The role of the interventional radiologist in the management of dialysis patients continues to expand, encompassing both placement and maintenance of many forms of venous access. Central venous catheter placement may be indicated both for patients who require temporary hemodialysis and for those who are awaiting renal transplantation or maturation of surgical prosthetic grafts or fistulae. In this article, the authors discuss key placement, management, and complication issues of hemodialysis catheters.
Management of hemodialysis catheters
Ziv J. Haskel, MD, FSCVIR and Michael C. Cohn, MD
is Associate Professor of Radiology and Director of the
Interventional Radiologic Research Laboratory, and
is Clinical Instructor in Radiology at the Hospital of the
University of Pennsylvania in Philadelphia, PA.
In 1991, approximately 200,000 Americans were treated for
end-stage renal disease 60% with hemodialysis (HD).
In 1993, over 160,000 patients with chronic renal failure underwent
The yearly incidence of patients with end-stage renal disease has
nearly doubled during the last decade. Although renal
transplantation is the preferred treatment for most renal failure
patients, the availability of donor organs continues to limit
growth in the number of transplants. Thus, most patients are
maintained with hemodialysis. As the average age of the U.S.
population continues to rise, both the prevalence of dialysis and
associated comorbid conditions increase.
Creation and maintenance of vascular access for hemodialysis
continues to present a complex challenge for nephrologists,
surgeons, and interventional radiologists. Present methods of
dialysis access include surgically created arteriovenous fistulae
(e.g., Brescia Cimino fis tulae
, prosthetic arteriovenous grafts, and dual lumen central venous
catheters. Many physicians consider the autogenous radiocephalic
fistula to be the most desired option because of its high long term
patency and low rate of associated complications. Indeed, the
Dialysis Outcomes Quality Initiative (DOQI) guidelines recommend
that physicians try to establish working native fistulae in as many
dialysis patients as feasible.
Despite the relatively trouble free nature of mature
arteriovenous fistulae, the majority of patients in the United
States are dialyzed through prosthetic grafts. Results from the
Medicare End-Stage Renal Disease program revealed that 83% of
patients who were dialyzed for more than 3 months were treated with
These grafts carry their own set of complications, including
pseudoaneurysms, infection, ipsilateral extremity edema due to
venous hypertension and, above all, graft thrombosis. Graft failure
most commonly is the result of smooth muscle cell proliferation at
and just beyond the venous anastomosis, and often it requires
repeated angioplasty, stenting, or surgical revisions to preserve
Central venous catheter placement for HD has replaced the
original Scribner external arteriovenous shunt.
The procedure may be indicated for patients with acute renal
failure requiring temporary HD, and for patients awaiting renal
transplantation or maturation of surgical prosthetic grafts or
fistulae. In some cases, these catheters must provide life long HD
access because all potential fistula sites have been depleted. In
1979, Uldall et al emphasized the advantages and convenience of
transvenous subclavian access using a double lumen catheter.
Since then, many centers have reported their results using similar
catheters for temporary and permanent HD access.
Temporary hemodialysis catheters
Temporary hemodialysis catheters are noncuffed, semistiff,
tapered, dual lumen devices designed for short term HD,
plasmapheresis, or photopheresis. They are available in a variety
of lengths and are placed using standard percutaneous techniques.
The majority of temporary HD catheters are constructed of
polyurethane, which has the advantage of tensile strength, allowing
construction of large bore catheters with thin walls. It is also
stiff enough for percutaneous insertion without a sheath, and yet
it softens in response to body temperature.
Typically, a 15-cm long catheter is suitable for right internal
or external jugular catheters, while 20-cm devices are necessary
for left-sided catheters. These catheters can be bonded with
antiseptic substances, such as silver sulfadiazine and
chlorohexidine, which may decrease bacterial colonization of the
While some investigators have reported satisfactory long-term
success using these catheters,
most practitioners agree that tunneled access catheters provide
improved catheter stability and lower infection rates when used for
long-term access. DOQI guidelines recommend use of a tunneled
catheter if the length of catheterization is expected to exceed 3
In our experience, the steps required to tunnel and place a cuffed
long-term catheter add little additional time to catheter
insertion. Accordingly, we now place tunneled catheters in all
patients in whom we anticipate the need for more than 2 weeks of
HD. This policy has reduced catheter infection rates and the
incidence of accidental catheter withdrawal, and has improved
patient acceptance of central catheters. The exceptions to this
policy include patients with bacteremia and those with
uncorrectable coagulopathies. Ideally, prothrombin time (PT) should
be corrected to less than 16 seconds, international normalization
ratio (INR) less than 1.3, and platelets to more than 50,000/mm
before tunneled catheter placement; for translumbar catheter
placement, the PT is corrected to normal if possible. In patients
with bacteremia, placement of a tunneled catheter is deferred until
blood cultures are proven to be negative and the patient is
afebrile for at least 24 hours.
