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Clinical Observations |
1 Present address: American Access Care, Medford, MA 02115.
Received November 29, 2004;
accepted after revision May 25, 2005.
Address correspondence to A. Falk
(abigailfalk123{at}pol.net).
Abstract
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CONCLUSION. Placement of brachiocephalic catheters for central venous access is safe and provides an alternative access in patients with internal and external jugular vein occlusion.
Keywords: catheters • central venous devices • dialysis
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Hemodialysis access can be a challenging problem in patients who have thrombosed the jugular veins. When the more common access sites are no longer available, alternative access sites become necessary. These sites include the brachiocephalic, translumbar, transrenal, transhepatic, and femoral veins, and potentially include the insertion of catheters in collateral venous pathways [2-8].
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Each patient's vascular access history and radiologic studies were reviewed. Specific attention was paid to the number and location of previous catheters, grafts, and fistulas, the documentation of known central venous disease, and failed attempts at catheter placement. Follow-up data were obtained from radiology records, the dialysis nursing staff, nephrologists, and the dialysis research coordinator at weekly interdisciplinary conferences held in conjunction with the interventional radiologists at our institution. This information included the technical success, complications, and clinical outcomes of all procedures. All follow-up data were documented in a database of all tunneled dialysis catheters placed and/or removed from January 2000 through June 2003. This was done in conjunction with the hemodialysis access research group cited earlier and included the brachiocephalic venous catheters. Institutional review board approval was obtained for this retrospective analysis.
Catheter Insertion Methods
All procedures were performed in the interventional suite with written
informed consent from each patient. The patient was positioned supine with the
head placed directly on the table and turned opposite the catheter insertion
site. All patients underwent sonographic evaluation to assess the patency of
the jugular veins before catheter placement. If both the internal and external
jugular veins were occluded, patency of the brachiocephalic vein was assessed
using an ultrasound beam. Specifically, the transducer was positioned just
above the clavicle and angled toward the mediastinum, applying pressure as
needed to direct the ultrasound beam posterior to the clavicle. Color-flow
Doppler imaging was used to delineate arterial from venous flow in the
visualized vessels. Contrast imaging via injection through the collateral neck
vein was used to confirm patency of the brachiocephalic vein in one
patient.
After localization of the brachiocephalic vein, the patient was prepared in the standard fashion. The access site and chest wall were cleaned with povidone-iodine. A 9.5-MHz ultrasound transducer (SiteRite, Dymax) or 10.5-MHz ultrasound transducer (SonoSite, SonoSite) was covered with a sterile sheath. The brachiocephalic vein was punctured under direct ultrasound visualization using a 21-gauge micropuncture needle (Fig. 1A). Note that the needle is placed posterior to the transducer. A 0.018-inch guidewire was inserted through the needle and guided in the vein under fluoroscopic visualization (Fig. 1B). A dermatotomy was made with a number 11 scalpel. The needle was removed and a dilator sheath was placed (Micropuncture Introducer Set, Cook). A 0.035-inch extra-stiff guidewire was inserted through the coaxial dilator, which was then converted to a 15-French peel-away introducer sheath. A subcutaneous tunnel was created from the venotomy site inferiorly to the lateral chest wall using a tunneling instrument. The catheter was attached to the tunneler, pulled through the tunnel, and inserted through the sheath. Under fluoroscopic guidance, the tip of the catheter was positioned at the superior vena caval/right atrial junction (Fig. 1C). The peel-away sheath was then removed. Bleeding at the venotomy site was managed with manual compression. After the procedure, adequate catheter function was indicated by an ability to aspirate greater than 5 mL/s per port without resistance [9]. In all patients, technical success was defined as one hemodialysis session with a flow of more than 200 mL/min after catheter insertion.
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Catheter Management
Catheters with flow rates lower than 200 mL/min were initially managed with
the instillation of a thrombolytic agent into both lumens of the catheter.
Either 2 mg of tissue plasminogen activator (tPA) or 0.4 U reteplase was
instilled into each port of the catheter and allowed to dwell for 60 minutes
[10,
11]. If this treatment failed,
the patient was referred to interventional radiology for evaluation. Images
were obtained to evaluate tip position and catheter kinking. The catheter cuff
was freed from the subcutaneous tunnel and the catheter retracted so that the
distal tip was within the brachiocephalic vein. An imaging study was performed
by injecting a contrast agent through the catheter to evaluate for the
presence of a fibrin sheath and/or thrombus formation. If a fibrin sheath was
identified, a superstiff hydrophilic guidewire was inserted through the
proximal lumen, and the catheter was exchanged for a balloon catheter. Several
inflations were performed using an 8- to 10-mm-diameter angioplasty balloon to
disrupt the fibrin sheath. A new catheter was then placed over the guidewire,
and the catheter tip was positioned within the right atrium. If thrombus was
identified surrounding the old catheter, patients received a
hypercoagulability workup, and long-term anticoagulation was considered.
Patients with catheter-related bacteremia were treated with antibiotics. Loading doses of 20 mg/kg vancomycin and 2 mg/kg gentamicin were given. This was followed by 1 mg/kg gentamicin IV after hemodialysis. Antibiotic selection was adjusted as appropriate for the blood culture species and sensitivity results.
