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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 1  |  Page : 44-48
Non-cuffed dual lumen catheters in the external jugular veins versus other central veins for hemodialysis patients


Division of Vascular Surgery, Sina Hospital, Medical Sciences/Tehran University, Tehran, Iran

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   Abstract 

To compare prospective between insertion of non-cuffed dual lumen catheter in the external jugular vein and other central veins for hemodialysis (HD), we studied 68 chronic dialysis patients randomly allocated into two groups: one with external jugular vein catheterization as access for HD and another with other central venous catheterization, internal jugular or subclavian vein. Our results showed there were no significant differences regarding successful cannulation, com­plications, total numbers of dialysis, development of pain and infection at the site of cannulation, patency rate of the catheters, and efficacy of hemodialysis between both groups. In addition, the patency of the catheter in the external jugular vein was not affected by previous cannulation of other central veins. In contrast, there was a significant correlation between numbers of attempts for cannulation in both groups and development of hematoma and infection, (p< 0.05). In conclusion, our results showed that the external jugular vein may be an alternative for other central veins for insertion of temporary non-cuffed hemodialysis catheter.

Keywords: Dual lumen catheter, Non-cuffed catheter, Hemodialysis, External jugular vein

How to cite this article:
Moini M, Rasouli MR, Kenari MM, Mahmoodi HR. Non-cuffed dual lumen catheters in the external jugular veins versus other central veins for hemodialysis patients. Saudi J Kidney Dis Transpl 2009;20:44-8

How to cite this URL:
Moini M, Rasouli MR, Kenari MM, Mahmoodi HR. Non-cuffed dual lumen catheters in the external jugular veins versus other central veins for hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Nov 22];20:44-8. Available from: http://www.sjkdt.org/text.asp?2009/20/1/44/44705

   Introduction Top


Vascular access represents a major problem in long-term hemodialysis (HD) patients. Implan­tation of catheters can provide a temporary or permanent central venous access for HD. [1] Complications associated with these catheters represent one of the most important sources of morbidity among end-stage renal disease (ESRD) patients. There is no general agreement about the optimal vein for catheterization since risk factors for catheter related complications have not been entirely elucidated. [2]

External jugular vein has been introduced as an alternative vein for placement of venous ca­theters by several authors and the results of this procedure is compatible with standard methods. [3],[4],[5],[6],[7],[8]

The aim of our study was comparison between the results of insertion of non-cuffed dual lu­men catheter for hemodialysis in the external jugular vein and cannulation of the internal ju­gular or subclavian veins in ESRD patients who were waiting for maturation of arteriovenous fistula (AVF) or graft (AVG).


   Patients and Methods Top


This study was performed at Sina Hospital, Tehran University of Medical Sciences. The ethical committee of human research of our university approved the study. All patients signed a consent form before entering the study.

Patients with ESRD who had been referred to our center for implantation of temporary cathe­ter were entered the study. The patients who needed catheter insertion for other causes such as acute renal failure, physiologic monitoring at the operating room or ICU were excluded from the study.

The study patients were randomly allocated to two groups of the central venous catheterization and the external jugular vein cannulation. In the central vein catheterization group, patients can­nulated via the internal jugular vein or the sub­clavian vein in case the patients had previous history of the internal jugular vein cannulation. Preoperative imaging was not performed in these patients.

All the catheters inserted under local anesthe­sia and sterile condition. The patients were po­sitioned in a Trendelenburg position, and by using a needle and syringe the location of the veins were identified. Then, Seldinger's tech­nique was used to cannulate the vein with a guide wire. [9] The guide wire was passed through the lumen of a large-bore needle into the vein. This was followed by dilators to make a passage for the catheter. Then, the catheter was passed over the guide wire into position within the central venous circulation. We didn't use ultrasound or fluoroscopy to guide the insertion of the catheters. Chest x-ray was used to deter­mine the catheter site after insertion.

Data such as demographics, history of neck surgery, previous central vein cannulation and fracture of the clavicle were obtained from questionnaires that had been filled by vascular surgeon after procedure.

The patients were followed up monthly for 3 months and in each visit the following items were assessed:

  1. Development of catheter infection.
  2. Patency of the catheter.
  3. Efficacy of hemodialysis, which was sub­jective and defined as improvement of ge­neral condition of patient after HD.
  4. Pain at the site of the catheter.


Statistical analysis

Statistical comparison was performed by x² analysis using SPSS software (version 10). P values < 0.05 were considered significant.


   Results Top


Sixty-eight patients (38 male and 30 female) entered the study and divided into two groups randomly. Patients of the first group were catheterized via the central (internal jugular or subclavian) veins, while the second group was cannulated via the external jugular vein. The mean age of the patients was 52 ± 12.6 years, which ranged from 29 to 78 years. The causes of chronic renal failure of the patients are shown in [Table 1].