Long-term/permanent HD catheters
In the past 5 years, percutaneous placement of long-term or
permanent hemodialysis catheters by radiologists, nephrologists,
and surgeons has dramatically increased. The advantages of
radiological placement include accurate and safe venipuncture using
sonographic guidance, precise final catheter positioning, the
ability to provide same day service, the use of light conscious
sedation instead of general anesthesia (and resultant shorter
recovery times), and the potential for reducing costs (figure
A properly positioned tunneled, left internal jugular
hemodialysis catheter. Note the smooth curve of the catheter in
the subcutaneous tunnel (arrows). The catheter tip is in the
The technical skill in catheter placement under fluoroscopic and
sonographic guidance that is intrinsic to interventional radiology
makes primary catheter misplacement and malfunction rare. This has
driven corporate development toward catheters and introduction kits
more suited to nonsurgical techniques. A number of commercial
catheter sets have been developed to approach these goals. They are
largely distinguished by the outer shapes of the catheters (round
vs oval), the shapes of the lumina (semilunar vs round), and
whether they are a single catheterdouble lumen design, or a twin
cathetersingle shaft design. Most of these catheters have a Dacron
cuff that is positioned within the subcutaneous tunnel at least 2
cm from the skin exit site. The Dacron cuff eventually becomes
ingrown with connective tissue and provides a secure anchor and
mechanical barrier to infection.
Placing the catheter tip in theright atrium results in fewer
catheter malfunctions when compared to placing the tip in the
superior vena cava.
The results of catheter placement can be assessed in terms of
technical success, complication rates, vascular thrombosis,
catheter patency, and infection rates. Unfortunately, much of the
relevant published literature on these topics consists of
retrospective reviews of single site experiences. Prospective
comparative trials of different catheter designs and placement
approaches are forthcoming.
Technical success can be defined as the ability to introduce a
tunneled catheter into a venous location to allow immediate and
effective HD. In one of the largest series of radiologist placed
catheters, Lund et al retrospectively reviewed the outcome of 237
subclavian tunneled silastic catheters. Immediate technical success
was not noted.
Nevertheless, operators should expect a very high technical success
rate once they become familiar with central venous punctures and
catheter placement techniques.
Relatively caudal jugular catheterization between the two heads
of the sternocleidomastoid muscle generally is preferable to the
anterior approach because of the resultant gentler curve and less
kinking of the catheter as it turns caudally into the subcutaneous
tunnel. The external jugular vein, often prominent in HD patients
because of their high intravascular fluid states, also can be used
for vascular access. Particular attention must be paid to the
course of the catheter as it passes from the external jugular
venotomy to the subcutaneous tunnel. In our experience, catheters
placed in this vessel may be more prone to kinking because of the
highly superficial position of the catheter and the sharp turn it
must make into the tunnel (figures 2,3,4).
Demonstration of use of the external jugular vein for tunneled
catheter placement. The superficial entry into the vein has led
to kinking of the catheter (arrow).
Unsatisfactory catheter function due to poor catheter positioning
and fibrin sheath formation. A tunneled catheter was introduced
through a high internal jugular approach (arrow). The catheter
tip lay against the wall of the superior vena cava (curved
arrow). A fibrin sheath encases the catheter shaft within the
inominate vein (arrowheads).
Inadvertent catheter retraction. An initially well positioned
leftsided catheter (A) pulled back several centimeters after the
patient sat up (B). The operator did not take into account the
effect of the thick soft tissues overlying this patient's
In the last few years, small transducer sonographic units have
become available for vascular guidance (e.g., Site Rite, Bard
Access Systems, Salt Lake City, UT). These relatively inexpensive
units can easily be moved from room to room and sterilely draped.
Sonographic guidance of jugular punctures has proved invaluable in
choosing venous access sites (particularly in patients with
multiple prior catheters) and in minimizing puncture site
complications. In over 400 HD catheter placements and
reinterventions, our technical success rate has exceeded 97%.
