statistically significant difference. Data analyses were performed by using SAS version 8.2 software (SAS Institute, Cary, NC).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONADDENDUMREFERENCES |
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One catheter was removed after commencement of successful peritoneal dialysis (26 days after catheter placement). Two catheters were removed for possible infection at 77 and 152 catheter days after placement. Both catheters were functioning and had nonpurulent access sites but had positive blood cultures. Cultures from both catheter tips were negative for bacterial growth, however. One patient still had a functioning catheter at the end of the follow-up period (599 catheter days).
There were 30 total catheter exchanges in 10 patients (48%). Number of exchanges per patient in this group ranged from one to six (median, 3.5 exchanges; mean, 3.0 exchanges). The initial device service interval (time to exchange) ranged from 1 to 178 days (median, 18 days; mean, 64 days) after initial catheter placement for the 10 patients. The most common reason for catheter exchange was decreased function (device failure) from catheter thrombosis or a fibrin sheath in nine patients. One catheter was exchanged 2 days after placement because of a hole in the catheter. Seven patients required additional catheter exchanges (ie, more than one) as follows: One patient required one exchange, one patient required two, four patients required three, and one patient required five (and the catheter is still functioning as of the writing of this article). The most common reason for repeat catheter exchange was device failure in eight cases (1–274 catheter days). Six catheters were exchanged because of unsatisfactory positioning: three for catheter kinking between the liver and abdominal wall (1, 14, and 17 catheter days, respectively) and three for tip migration and exposure of the fibrin cuff (11, 32, and 54 catheter days, respectively). Positive blood cultures without an infected tract necessitated exchange of three catheters at 6, 125, and 239 catheter days after the previous exchange. Three were exchanged because of catheter damage (two for a hole in the catheter, one for a cracked hub) at 6, 50, and 65 days, respectively. Of the 30 catheter exchanges, the catheter tip was placed in the right atrium in 26 procedures and in the inferior vena cava in four. Balloon angioplasty was performed during catheter exchange in two patients (one with a 10-mm balloon and the other with a 20-mm balloon) to disrupt a fibrin sheath.
Three patients had early device failure, which was defined as device failure that occurred up to 7 days after placement and required catheter exchange. Device failure occurred at 1, 2, and 3 days after catheter placement, and resulted from catheter occlusion in two patients (at 1 and 3 days) and a hole in the catheter in the third patient (at 2 days). Early exchange failure occurred in five patients because of device failure at 1 day in two patients, infection at 6 days in one patient, catheter damage at 6 days in one patient, and kinking outside the liver capsule at 1 day in one patient.
Thirteen catheters were either dislodged (five patients) or removed electively (eight patients). One patient whose catheter dislodged was admitted for hemorrhage but required no treatment, as noted later. One patient with mild coagulopathy underwent tract embolization with microfibrillar collagen (Avitene; C. R. Bard, Woburn, Mass) to prevent bleeding. No other complications regarding catheter removal were encountered.
Safety
There were six complications in the 21 catheter placements (29%) in 16 patients (38%). One patient presented to a local hospital with bleeding from the access site 18 days after catheter placement. The bleeding had ceased by the time the patient arrived at our center, but the transhepatic catheter was looped outside the liver capsule and required new access for catheter placement, which was performed at the time of removal of the dislodged catheter. One catheter kinked between the liver and the abdominal wall 1 day after exchange and required a second catheter exchange. A tear was noted in the liver capsule in one patient during catheter placement, and computed tomography (CT) was used to confirm a small perihepatic hematoma. The patient was stable throughout the procedure and during the immediate recovery period. She became hypotensive during dialysis several hours later, however, and was admitted to the intensive care unit, where she recovered.
One patient died from a previously diagnosed subdural hematoma upon return to the hospital room after catheter placement. Bleeding from the catheter tract occurred in one patient after catheter exchange. This was self-limiting but resulted in hospital admission for observation. One patient became hypotensive and tachycardic several hours after catheter placement. CT was used to diagnose massive intraperitoneal hemorrhage, and the patient returned to the interventional radiology department to undergo angiography (Fig 3a). Angiographic findings revealed hemorrhage from the right hepatic artery, which was embolized successfully (Fig 3b–d). Despite intensive medical therapy, however, the patient died the following day.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONADDENDUMREFERENCES |
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The technique for placement of transhepatic dialysis catheters is straightforward, especially for interventional radiologists who are experienced in percutaneous transhepatic cholangiography with drainage and the placement of tunneled dialysis catheters by means of other access locations. The contraindications to placement are much the same as those for percutaneous transhepatic cholangiography with drainage, including coagulopathy and ascites. We encountered only one problem during placement, which was a small tear of the liver capsule that did not require treatment. A catheter was successfully placed into a central venous location in all patients, and no patients were excluded.