When the patient was afebrile and blood cultures had been negative for 1 week, the catheter was exchanged for a new tunneled hemodialysis catheter, usually through the existing tunnel. Antibiotic therapy continued for 3 weeks from the date of the catheter exchange. Antibiotic therapy was continued for longer if complications such as endocarditis or osteomyelitis were present.
All patients who received brachiocephalic catheters were instructed not to have their catheters removed unless interventional radiology was present, their permanent access had matured and was functioning, or plans for other access had been made.
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Thirty-three catheters were inserted in the right brachiocephalic vein and 11 in the left. Looking more closely at the left-sided catheters, 11 catheters were placed in seven patients. Of these seven patients, three were scheduled for placement of a right-sided access, one was managed exclusively with catheters, three had right-sided subclavian and brachiocephalic venous occlusions, and one patient had recent removal of an infected right internal jugular catheter with concomitant right internal jugular occlusion (it was thought best at the time to stay away from the patient's right side).
Types of hemodialysis catheters included 14 Vaxcel (Boston Scientific), 13 Optiflow (CR Bard), 10 MoreFlow (AngioDynamics), five HemoGlide (CR Bard), one pediatric catheter (Medcomp), and one unknown catheter brand. Catheter length varied from 19 cm to 27 cm.
All procedures were technically successful. All catheters were successful in providing acceptable blood flow (> 200 mL/min) during the first hemodialysis treatment.
Complications
Forty-two catheters were placed by an attending physician experienced in
brachiocephalic venous puncture, and two catheters were placed by an
interventional radiology fellow with less experience in brachiocephalic venous
puncture. No complications occurred with the experienced attending physician.
One procedure-related complication occurred with the fellow, yielding an
overall complication rate of 2.3%. One patient had inadvertent puncture of the
subclavian artery with a 21-gauge micropuncture needle. This was identified
immediately by the steady drops of blood coming through the hub of the needle.
The needle was removed and the brachiocephalic vein subsequently cannulated
successfully by the attending physician. The patient remained asymptomatic and
therefore no further imaging was done. This was a minor complication that did
not require additional therapy. No major complications occurred.
Thirty-Day Patency
At 30 days, 30 (68.2%) catheters were fully functioning. Six catheters
(13.6%) were removed before 30 days—three for blood flow less than 200
mL/min (days 2, 3, and 26), two for permanent working access (days 23 and 28),
and one for infection (day 10). Two catheters (4.5%) inadvertently fell out on
days 11 and 23, despite proper suturing and appropriate tip position at the
superior vena cava/right atrial junction. Six catheters (13.6%) were lost to
follow-up.
Long-Term Follow-Up
Long-term follow-up data were available for 16 of the 30 catheters that
were patent at 30 days. The mean follow-up period and long-term catheter
survival was 92 days, with a total of 1,468 catheter days. Eight catheters
(50%) were removed when they were no longer needed at days 35, 40, 43, 55, 81,
98, 144, and 194. Six catheters (37.5%) were removed for infection on days 39,
42, 52, 87, 91, and 288, yielding an infection rate of 0.41 per 100 catheter
days. Only one infected catheter was exchanged after antibiotic treatment; the
remaining five infected catheters were removed. One catheter was exchanged for
blood flow less than 200 mL/min on day 133. One catheter was exchanged because
of a cracked port on day 46.
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The brachiocephalic vein provides an alternative access site for insertion of a tunneled hemodialysis catheter when conventional sites are not available [2, 14]. Our optimal technical success rate (100%) for catheter insertion may be attributed to the visualization of the brachiocephalic vein under ultrasound beam and the use of sonographic guidance for needle placement. In our experience, this visualization of the brachiocephalic vein is the more challenging aspect of the procedure and bears description. We had two portable ultrasound units readily available in the angiography suite, a 9.5-MHz ultrasound transducer (SiteRite, Dymax) and a 10.5-MHz transducer (SonoSite, SonoSite). The probe head of the 9.5-MHz ultrasound transducer was generally preferred for puncture because its width is 2.5 cm compared with 5 cm for the 10.5-MHz ultrasound transducer. To visualize the brachiocephalic vein, the transducer was typically placed just cephalad to the clavicle and then angled medially and caudally so that the beam passed posterior to the clavicle toward the mediastinum. With the wider transducer, angulation of the ultrasound beam was more difficult because the transducer head would align itself with the direction of the clavicle and the beam would be angled laterally. In large patients, visualization of the target vein was difficult. To see the target vein, it was necessary to apply pressure to the transducer so that the beam could be directed posterior to the clavicle. The maneuver prohibits attachment of the needle guide because surrounding skin and soft tissues often envelop the transducer. By implication, therefore, the operator must be comfortable with freehand punctures in these patients. This requires good hand and eye coordination and practice. In the most difficult patients, the Acuson Sequoia (Siemens Medical Solutions) ultrasound machine was used for initial imaging to visualize the brachiocephalic vein. Once the vein was localized, the SonoSite or SiteRite was used for puncture.