Procedurerelated pneumothoraces have proved extremely rare, to the
point that routine chest radiographs after sonographically guided
venipunctures are no longer obtained. While serious complications
have been reported with catheter placement, the incidence is
typically less than 1% (table 1).
|Reported complications of
dialysis catheter placement
|Exit site/ tunnel infection
|Septicemia / bacteremia
|Subclavian/carotid artery injury
|Thoracic duct injury
|Right atrial puncture
|Brachial plexus injury
For many years, both temporary and long-term HD catheters have
preferentially been placed into the subclavian veins. Prospective
venographic studies have since documented catheter-related
subclavian vein stenoses and thromboses in 42 to 50% of patients.
Left-sided catheters also are more prone to cause problems, perhaps
due to constant motion of the catheter against the wall of the
inominate vein. Venous obstructions can develop remarkably quickly.
In a study of 52 patients with temporary subclavian and internal
jugular HD catheters, Cimochowski et al found that 50% of
subclavian catheter patients developed marked venous stenoses (mean
catheter dwell time of 11.5 days) compared with internal jugular
catheter patients (no incidence; mean catheter dwell time 15 days).
Agraharkar et al sonographically evaluated 96 patients who
underwent 144 separate internal jugular vein HD catheter placements
(116 veins). Only two jugular thromboses related to percutaneous
catheter placement were found (1.7%), compared with five (4.3%)
found in patients who underwent surgical cannulation.
A catheter tip positioned within the cephalic portion of the
superior vena cava has also been linked to a higher risk of central
venous thrombosis (figure 5).
Superior vena cava syndrome caused by the tip of a dialysis
catheter positioned within the distal superior vena cava (arrow).
The cavagram, performed from a right internal jugular approach,
demonstrates retrograde flow within the azygous (open arrow) and
hemiazygous (curved arrow) veins.
Subclavian vein stenosis may lead to transient ipsilateral arm
swelling until venous collaterals sufficiently enlarge. In non-HD
patients, the thrombosis may prove of little clinical importance.
Yet, in HD patients it can render that arm useless for surgical
creation of a permanent arteriovenous access because of the
resultant venous hypertension. While central lesions can often be
treated with thrombolysis, angioplasty, and stent placement, most
surgeons choose not to create an arteriovenous fistula or graft
peripheral to a previously stenotic or thrombosed subclavian or
inominate vein which has been angioplastied or stented. However, we
have recanalized and stented occluded brachiocephalic veins in
order to provide a route for HD catheter placement. In general, it
must be emphasized that subclavian catheters should not be placed
in patients who have or may need permanent upper extremity HD
Use of the right internal jugular vein (IJV) obviates many of
the risks associated with subclavian vein access. The right IJV
approach also makes placement easier because the large peelaway
sheaths through which the catheters are advanced are less likely to
kink, given the straight line of access. Accordingly, right IJV
catheter approaches should be the primary choice for HD catheter
placement. If possible, occluded IJVs should be recanalized in
order to avoid use of secondary access sites (figure 6).
A 55-year-old woman with failed extremity accesses now requires
permanent dialysis catheters. Both left and right
catheter-related inominate and subclavian occlusions developed,
requiring venous stent placement. (A) A right arm venogram. The
right subclavian and inominate vein stent is occluded (arrow).
Collateral veins supply the superior vena cava. The left
inominate vein stent was also occluded (not shown). (B) After
long-term failure of multiple transhepatic dialysis catheters,
transhepatic access was used to assist in recanalization of the
occluded right inominate vein stent. The stent was punctured
directly, and a guidewire was threaded through the occlusion,
snared, and exteriorized through the transhepatic approach
(arrows). (C) An angioplasty balloon was threaded through the
mesh of the stent and used to create a channel within the
occluded stents. (D) Finally, a tunneled hemodialysis catheter
was inserted through the stent mesh. (Images courtesy of Michael
C. Soulen, MD, Hospital of the University of Pennsylvania,
When IJV access is no longer feasible, translumbar catheters
provide a viable alternative route.
Although common femoral vein catheter placement is straightforward,
femoral catheters possess a higher rate of infection, a risk of
pelvic vein thrombosis, and the theoretic possibility of excessive
mechanical stress upon a catheter due to motion at the hip joint.
Despite these caveats, in our opinion, alternate approaches should
be exhausted before resorting to subclavian catheter placement. In
patients with extensive central venous and caval thrombosis,
successful transhepatic and intercostal collateral vein placement
of catheters has proven useful (figure 7).
