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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 1  |  Page : 37-42
Tunneled Femoral Vein Catheterization for Long Term Hemodialysis: A Single Center Experience


Department of Internal Medicine, Nephrology Division, King Fahd Hospital of the University, King Faisal University, Al-Khobar, Saudi Arabia

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   Abstract 

Femoral veins have been used for decades to position temporary hemodialysis catheters. Few reports, however, describe its use for permanent vascular access. This study describes the use of tunneled femoral vein catheters as permanent vascular accesses. Fourteen chronic hemodialysis patients (nine males and five females) had tunneled central venous catheters placed in the femoral vein from November 2004 to July 2005. The age of the patients ranged from 21 to 68 years with a mean of 49.8 ± 5.9 years. Placement of a catheter via the internal jugular veins was impossible in 10 patients whose course was complicated by thrombosis or strictures of the superior vena cava. The remaining four patients had exhausted conventional access sites. The insertion of the femoral catheters involved a subcutaneous tunnel that was created by retrograde passage of the catheter through the cannula to the point of exit at a preselected site in the epsilateral thigh away from the groin. The life span of the tunneled femoral catheter ranged between 32-240 days; median time in place was 182 days. There were four incidences of tunnel infection with Pseudomonas aeruginosa, E. coli, and Streptococcus epidermidis, which were treated successfully without the need for catheter removal. Other complications such as bleeding, kinking, migration of the catheter, arterial puncture, retroperitoneal or femoral hematomas were not observed. We conclude that tunneled femoral catheters are suitable alternatives for long-term hemodialysis access. Additional studies with a greater sample size are needed to confirm this conclusion.

Keywords: Femoral vein, tunneled, infection, thrombosis, hemodialysis

How to cite this article:
Al-Hwiesh AK, Abdul-Rahaman IS. Tunneled Femoral Vein Catheterization for Long Term Hemodialysis: A Single Center Experience. Saudi J Kidney Dis Transpl 2007;18:37-42

How to cite this URL:
Al-Hwiesh AK, Abdul-Rahaman IS. Tunneled Femoral Vein Catheterization for Long Term Hemodialysis: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2020 Sep 20];18:37-42. Available from: http://www.sjkdt.org/text.asp?2007/18/1/37/31843

   Introduction Top


Blood stream infections are common and serious complications of central venous catheters used for hemodialysis. To decrease catheter colonization, some physicians advocate tunneling the catheter in the subcutaneous tissue during insertion. This technique has proved effective in tunneled central catheters inserted in internal jugular and subclavian veins. [1],[2],[3]

Recently, it has been found that the subclavian vein should not be used as a common site for catheter placement, since it is associated with a high incidence of vascular stenosis. [4],[5] Hence, vascular access through the internal jugular vein is becoming the first choice. However, repeated attempts at cervical and thoracic vein catheterization have been associated in many patients with a significantly high incidence of complications such as arterial injuries, vascular thrombosis, infections, and hemothorax. In others, these repeated attempts have left the patients with no alternative cervical or thoracic venous access sites. The percutaneous insertion of a tunneled femoral catheter may be an acceptable option in these selected patients.

This study describes the experience of our center with the use of tunneled femoral vein catheters as permanent vascular accesses.


   Methods Top


Fourteen chronic hemodialysis patients (nine males and five females) had tunneled central venous catheters placed in the femoral vein from November 2004 to July 2005. The age of the patients ranged from 21 to 68 years with a median of 55 years (mean: 49.8 + 5.9). The patients' characteristics are shown in [Table - 1].

All patients had initially received central lines via a subclavian vein, which have been removed either accidentally or secondary to catheter obstruction or infectious complications. Placement of a new catheter via the internal jugular veins was im­possible in 10 patients who suffered from thrombosis or strictures of the superior vena cava. The remaining four patients had exhausted conventional access sites and no other options were left.