The transhepatic catheter functioned well for vascular access in a number of patients. This is not surprising, however, since the catheter was placed for the most part in the right atrium, which has been shown to produce the best results at dialysis (14,15). However, long-term maintenance of this access was problematic. Five of the original 16 catheters (31%) dislodged prematurely, and the patients denied any exceptional trauma or pulling of the catheter. Along with complete dislodgment, kinking of the catheter outside the liver capsule was problematic in a number of patients, although we are still unable to predict if and when this will occur. We believe both kinking and catheter dislodgment are most likely the result of respiratory motion, which allows the catheter to migrate back between the liver and the thoracic wall. In addition, three catheters were exchanged because of damage, although two of these were in the same patient.
As with the more traditional access sites, a number of catheters also required exchange or removal because of decreased catheter function and infection. Catheter exchange for infection in this series always occurred in the setting of bacteremia that was treated with appropriate antibiotics, and in no patient was tunnel infection evident by means of gross inspection. Given this, the 21 catheters required 30 catheter exchanges for access maintenance. The reported secondary patency of central venous catheters at 12 months presents a wide range, from 25% to 98%, depending on the study (16). However, the center that reported 25% patency noted that at the time, catheters were removed for infection (including bacteremia) and dysfunction rather than the current practice of catheter exchange over a guide wire or stripping of a fibrin sheath (17). These figures apply almost exclusively to upper-body catheters with regard to dysfunction alone and exclude infection. One must concede that since alternative central venous access was poor or nonexistent in many of our patients, the usual criteria for catheter removal were not applied as readily. Finally, early failure (
7 days after placement) occurred in three patients (19%) and required catheter exchange. By using this same time frame, Wong et al (18) found an 8% early failure rate for catheters, the vast majority of which were placed by means of jugular or subclavian veins (97%). It is clear that we had greater difficulty maintaining the transhepatic access than the traditional upper body access.
A complication rate of 29% of the catheter placements in 38% of the patients is significantly higher than that reported for jugular access and higher than what we have encountered in our own experience (17,19). Despite normal or normalized coagulation parameters, bleeding represented four of the six complications and resulted in the only procedure-related death. It is clearly best if the patient is cooperative for needle placement, tract dilation, and final catheter placement. Unfortunately, many patients that require transhepatic access have no other available sites for even temporary catheters and present to the interventional suite in a poor constitutional state, in spite of exhaustive preprocedural medical care. However, we cannot state with certainty that the patients who experienced bleeding were in any different state or that the technical aspects of the procedure varied in any way from those in patients who did well.
Although embolization of the transhepatic tract during catheter removal has been advocated by some, we performed this in only one patient who was in fact no different than the others, and tract embolization was performed at the discretion of the interventionist (9,10). Interestingly, 13 catheters were removed electively or were dislodged prematurely. Only one patient had alleged bleeding complications. Although bleeding from this patient’s tract was reported by an outside referring center, the patient required no therapy upon arrival at our center and underwent placement of a new transhepatic catheter.
There are a number of limitations in the current study. It is an observational retrospective case series, and the intervention is therefore not directly compared with an alternative one. Data clustering (ie, the fact that some patients received more than one catheter) may also be a source of potential confounding. Five interventional radiologists performed the procedures; therefore, the technique, including the catheter type and tip locations, was not standardized but was rather at the discretion of each radiologist. Studies for the presence of a fibrin sheath were not performed, although angioplasty was performed twice empirically. Patients were not routinely evaluated for other possible untraditional access sites.
Although a difference in median number of access days between men and women was not apparent, the study may have been underpowered to detect such an association. In addition, this does not rule out associations between patient sex and mortality or patient sex and any other outcomes. Even given these shortcomings, however, this represents by far the largest series of transhepatic dialysis catheters and provides insight into the advantages and disadvantages of this particular access procedure.
Transhepatic catheter access for hemodialysis represents a viable option for patients who have exhausted other potential vascular access sites. It is associated with a finite complication rate, however, and requires a relatively high degree of maintenance to preserve functional access.
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ADDENDUM |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONADDENDUMREFERENCES |
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, T.P.S; study concepts, T.P.S., J.M.R., D.N.R.; study design, T.P.S.; literature research, T.P.S.; clinical studies, T.P.S., J.M.R., D.N.R.; data acquisition, T.P.S., J.M.R.; data analysis/interpretation, T.P.S., D.N.R.; statistical analysis, D.N.R; manuscript preparation, T.P.S., J.M.R., D.N.R.; manuscript definition of intellectual content, T.P.S.; manuscript editing, revision/review, and final version approval, T.P.S., J.M.R., D.N.R.
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONADDENDUMREFERENCES |
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This article has been cited by other articles:
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  G. J. Rosa-Diez, R. G. Lambertini, O. Peralta, L. H. Diodato, S. L. Algranati, and R. D. Garcia-Monaco Transhepatic venous access as an alternative for Tesio catheter in the case of a patient on haemodialysis with antiphospholipid syndrome Nephrol. Dial. Transplant., July 1, 2006; 21(7): 2031 - 2033. [Full Text] [PDF]
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