Femoral Vein Tunneled Catheters as a Last Resort to Vascular Access: Report of Five Cases and Review of Literature

Abstract

Vascular access (VA) remains a thorny problem in at least some patients requiring hemodialysis (HD). When options like arterio-venous fistulae, grafts, and thoracic tunneled central catheters are exhausted, the patient survival becomes endangered. The choices left are limited to transplantation, peritoneal dialysis, and translumbar and femoral catheter insertion. The latter may, in many instances, be the only possibility. We report our experience in six patients, in whom all the vascular accesses were exhausted and transplantation or peritoneal dialysis could not be performed. Hence, we opted for femoral tunneled catheters (FTC) as a permanent and sole VA. The mean follow up period was 16 months (8–22 months). The mean age of the patients was 53.1 (35–72) years, the mean time on HD was 3.125 years (2–4.5), and the mean number of vascular accesses was 4.7 (4–7). In five patients, a Permcath (Quinton, Kendall) was inserted, and in one patient, a twin Tessio catheter (MPS, Germany) was inserted. All patients were administered aspirin or clopidogrel to prevent catheter thrombosis. Aseptic nursing procedures and personal hygiene were emphasized. All catheters were functional at 2.5 months. The mean blood flow was 220 mL/min (200–240 mL/min). One patient died at 18 months, with a functional catheter, due massive gastro-intestinal bleed not directly related to the FTC. In one patient, the site of the catheter was changed at 6.5 months due to accidental pulling of the catheter by the patient. One catheter flow became inadequate after nine months, which could be reversed with streptokinase or tissue plasminogen activator. One patient presented excessive bleeding at the time of insertion that was controlled after 25 minutes of compression against the pelvic bone. One patient presented deep vein thrombosis with catheter thrombosis that required reinsertion of the catheter three months later. In one patient, the catheter functioned for 19.5 months after insertion. It is noteworthy that no patient developed catheter-related septicemia. None of the patients developed late hemorrhage. We conclude that tunneled femoral catheter is a viable option in patients with exhausted VA. Strict aseptic nursing technique and personal hygiene are essential. A multi-center study would give a better insight into this type of VA.

Keywords:

• tunneled femoral catheter
• dialysis
• renal failure
• vascular access failure
• complications

INTRODUCTION

Vascular access (VA) is an essential prerequisite for the performance of hemodialysis. These can be of different types, including arterio-venous fistulae, arterio-venous synthetic grafts, and deep vein (internal jugular, subclavian, translumbar, and femoral) catheterization. In some patients, these VAs gets exhausted, and the options left are very limited. Recently, femoral-tunneled catheterization (FTC) emerged as an option in these patients.[1,[2]] The risks of temporary femoral catheterization include essentially sepsis, thrombosis, and malfunction.[1–4] We performed tunneled femoral catheterization in six patients in whom no other alternative for VA was available. We report herewith our results.

PATIENTS AND METHODS

We looked retrospectively into our series of six patents that underwent FTC because of VA exhaustion. The follow mean period was 16 (8–22) months. The catheters inserted were Permcath (Quinton Kendall) in five cases and Tessio (MPS, Germany) in one case.

The patients mean age was 53.1 (35–72) years. The patient's characteristics and the history of vascular accesses are summarized on Table 1.

Table 1 Patient characteristics

Patient	Age	Sex	Etiology of the ESKD and morbidity	Exit site infection	Complications
1	65	M	DM, HTN, CVA	No	Accidental pullout
2	37	M	HTN, DM	No	Nil
3	72	F	HTN, IHD	No	Nil
4	48	M	DM, IHD	No	Per insertion bleeding, accidental pullout, deep vein thrombosis
5	62	M	DM, HTN	No	Nil
6	35	M	Lupus nephritis with APL AbS	No	Partial thrombosis of the catheter

Abbreviations: ESKD = end stage kidney disease, DM = diabetes mellitus, HTN = hypertension, IHD = ischemic heart disease, APL AbS = anti-phospholipid antibody syndrome, CVA = cerebro vascular accident.