Color-flow Doppler imaging was invaluable in delineating arterial from venous flow in the visualized vessels. In one patient, for example, when the brachiocephalic vein was not visualized initially, injection of contrast into a collateral neck vein through the needle facilitated the identification of a patent brachiocephalic vein. In that case, the patient was rescanned with the ultrasound unit and the puncture was made under sonographic guidance. Ultrasound allows the visualization of all structures along the intended path of puncture and can therefore help avoid injury to adjacent arteries or the lung. In the reported series of patients, inadvertent puncture of the subclavian artery with a 21-gauge needle by a lesser-experienced physician was noted in one patient. However, this was recognized right away by the continuous flow of blood from the needle, and the aberrant needle was removed immediately.
To reiterate, brachiocephalic venous puncture is not random. The vein is visualized on and then punctured under direct guidance. In experienced hands, this puncture is not much riskier than an internal jugular puncture. The initial puncture is made with a 21-gauge needle. A 21-gauge needle itself is the cause of very few complications.
No major complications were associated with catheter placement in this group of patients. No infection or other acute complication occurred within the first 24 hours or within the first 30 days after catheter insertion. Procedure-related vascular access complications such as hemorrhage, hematoma, infection, cardiac arrhythmias, and thrombosis thus were not seen. Although larger series of patients may be needed to ascertain more fully the occurrence of such complications or of early infections, these data are promising.
The longer-term infection rate in our study group was 0.41 per 100 catheter days and is in the range reported in the literature for de novo central venous catheter placement or for dysfunctional catheter replacement [15-21]. These rates have ranged from 0.22 per 100 (surgical implantation) to 0.38 per 100 (radiologic implantation) catheter days in one series [20] to 0.39 per 100 catheter days in another series of prospectively evaluated patients in whom the definition of infection was stringently based on positive blood cultures [17]. In a review of central venous dialysis catheter infections in large and well-established dialysis programs, Saad [20] reported bacteremia rates of 0.22 to 0.55 per 100 catheter days. Again, the rate of infection observed in this study is comparable to those estimated in this review for jugular insertions. A brachiocephalic vascular access achieved under the conditions of this study thus does not appear to contribute to any increase in procedure-related complications or infections compared with the internal jugular approach. The favorable early complication profile is evidence of the potential safety of brachiocephalic access when attempted with ultrasound visualization. In the hands of an experienced interventionalist, we have shown that the procedure can be safe and provide essential vascular access among patients with thrombosed jugular veins who require hemodialysis catheter placement.
The long-term performance of these catheters is important. At 30 days, 68.2% of the catheters in the study group remained fully patent. The mean long-term catheter survival of 92 days approximates the 86.6 days reported in a retrospective analysis of 427 tunneled hemodialysis catheters at a large medical center in 2004 [15]. Overall, 16 catheters were included for long-term analysis.
Was our hospital protocol flawed, placing temporary catheters in patients with end-stage renal disease contralateral to a planned or maturing access so that the high venous flow from the access across the central veins would not be impeded? If a patient with a right-sided hemodialysis access had a patent right internal or external jugular vein, why wasn't this site used? Can left brachiocephalic venous catheters potentially stenose and/or occlude the brachiocephalic vein as left subclavian catheters do? No data are available on the time course of the formation of central venous disease secondary to catheter placement. Ultimately, all catheters can result in venous stenosis and occlusion, whether the catheters are right or left sided. Therefore, at the time of this study we believed that if a patient could receive a temporary left-sided catheter as an interim access to permanent access placement on the right, no data suggested this was an incorrect way to practice. In addition and as an aside, if a patient is being managed exclusively with catheters, this point becomes less important. Looking specifically at the seven patients who received left-sided catheters, three had right-sided subclavian and brachiocephalic venous occlusions, one had recent removal of an infected right internal jugular catheter with a right internal jugular occlusion, and the last three may have had patent right internal jugular or external jugular veins. It is not clear whether the patients with either of these types of veins should have had a catheter placed on that side, ipsilateral to their planned access. Nevertheless, further studies are warranted to assess the long-term implications of placing a catheter on the same side as a maturing access and what the differences are, if any, between right- and left-sided catheters.
Why not use the femoral vein for access before using the brachiocephalic vein? The practice at the hospital where this study was performed was to use the femoral vein in patients where brachiocephalic access could not be attained. Femoral vein access has a low primary patency rate and significant complications and therefore was not the vein of choice after internal and external jugular occlusions [7].
This study is limited by its retrospective nature and relatively short duration of follow-up. As a result, the long-term risk of stenosis and/or infection in the brachiocephalic catheter could not be determined. Further, because of the small numbers of catheters available for long-term follow-up, long-term catheter patency could not be adequately determined. Knowledge of these factors is important to determine more completely the safety of a brachiocephalic access for cases where the hemodialysis catheter serves a more permanent function. Note that, as recommended by the National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI) guidelines [1], the internal jugular approach is still the preferable site for hemodialysis catheter insertion. However, we have shown here that among patients in whom this is not a choice, a brachiocephalic insertion under ultrasound visualization may be a reasonable alternative approach and can be safe and functional.
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