Polyurethane dual lumen tunneled catheters, 30 cm long - 7 French with two 16-gauge channels - (Seldiflex, Plastimed, Saint Len, France) were inserted using the Seldinger method. Catheters were inserted in the minor surgery room under strict aseptic conditions. The insertion site was prepared with povidone iodine or 0.5% chlorhexidine. The subcutaneous tunnel was fashioned by retrograde passage of the catheter through the cannula to the point of exit at a preselected site in the epsilateral thigh. The distance separating the cutaneous puncture site from the venous entry had to be approxi­mately 10 cm. Intravenous tubing and semi­permeable transparent dressing (Opsite IV 3000, Smith and Nephew Med Ltd.,Hull, United Kingdom), were changed routinely every 72 hours. Catheter dressings were inspected by trained nurses twice per week for the appearance of local signs of infection. Blood sampling or administration of medications were not permitted through the line. Catheter exit site swabs and blood cultures were collected on a weekly basis. Blood flow rate (as measured by pump speed), as well as systolic and diastolic blood pressures were recorded at half-hourly intervals during each hemodialysis session. Drop in blood flow by greater than or equal to 20% below that prescribed in the absence of hypotension, hypovolemic episode, or patient/catheter malposition was considered to be secondary to catheter malfunction. In all patients, blood flow was kept at 300 ml/min or more. A routine intradialytic heparin protocol was used.


   Results Top


The duration of functional life of the tunneled femoral catheter ranged between 32-240 days; median time and mean were 182 and 149.3 + 13.8 days, respectively.

No complications occurred during the insertion procedure. One catheter had to be removed after 86 days because of a successful establishment of an A-V fistula. Another catheter had to be removed after 160 days because of catheter obstruction. The remaining 12 catheters functioned without problems with a blood flow of 300-350 ml/min during dialysis. There were four incidences of tunnel infection with Pseudomonas aeruginosa, E. coli, and Streptococcus epidermidis which were treated successfully without the need for catheter removal. In one case, the procedure was complicated by femoral vein thrombosis associated with E. coli bacteremia. In the other 11 patients there were no catheter­related infectious complications. Other complications such as bleeding, kinking, migration of the catheter, arterial puncture, retroperitoneal or femoral hematomas were not observed [Table - 2].


   Discussion Top


The femoral vein is the hemodialysis temporary access site of choice by most nephrologists. Catheterization of the femoral vein is relatively easy to perform, safe and convenient. In contrast to access via the subclavian or internal jugular veins, which may involve life-threatening complications, there is a comparatively low risk of insertion-related complications by using the femoral route[6]. The pulse of the femoral artery serves as a landmark for the vein; in the case of bleeding, the vessel can be directly compressed against the hard surfaces of the femur and the pelvis. Thrombosis or structures of the superior vena cava may preclude placement of a central catheter via the internal jugular route. In such patients, insertion of tunneled femoral vein catheters would seem to be a rational alternative. Lazrus et al [7] reported on five adult patients undergoing transplantation of autologous bone marrow in whom tunneled femoral central venous catheters were placed and remained in place for a median of 35 days. There were two infectious complications that resolved with antibiotic therapy without removal of the catheter. [7] Another report was published concerning an adult patient who received high-dose chemotherapy and allogeneic peripheral blood stem cell transplantation via a femoral Hickman catheter for recurrent high-grade non­Hodgkin's lymphoma; this catheter was successfully used for three months. [8] Conventional femoral vein catheterization has been frequently associated with infections because of fecal contamination. [9] Infection mainly originates from the skin catheter junction, [10] especially in catheters used for the short term; [11],[12],[13] that is why it has been suggested that subcutaneous tunneling of the catheter could reduce the transmission of pathogens by increasing the distance between the skin-catheter junction and the vein. Meanwhile, the use of tunneled catheters proved to be associated with a three-fold decrease in catheter-related sepsis. [14] A similar conclusion has been reported by Timsit et al [15] in critically ill patients. Although reports are conflicting, long-term cannulation of the femoral vessels for the purpose of hemodialysis was believed to carry a higher risk of infection compared to non-femoral cannulation. [16], [17],[18],[19],[20],[21] However, in a recent study by Daniel, the incidence of catheter­related infections with femoral catheters were similar to those previously reported with jugular catheters. [22] In the present study, the incidence of catheter-related site infections and catheter -related bacteremia with tunneled femoral catheters was only 28.6%, and 7.1%, respectively. The use of subcutaneous tunneling to remove the exit site of the catheter from the perineal area may have significantly reduced the risk of infection. Another explanation is the low incidence of thrombosis in our patients, as there is an association of thrombosis and sepsis. [23],[24],[25] In addition the relatively short duration of the catheter in place (mean 149.3 + 13.8 days) may have contributed to the low incidence of catheter-related thrombosis in our series, as previous studies[26],[27],[28] have shown that thrombosis usually occurs after a median of seven weeks. For many years, inadequate delivery of blood flow for dialysis has been a consistent concern. Inadequate blood flow can be divided into acute and chronic phases: acutely diminished flow may be due to systemic hypotension, catheter malpositioning, or other mechanical problems. While diminished flow occurring later may be due to thrombosis or formation of a fibrin sheath, in addition to mechanical problems. [29]