A transhepatic dialysis catheter. The leading tip of the catheter
has been directed into the caudal inferior vena cava. In this
case, thrombus has formed around the catheter tip (arrow); the
clot was removed using a combination of lytic and mechanical
means (not shown).
Poor catheter flow may be caused by catheter malpositioning,
migration, thrombosis, or fibrin sheath formation. Fibrin sheath
formation around indwelling catheters is a common biologic response
to all existing venous catheters.
In a 1971 autopsy study, Hoshal et al found that fibrin enveloped
most catheters within 5 to 7 days of insertion.
In that series, fibrin deposition began at the venous entry site
and at the leading end of the catheter where the tip contacted the
vein wall. Fibrin deposition spreads onto the entire catheter from
these two sites of intimal injury. This process, in large part,
accounts for non-infection-related loss of catheter function. The
angiographic signs of fibrin sheath formation include a filling
defect around the catheter tip, occlusion of contrast flow through
the end hole of the catheter, or backflow of contrast along the
side of the catheter within the sheath (figure 3).
Many companies have touted improved catheter function and
durability based upon their unique designs (figure 8). As an
example, the Tesio Twin Cath (Medcomp, Harleysville, PA) is said to
provide a longer interval to failure because each of its single
lumen catheters has multiple side holes and a larger effective
lumen. Intuitively, larger bore catheters will deliver higher
initial flow rates, allowing shorter HD sessions. Whether such
catheters provide durable high flow must still be addressed.
Several paired lumina or split-tip design catheters have been
touted as providing higher dialysis flow rates.
In fact, it is difficult to compare patencies of different
catheter designs because of widely varying definitions of loss of
catheter function. In some series this is simply not defined, while
in others it is defined as catheter occlusion or inability to
sustain HD flow rates above 200 ml/min.
In other reports, loss of patency was defined as catheters that did
not respond to urokinase therapy and required removal. These
reporting differences account, in large part, for the wide range
reported (1.4% to 50%) of thrombotic complications.
Ideally, catheter function is best described using a clear
definition of function and life-table or Kaplan-Meier analysis.
Using the aforementioned definition of low flow rates and/or
occlusion, Lund et al reported an overall cumulative patency of 44%
at 6 months and 25% at 12 months.
In our review of 114 tunneled HD catheters, 6-month patency was 55%
and 12-month patency was 50%. In our series, loss of patency was
defined as catheters from which blood could not be aspirated or
injected through one or both ports, or catheters in which
consistently adequate flow rates (greater than 250 ml/min) could
not be achieved despite repeated use of transcatheter urokinase.
Trerotola et al randomly placed conventional 13.5-F silicone HD
catheters or high flow splittip cathetersin 24 patients requiring
tunneled access. These researchers found that both catheters
delivered acceptable flow rates (within DOQI recommendations),
although the split tip catheter did provide higher effective flow
These results emphasize the need for larger scale, prospective,
comparative trials of different catheter designs, as well as
research aimed at blunting the thrombotic response to all such
Infection is the second most common cause of catheter
malfunction. Site infections can range from mild erythema to
purulent exit site and tunnel infections.
typically cause these infections. Bacteremia and septicemia also
can be caused by these pathogens, although more virulent
gramnegative rods (e.g.,
species) often are implicated. A number of techniques can be used
to decrease catheter related infections:
1) Use of surgical hand scrubs, hats, and masks worn during
insertion of catheters, as well as use of barriers such as sterile
drapes, gowns, and gloves.
2) Skin preparation with chlorohexidine at the time of catheter
insertion. This has proven more effective than povidone iodine or
alcohol in the prevention of infection during insertion of
percutaneous intravascular devices, although additional studies are
recommended for verification.
3) The use of antiseptic or silver ion-impregnated cuffs. This
may reduce risks of catheter infections by inhibiting migration of
bacteria into the puncture site.
4) Coating catheters with heparin. This has been found to reduce
the incidence of catheter infections in some studies.
5) Coating catheters with antimicrobial agents. This has reduced
the rate of catheter-related infections. However, the role of such
catheters in HD patients is unclear, as their bacteriocidal
activity is measured in weeks.
6) Use of prophylactic antibiotics before catheter placement has
not been shown to decrease the rate of catheter-related infection.