Group 1 (34 cases)

In this group all the patients were cannulated via the internal jugular or the subclavian veins [Table 2]. The age of the patients ranged from 29 to 78 (mean: 51.5 ±12.9) years. Of 34 cases, 21 patients had no history of previous central venous cannulation, while 9, 3, and 1 cases had the history of catheterization for 1, 2 and 3 times, respectively.

We could insert the dual lumen catheter at firs attempt of cannulation in 18 (52%) patients, while the cannulation was successful in 12 (35%) cases in the second attempt. The dual lu­men catheter was inserted in 3 and 1 cases after 3 and 4 times of attempt of cannulation, res­pectively. Four patients (2 men and 2 women) developed hematoma at the site of cannulation. Other complications such as pneumothorax, hemothorax, and arterial rupture or mispuncture did not occur in this group. [Table 4] shows complications occurred in this group.

Of 34 cases, hemodialysis was not possible with the inserted catheter in 2 cases, therefore, we were forced to cannulate these patients via the external jugular vein.

The number of hemodialysis was less than 20 in 6 (17%) patients, while in 13 (34%) patients it was more than 30 times. It ranged from 20 to 30 times in remainders, [Table 5].

Group 2 (34 cases)

The dual lumen catheter was inserted in the external jugular vein in this group [Table 3]. Two patients in this group lost to follow-up. The mean age of the patients was 52.5 ± 12.6 (ranged from 32 to 78) years. Eighteen patients were not cannulated previously. However, 8, 4, and 2 patients had previous history of catheter placement for 1, 2, and 3 times, respectively. Two patients had been cannulated for 4 times. There were 1, 2, and 3 attempts of cannulation in 22, 9, and 3 cases, respectively.

Of 32 cases, HD was not possible in 2 (6%) cases with the inserted catheter, and they were cannulated via central veins.

Hematoma developed in 5 cases (one man and 4 women) at the site of the catheter insertion. Pneumothorax, hemothorax, and arterial rupture or mispuncture did not occur in this group, too, [Table 4].

The number of HD sessions was less than 20 in 6 (18%) patients and more than 30 times in 8 (25%) cases. In the remainder, it was between 20 to 30 times,[Table 5].

Comparison between the two study groups

Our results showed there were no significant differences regarding successful cannulation, complications, total numbers of dialysis, deve­lopment of pain and infection at the site of can­nulation, patency rate of the catheters, and effi­cacy of HD between both groups. In addition, the patency of the catheter in the external jugu­lar vein was not affected by previous cannula­tion of other central veins.

In contrast, there was a significant correlation between numbers of attempts for cannulation both groups and development of hematoma and infection, (p< 0.05).


   Discussion Top


Our results are in favor of using the external jugular vein for catheterization and use as a vascular access for HD.

Efficacy of the external jugular vein catheteri­zation for different purposes has been empha­sized in several studies. [3],[4],[5],[6],[7],[8] In 1990, Manishen, et al reported successful insertion of triple-lumen catheter in the external jugular vein instead of the central veins cannulation. [4] Taylor and asso­ciates in 1992 cathetrized all the children who needed cardiac surgery via the external jugular vein. [5] They reported successful cannulation in 51% of the patients. In the present study we used the external jugular vein to insert non­cuffed dual lumen catheter in patients with chronic renal failure who needed temporary vascular access for hemodialysis before matu­ration of AVF or AVG.

In Iran, non-cuffed catheters are usually used as temporary vascular accesses of HD. It is the reason that we used these catheters in this study. However, higher rate of infection in these kinds of catheters is well known. [10],[11],[12],[13] Patients followed up for 3 months during the maturation of per­manent vascular accesses, which was an appro­priate period for evaluation of complications and efficacy of the catheters.

Although the use of the "temporary" jugular catheter is advised for less than 3 weeks, [14] our results showed these catheters could be used for longer periods with acceptable rates of compli­cations and patency as previously reported. [15]

Of 66 patients remained in the study, infection and thrombosis of the catheter occurred in 4 (6%) and 5 (8%) of the cases. All the infections occurred during the third month, while all the thrombosis occurred during the second month. Thrombosis of the subclavian developed in one patient and manifested with upper extremity edema.

Although pneumothorax follows insertion of the central venous catheter in 1% to 6% of cases, [16],[17],[18],[19],[20],[21] it did not occur in our study. Similarly, we did not encounter other serious complications such as hemothorax or carotid artery mispunc­ture.

Our results showed there were no significant differences regarding successful cannulation, complications, numbers of dialysis, development of pain and infection at the site cannulation, patency rate of the catheters and efficacy of hemodialysis between both study groups.

Previous history of central venous cannulation and numbers of attempts of catheter insertion are independent risk factors for development of complications. [22],[23] According to our findings, previous cannulation of the central veins does not influence patency of the catheters inserted in the external jugular veins. This is an advan­tage for patients who have history of central venous catheterization. However, by increasing the numbers of attempts for cannulation of the external jugular vein, the risk of development of complications such as hematoma and infec­tion increases.

According to these facts, it seems that the external jugular vein not only can be used as an alternative for the internal jugular and subcla­vian veins for insertion of temporary noncuffed hemodialysis catheters, but also can be used as the technique of choice in patients with pre­vious history of the central veins' catheteriza­tions.