Five patients were males. The mean number of vascular accesses was 4.7 (4–7). All of the catheters were inserted between August 2004 and October 2006. The mean age of the patients was 53.1 (35–72) years. The length of the catheters was 36 cm. All of the catheters were inserted in the operation theater, as is the case for all tunneled catheter placement at our center. The catheters were inserted under strict aseptic percutaneous technique under local anesthesia. The catheters were locked with heparin (5000 units/mL). Aseptic precautions were taken at each handling of the catheters during the sessions of hemodialysis. The catheters were not used for other purposes than hemodialysis. Patients were instructed to maintain a good personal hygiene.

RESULTS

In our series, the functional life of the tunneled femoral catheters ranged between 2.5 to 19.5 months. One of our patients had relatively excessive bleeding in the immediate postoperative period, which could be arrested with compression against the pelvic bone for 25 minutes. The same patient developed thrombosis of the catheter lumen at 62 days. Hence, a new catheter had to be reinserted. The second FTC remained functional for 11 months but had to be removed because of deep vein thrombosis. One patient died at 19.5 months, with a functional catheter, due to cerebro-vascular accident (CVA), most probably unrelated to the FTC because he did not show evidence of thrombo-embolic disease. One patient had to undergo reinsertion of the catheter after three months of initial insertion due to accidental pullout by the patient. None of the patients under study had catheter-related infection or septicemia, kinking of the catheter, migration of the catheter, or retroperitoneal or femoral hematomas.

DISCUSSION

VA in the form of arterio-venous fistula or arterio-venous graft is pivotal for adequate hemodialysis in patients with end stage kidney failure. Unfortunately, in some patients, these VA get damaged with no possibility of repair. In these patients, tunneled internal jugular catheters can be inserted for variable periods. Some patients will develop septicemia, internal jugular or superior vena cava thrombosis, or stenosis.[5–7] In such patients, FTC remains almost the only viable option for haemodialysis.[1–4]

Catheterization of the femoral vein is one of the most frequent procedures used for temporary access for HD. The risks of the procedure, though low, include hemorrhage, thrombosis, infection, malfunction, and accidental arterial injury. Infections and thrombosis are major concerns in FTCs.[2,[5],[6]] Infection of the catheter is a serious complication that may lead to sepsis and require removal of the catheter. However, there have been reports of good outcome with conservative treatment.[4] Abdullah et al. recently reported successful treatment of catheter-related infections with Pseudomonas aeruginosa, E. coli, and Streptococcus epidermidis without removal of the catheters. A remarkable aspect of our and other series[1,[2],[4]] is the low rate of infection of FTC and consequently low rates of catheter related septicemia (CRS). None of our patients under discussion developed CRS. Nevertheless, this requires further confirmation with a larger series.

A blood flow rate of 200–300 mL/min during hemodialysis may be acceptable in cases of FTC. In patients of this study, the rate was 200–240 mL/m. The flow of blood in the catheter usually may decrease with time or stop abruptly due to thrombosis, whether complete or partial, of the catheter. Screening of patients on femoral vein catheters with serial ultrasound has been proposed for the evaluation of thrombosis.[8] These thrombotic complications are preventable to a good extent by proper locking of the catheter after the HD session and possibly by the use of anti-platelet agents. In our series, thrombosis occurred in two out of six patients. This rate may be acceptable in view of the context of the heavy history of multiple vascular access thrombosis in these patients. This low rate may be due to the systematic use of anti-platelet agents. Nevertheless, a series with a larger number of patients is necessary to have a proper evaluation of this aspect.

CONCLUSION

We conclude that tunneled femoral catheterization is a reasonable option for maintenance hemodialysis patients who have exhausted all other means of vascular access. However, all efforts should be furnished to maintain the ideal vascular access for hemodialysis, which is the arterio-venous fistula.

DECLARATION OF INTEREST

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.