Until recently, blood flow rates below 200 ml/min were generally considered inadequate; however, the DOQI guidelines raised the standard for blood flow rates by suggesting a minimum flow rate of 300 ml/min.[30] In our study we did not encounter difficulties in achieving this goal. We conclude that tunneled femoral catheters are suitable alternatives for long-term hemodialysis access. Additional studies with larger sample sizes are needed to confirm this conclusion.

 
   References Top

1.Pervez A, Zaman F, Aslam A, et al. Port catheter placement by nephrologists in an interventional nephrology training program. Semin Dial 2004;71:61-4.  Back to cited text no. 1    
2.Lund GB, Trerotola SO, Scheel PF Jr, et al. Outcome of tunneled hemodialysis catheters placed by radiologists. Radio­logy 1996;198:467-72.  Back to cited text no. 2  [PUBMED]  
3.Gibson SP, Mosquera D. Five years experience with the Quinton Permcath for vascular access. Nephrol Dial Transplant 1991;6:269-74.  Back to cited text no. 3  [PUBMED]  
4.Schillinger F, Schillinger D, Montagnac R, et al. Post catheterization vein stenosis in hemodialysis: comparative angiographic study of 50 subclvian and 50 internal jugular access. Nephrol Dial Transplant 1991;6:722-4.  Back to cited text no. 4  [PUBMED]  
5.Cimochowski GE, Worley E, Rutherford WE, et al. Superiority of the internal jugular over the subclavian access for temporary hemodialysis. Nephron 1990;54:154-61.  Back to cited text no. 5  [PUBMED]  
6.Kanter RK, Zimmerman JJ, Strauss RH, et al. Central venous catheter insertion by femoral vein: safety and effectiveness for pediatric patient. Pediatrics 1986;77:842-7.  Back to cited text no. 6    
7.Lazarus HM, Creger RJ, Bloom AD, et al. Percutaneous placement of femoral central venous catheter in patients undergoing transplantation of bone marrow. Surg Gynecol Obstet 1990;170:403-6.  Back to cited text no. 7  [PUBMED]  
8.Rabitsch W, Kalhs P, Herold C, et al. Central venous catheter inserted percutaneously via the femoral vein can be used long term in recipients of allogenic peripheral blood stem cell transplants. Bone Marrow Transplant 1999;24:115-6.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Pearson ML. Guideline for prevention of intravascular-device-related infection. Infect Control Hosp Epidemiol 1996;17:438-73.  Back to cited text no. 9  [PUBMED]  
10.Maki DG, Weise CE, Sarafin HW. A semiquantitative method for identifying intravenous-catheter-related infection. N Engl J Med 1977;296:1305-9.  Back to cited text no. 10  [PUBMED]  
11.Fan ST, Teoh-Chan CH, Lan KF, et al. Predictive value of surveillance skin and hub cultures in central venous catheters sepsis. J Hosp Infect 1988;12:191-8.  Back to cited text no. 11    
12.Linares J, Sitges-Serra A, Carau J, et al. Pathogenesis of catheter sepsis: a prospective study with quantitative and semiquantitative cultures of catheter hub and segments. J Clin Microbiol 1985;21:357-60.  Back to cited text no. 12    
13.Sequra M, Uado L, Guiro X, et al. A prospective study for a new protocol for in situ diagnosis of central venous catheter­related bacteremia. Clinical Nutrition 1993;12:103-7.  Back to cited text no. 13    
14.Timsit JF, Sebille V, Farkas JC, et al. Effects of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients: a prospective randomized multicenter study. JAMA 1996;276:1416-20.  Back to cited text no. 14  [PUBMED]  