 
   References Top

1.Apsner R, Sunder-Plassmann G, Muhm M, Druml W. Alternative puncture site for implantable permanent haemodialysis catheters. Nephrol Dial Transplant 1996;11(11):2293-5.  Back to cited text no. 1    
2.Naumovic RT, Jovanovic DB, Djunkovic LJ. Temporary vascular catheters for hemodialysis: A 3-year prospective study. Int J Artif Organs 2004;27(10):848-54.  Back to cited text no. 2    
3.Longo S, Cappone C, Saracco P, et al. The exter­nal left jugular vein as an access for placement of long-term permanent central venous catheters in children. Minerva Pediatr 1989;41(4):183-7.  Back to cited text no. 3    
4.Manishen WJ, Paradowski L. Triple-lumen central venous access via the external jugular vein. Chest 1990;98(4):140-1.  Back to cited text no. 4    
5.Taylor EA, Mowbray MJ, McLellan I. Central venous access in children via the external jugular vein. Anaesthesia 1992;47(3):265-6.  Back to cited text no. 5    
6.Segura-Vasi AM, Suelto MD, Boudreaux AM. External jugular vein cannulation for central venous access. Anesth Analg 1999;88(3):692-3.  Back to cited text no. 6    
7.Berthelsen P, Hansen B, Howardy-Hansen P, et al. Central venous access via the external jugular vein in cardiovascular surgery. Acta Anaesthesiol Scand 1986;30(6):470-2.  Back to cited text no. 7    
8.Mariani PJ. External jugular venous access to the central circulation. J Emerg Med 1989;7(1): 70-80.  Back to cited text no. 8    
9.Seldinger SI. Catheter replacement of the needle in percutaneous arteriography. Acta Radiol 1953;39(5):368-76.  Back to cited text no. 9    
10.Randolph AG, Cook DJ, Gonzales CA, et al. Tunneling short-term central venous catheters to prevent catheter-related infection: a meta­analysis of randomized, controlled trials. Crit Care Med 1998;26:1452-7.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Flowers RH, Schwenzer KJ, Kopel RF, et al. Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection: a randomized, controlled trial. J Am Med Assoc 1989;261:878-83.  Back to cited text no. 11    
12.Timsit JF, Sebille V, Farkas JC, et al. Effect of subcutaneous tunneling on internal jugular catheter-related sepsis in critically ill patients: a prospective randomized multicenter study. J Am Med Assoc 1996;276:1416-20.  Back to cited text no. 12    
13.Keohane PP, Jones BJ, Attrill H, et al. Effect of catheter tunnelling and a nutrition nurse on catheter sepsis during parenteral nutrition. A controlled trial. Lancet 1983;2:1388-90.  Back to cited text no. 13    
14.NKF-K/DOQI. Clinical Practice Guidelines for vascular access: Update 2000. Am J Kidney Dis 2001;37:S137-81.  Back to cited text no. 14    
15.Ponikvar R, Buturovic-Ponikvar J. Temporary hemodialysis catheters as long-term vascular access in chronic hemodialysis patients. Ther Apher Dial 2005;9(3):250-3.  Back to cited text no. 15    
16.Bernard RW, Stahl WM. Subclavian vein catheters: a prospective study of non Infectious complications. Ann Surg 1971;173(2):184-90.  Back to cited text no. 16    
17.Herniques HF, Karmy-Jones R, Knoll SM, et al. Avoiding complications of long-term venous access. Am Surg 1993;59(9):555-8.  Back to cited text no. 17    
18.Herbst CA Jr. Indications, management and complications percutaneous Subclavian catheters. Arch Surg 1978;113(12):1421-5.  Back to cited text no. 18    
19.Sariego J, Bootarobi B, Matsumoto T, et al. Major long-term complications in 1,422 perma­nent venous access devices. Am J Surg 1993; 165(2):249-51.  Back to cited text no. 19    
20.Takasugi JK, O Connell TX. Prevention of com­plications in permanent central venous catheters. Surg Gynecol Obstet 1989;167(1):6-11.  Back to cited text no. 20    
21.Torramade JR, Cienfuegos JA, Hernandez JL, et al. The complications of central venous access systems: a study of 218 patients. Eur J Surg 1993;159(6-7):323-7.  Back to cited text no. 21    
22.Mansfield PE, Hohn DC, Fornage BD, et al. Complications and failure of subclvian-vein catheterization. N Engl J Med 1994;331(26): 1735-8.  Back to cited text no. 22    
23.Haire WD, Lynch TM, Lieberman RP, et al. Duplex scans before subclavian vein catheteri­zation predict unsuccessful catheter placement. Arch Surg 1992;127(2):229-30.  Back to cited text no. 23    

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Correspondence Address:
Majid Moini
Associate Professor of Vascular Surgery, Sina Hospital, Hassan-Abad Square, Tehran, 1136933511
Iran
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PMID: 19112218

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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