7) The use of permeable dressings such as gauze and tape
dressings has a lower risk of insertion site colonization and,
therefore, catheter related infections when compared with
transparent, relatively impermeable adhesive dressings.
Impermeable transparent dressings can actually increase the rate of
catheter infection by creating a warm, moist, contained environment
that promotes growth of microbial organisms on the skin.
Other risk factors for catheter infection include fever or
bacteremia at the time of insertion, and the age of the patient
(children have a higher rate of infection when compared to adults).
HIV disease has not, in and of itself, been associated with an
increased risk of infection.
In addition, the duration of catheterization has been strongly
linked to increasing the risk of infection. In a review of 786
non-tunneled HD catheter placements, Vanholder et al found a
significantly increased incidence of bacteremia in catheters left
in place for more than 10 days.
The bacteremia rate in the "chronic" group was 7.2% (mean catheter
dwell time 23 days) versus 3.4% in short-term patients (mean
catheter dwell time 6.1 days). Infection rates with tunneled
catheters appear to be lower than their non-tunneled equivalents,
although a risk remains, in part, related to the duration of
catheter placement. Schwab et al reported one episode of bacteremia
in a prospective study of 80 PermCaths (Quinton, Bothell, WA)
(median catheter use 8 weeks, range 3 to 22 weeks). Twenty-three
site infections were treated successfully with antibiotics.
Moss et al reported one episode of bacteremia in 54 patients (0.49
episodes per 100 patient-months), and nine site infections (5.3
episodes per 100 patient-months).
A study-to-study comparison of infection rates is difficult due to
inconsistencies in data reporting. Therefore, catheter infection
rates are probably best described in a manner that reflects the
duration of catheter placement. Lund et al reviewed several recent
studies with this approach, calculating infection rates using
life-table analysis, number of events per 100 days at risk, and
time to first catheter infection (table 3). In their study, there
were 32 episodes of infection (18.5%), seven of which were treated
conservatively with antibiotics. The infection rate was 0.20 per
100 days at risk. The probability of infection-free survival was
0.71 and 0.56 at 6 and 12 months, respectively. Notably, only one
site infection developed within 2 weeks of catheter placement. Our
infection rate in placing catheters under similar conditions is
15%, with a frequency of 0.15 per 100 days at risk.
The above data strongly support the contentionthat HD catheters can
be safely placed under sterile conditions outside of the operating
room without an increase in catheter infection rates.
Strategies for maintaining catheter function
The initial accumulation of thrombus or fibrin around the
catheter tip of the arterial (red) port impairs the ability to
withdraw blood at a rate sufficient to allow adequate HD. However,
this process may not yet affect the distal venous (blue) port, so
that reversal of the port connections to the dialyzer may allow the
treatment to proceed. This provides a temporizing effect and may
still yield unsatisfactory HD, as higher recirculation may occur
Venographic signs of fibrin sheath formation. This patient had
undergone prior left inominate vein stent placement for treatment
of an elastic, flow-limiting stenosis (arrow). (A) Contrast
injection into the venous (distal) port demonstrates a subtle
filling defect around the catheter tip (arrow). (B) Contrast
injection into the arterial (proximal) port demonstrates a
clear-cut filling defect around the catheter tip (arrow). There
is retrograde filling of the azygous vein (curved arrow),
reflecting the partial occlusion of the superior vena cava.
Initial medical management of failing catheters is instillation
of a thrombolytic agent into the catheter lumina. This has proven
effective at restoring function in most cases. A number of
different regimens can be used, ranging from a single per port
infusion of urokinase (Open-Cath, Abbott Laboratories, Abbott Park,
IL, 5000 IU/cc) to high dose infusions of higher concentrations of
urokinase (50,000 IU/cc).
The Open-Cath solution typically is allowed to dwell for 20 to 30
minutes, with repeated periodic attempts at catheter aspiration.
This process can be repeated with longer dwell times (30 to 60
minutes) before HD is reattempted. Six- to 12-hour infusions of
urokinase also have been successful.
Low dose warfarin (1 mg/day) appears to reduce the incidence of
catheter related thrombosis as well.
Additionally, in a study of bone marrow transplant patients, a
reduction of catheter thrombosis from 20% to 3.2% was found in
patients receiving 325 mg aspirin perday.
Earlier this year, urokinase was removed from the U.S. market by
the Food and Drug Administration (FDA). While there is currently no
specific recombinant tissue plasminogen activator (rt-PA)
formulation for catheter clearance, it is expected that one will
become available in the near future (Genentech, Personal
communication, May 1999).