15.Timsit JF, Bruneel F, Cheval C, et al. Use of tunneled femoral catheters to prevent catheter related infection: a randomized controlled trial. Ann Intern Med 1999;130:729-35.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Decker MD, Edwards KM. Central venous catheter infections. Pediatr Clin North Am 1988;35:567-613.  Back to cited text no. 16  [PUBMED]  
17.Collignon P, Soni N, Pearson I, et al. Sepsis associated with central vein catheter in critically ill patients. Intensive Care Med 1988;14:227-31.  Back to cited text no. 17  [PUBMED]  
18.Oliver MJ, Gallery SM, Thorpe KE, et al. Risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: a prospective study. Kidney Int 2000;58:2543-5.  Back to cited text no. 18    
19.Goetz AM, Wagner MM, Miller JM, et al. Risk of infection due to central venous catheters: effect of site of place­ment and catheter type. Infect Control Hosp Epidemiol 1998;19:842-5.  Back to cited text no. 19    
20.Murr MM, Rosenquist MD, Lewis RW II, et al. A prospective safety study of femoral versus non-femoral vein catheterization in patients with burns. J Burn Care Rehabil 1991;12:576-8.  Back to cited text no. 20    
21.Mermel LA. Prevention of intravascular catheter-related infection. Ann Intern Med 2000;132:391-402.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]
22.Daniel T, Murai MD. Are femoral broviac catheters effective and safe? A prospective comparison of femoral and jugular boviac catheters in newborn infants. Chest 2002;121:1527-30.  Back to cited text no. 22    
23.Pierco CM, Wade A, Moke Q, et al. Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children. Intensive Care Med 2000;26:967-72.  Back to cited text no. 23    
24.Stillman RM, Soliman F, Garcia L, et al. Etiology of catheter associated sepsis: correlation with thrombogenicity. Arch Surg 1977;112:1497-9.  Back to cited text no. 24  [PUBMED]  
25.Krafte-Jacobs B, Sivit CT, Mejia R, et al. Catheter-related thrombosis in critically ill children: comparison of catheters with and without heparin bonding. J Pediatr 1995;126:50-4.  Back to cited text no. 25    
26.Marsh D, Wilkerson SA, Cook LN, et al. Right atrial thrombus formation screening using two-dimensional echocardiograms in neonates with central venous catheters. Pediatrics 1988;81:284-6.  Back to cited text no. 26  [PUBMED]  
27.Mehta S, Connors Jr AF, Danish EH, et al. Incidence of thrombosis during central venous catheterization of newborns: a prospe­ctive study. J Pediatr Surg 1992; 27:18-22.  Back to cited text no. 27    
28.Joynt GM, Kew J, Gomersall CD, et al. Deep venous thrombosis caused by femoral venous catheters in critically ill adult patients. Chest 2000;117:178-83.  Back to cited text no. 28  [PUBMED]  [FULLTEXT]
29.Trerotola-Scot O. Hemodialysis catheter placement and management. Radiology 2000;215:651-8.  Back to cited text no. 29    
30.Schwab SJ, Besarab A, Beathard G, et al. NKF-DOQI clinical practice guidelines for vascular access. National Kidney Founda­tion-Dialysis Outcome Quality Initiative. Am J Kidney Dis 1997;30 (Suppl 3):S150-S91.  Back to cited text no. 30    

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Correspondence Address:
Abdulla K Al-Hwiesh
King Fahd Hospital of the University P.O. Box 40246, Al-Khobar, 31952
Saudi Arabia
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