When thrombolysis fails to restore patency, standard therapy
consists of catheter removal and insertion of a new catheter at a
different access site. The disadvantage of this approach is the
surrendering of a venous access site in patients with limited
potential access sites. Crain et al reported success using
percutaneous fibrin sheath stripping to prolong the functional
patency of failing catheters (blood flow rates <200 mL/min).
In this technique, a nitinol loop snare was used to tightly
encircle the catheter tip and strip the encasing sheath from the
catheter. Forty procedures were performed on 24 catheters in 23
patients. Immediate technical success was 100%, with a calculated
median added patency of 2.8 months. The procedure was repeated in
several patients to restore and prolong catheter function.
In contrast, our experience led us to abandon the above
technique because it appeared to provide no durable benefit in
improving catheter function.
Twenty-four procedures were performed on 22 patients with occluded
or failing catheters (blood flow rates <250 mL/min). Although
occluded catheters were reopened and failing catheters demonstrated
marked improvement in flow rates, these changes disappeared within
five HD treatments.
Currently, we manage failing catheters by exchanging existing
catheters over guidewires for new catheters through the existing
subcutaneous tunnels. This is rapidly performed on an out-patient
basis using local anesthesia (lidocaine with epinephrine) at the
catheter entry site and along the subcutaneous tract. The catheter
cuff is dissected free using a hemostat introduced at the skin exit
site. A single or pair of hydrophilic guidewires is introduced
through the catheter (one wire per lumen) and used to exchange the
old catheter for the new catheter. In many cases, the new catheter
is positioned slightly deeper within the atrium by using a longer
catheter or pushing the new catheter deeper into the tract.
In a retrospective comparison of 74 de novo catheter placements
and 40 catheter exchanges, catheter patency was equivalent: 67% and
60% at 3 months, 55% and 50% at 6 months, and 40% and 41% at 12
Notably, no significant difference between infection rates was
found in the two groups. We have since used this technique in over
180 cases with similar results. In a minority of cases, we have
introduced a vascular sheath over the exchange guidewire and used
an angioplasty balloon to disrupt the cavoatrial fibrin sleeve
prior to catheter replacement. It is unclear whether this provides
any additional benefit over simple catheter exchange, a process
that in and of itself typically disrupts the fibrin sheath.
Occasionally, there can be excessive oozing at the puncture site
after catheter exchanges. Numerous hematologic abnormalities
accompany renal dysfunction, including increased bleeding time,
defective platelet aggregation, adhesiveness, and factor 3
availability. While the resulting coagulopathy is best treated with
hemodialysis, intravenous desmopressin acetate (DDAVP) infusion can
provide a rapid and effective treatment for temporary reversal of
uremic hemorrhage in patients undergoing catheter placement or
other invasive procedures.
Management of catheter infections continues to evolve.
Typically, mild site infections can be treated with antibiotic
therapy without catheter removal. Grossly purulent exit site
infections, tunnel infections, and bacteremic or septic patients
should be treated with catheter removal and antibiotics. Catheter
tips should be sent for bacterial and yeast cultures upon
Our practice has been to delay placing a tunneled access at a
new site in a patient with bacteremia for several days after
initiation of antibiotic therapy and until blood cultures no longer
indicate the presence of circulating pathogens. In the interim, we
place a temporary jugular hemodialysis catheter, or the patient
undergoes one or two treatments with transient femoral
catheterization, performed by a nephrologist. There have, however,
been several reports of successful eradication of septicemia
complicating tunneled HD and non-HD catheters with antibiotics and
catheter exchange over a guidewire.
Carlisle et al treated 21 episodes of sepsis in HD patients with
Most infections were due to staphylococcal species and gramnegative
rods. Shaffer reported similar results in 13 consecutive cases of
In both series, catheters were not replaced in situ in patients
with frankly purulent site infections. This somewhat controversial
approach has the advantage of preserving an important access site,
limiting the cost and number of procedures, and limiting hospital
days required for management.
In summary, the role of interventional radiologists in the
management of dialysis patients continues to expand, encompassing
both placement and maintenance of many forms of venous access. It
is clear that we have both the abilities and sophisticated
techniques to percutaneously place all forms of HD catheters safely
and to maintain and preserve their function. The effective use of
these out-patient techniques can provide more rapid patient therapy
and lower hospital costs compared with standard operative