| Abstract|| |
To determine prevalence of central vein stenosis following catheterization with double-lumen temporary catheters, we performed color Doppler sonography in 100 consecutive patients. We detected central vein stenosis in 18 cases; 11 patients in subclavian vein (SCV), 4 patients in internal jugular vein (IJV) and SCV, 2 patients in SCV and brachiocephalic vein, and 2 patients in IJV stenosis. There were statistical difference between groups with and without stenosis regarding time from discontinuation of catheters and use of aspirin (ASA). We could not find any statistical difference between these two groups regarding age, sex, duration of having chronic kidney disease (CKD), and duration of catheter remaining in place. We also found that there was a high proportion of stenosis in patients who still had catheter in their veins (15 from 44 patients, 34%) in comparison with patients who had already the catheters removed from their veins (3 from 56 patients, 5%). We conclude that stenosis of central veins can result from long indwelling time of central catheter used for hemodialysis. Aspirin may have a protective role against stenosis.
|How to cite this article:|
Naroienejad M, Saedi D, Rezvani A. Prevalence of central vein stenosis following catheterization in patients with end-stage renal disease. Saudi J Kidney Dis Transpl 2010;21:975-8
|How to cite this URL:|
Naroienejad M, Saedi D, Rezvani A. Prevalence of central vein stenosis following catheterization in patients with end-stage renal disease. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Dec 3];21:975-8. Available from: https://www.sjkdt.org/text.asp?2010/21/5/975/68912
| Introduction|| |
Central venous access devices are necessary part of designed treatment plan for many medical conditions such as end-stage renal disease (ESRD), malignancy, intravenous nutritional support and conditions requiring parental therapy.  Between three and four million central venous access devices are placed annually for acute and chronic uses.  These devices could be complicated in many ways; the two major complications are infection and thrombosis.  Occurrence of the latter in temporary central venous catheters is especially troublesome because it limits using vessels of the arms on the side of catheterization for creating fistulas (AVF) or grafts (AVG) in future. These catheters are non-cuffed nontunneled catheters used in emergency cases of dialysis, in the presence of malfunction of the permanent vascular access or when the patient needs hemodialysis, but created arteriovenous fistulas (AVF) or grafts (AVG) is not mature enough to be used.  Only a small proportion of patients with thrombosis become symptomatic after catheterization. They present with extremity massive pain and edema. However, many patients remain asymptomatic till creation of AVF or AVG, which result in high blood flow in the vein having stenosis. This is the time when many patients, previously asymptomatic, reveal complications. , In addition to symptoms, stenosis can result in inadequacy and failure of AVF and AVG as accesses for hemodialysis on the side of catheterizations.
We aimed to investigate the prevalence and the predisposing factors of central venous stenosis following catheterization of subclavian vein (SCV) or internal jugular vein (IJV) in ESRD patients with temporary doublelumen central catheters.
| Materials and Methods|| |
This cross-sectional study was performed in the radiology and dialysis deprtment of Shahid Hasheminezhad hospital in Tehran during 2006-2007. We had a total of 100 patients in our cross-sectional study referred to our center for hemodialysis; 67 (67%) patients were male and 33 (33%) patients were female with a mean age of 48.2 ± 17.52 years. The mean duration of chronic renal disease in our patients was 3.14 ± 4.13 years. All of patients had undergone at least one session of central venous catheterization by temporary doublelumen catheters; 81 patients in the SCV and in 19 patients in the IJV. The SCV was catheterized in the left side in 17 (21%) cases and in the right side in 64 (79%) cases, while IJV was catheterized in the left side in 5 (26.3%) cases and in the right side in 14 (73.7%) cases. Forty four patients still had catheter in their veins and 56 patients did not have catheter in their veins at time of Doppler screen. There was no statistical difference in side of catheterization between these two veins (Chi-square test, P value = 0.21). Duration of having catheter in their veins was 1.00 ± 0.83 months and the time from removal of catheter was 21.90 ± 39.78 months. Twenty two patients were using ASA as anticoagulant drug and remaining 78 cases had no history of any anticoagulant drugs. All the patients underwent color Doppler sonography of SCV and IJV of both sides using Technus-MP device to detect and measure the severity of the venous stenosis.
| Statistical Analysis|| |
Numerical variables were presented as mean ± SD, while categorized variables were summarized by absolute frequencies and percentages. For the statistical analysis, the statistical software SPSS version 11.0 for windows (SPSS Inc., Chicago, IL) was used. Bivariate analysis was performed using the T-test and the chisquare test. All P values were 2-tailed, with statistical significance defined as P value < 0.05.
| Results|| |
Only 18 cases (18%) were document to have stenosis in their veins; 11 patients with SCV stenosis, 4 patients with concomitant IJV and SCV stenosis, 2 patients with concomitant SCV and brachiocephalic veins stenosis and 2 patients with IJV stenosis. All thromboses were at the side of catheterization. Of the 18 patients who showed stenosis in their veins, 15 patients (34.09%) still had catheter in their veins and 3 patients (0.05%) did not have catheter in their veins at time of Doppler screen.
Data regarding age, sex, duration of having CKD, duration of catheter remaining in the place, time from catheter removal and ASA consumption of patients with and without stenosis are shown in [Table 1], which compares the stenotic and the nonstenotic groups. The group with stenosis had catheter less time after removal of catheters and received less ASA less frequently than and non stenotic group at time of screen prevalence of stenosis (P < 0.05).
|Table 1 :Information of patients with and without stenosis and results of comparing two groups using Ttest.|
Click here to view
| Discussion|| |
We found a prevalence of 18% for stenosis following catheterization of central vein in our study patients. There was no difference in prevalence of stenosis either in the type of central vein or side of catheterization. We could not find any difference between the patients with and without stenosis with regard to age, sex, duration of CKD and duration of catheter remaining in place. But these patients were different in the time interval from catheter removal and the use of aspirin. We also found that there was a high proportion of stenosis in patients who still catheter had present in their veins in comparison with patients who had already removal catheter from their veins at time of Doppler screen.
Studies on the pathophysiology and histological characteristics of changes in vessels following injury are mostly performed in animal models. These studies illustrated the occurrence of a dynamic response of vessel wall in response to injury with different characteristic changes during the different time intervals from injury. , During the early days after catheter insertion, there is a focal endothelial damage and denudation and non-cellular thrombosis formation with no sign of organization. ,, When time passes in the absence of ongoing injury the lesions heal; otherwise, they undergo a process of organization with a resultant smooth muscle injury, deposition of collagen fibers, vessel wall thickening, and endothelialization, which can cause a permanent stenosis. ,,
Most of clinical studies on CVS following catheterization in ESRD patients are performed on permanent catheters, which have a long indwelling time. These studies have shown greater prevalence of stenosis in patients with SCV catheterization in comparison with IJV catheterization, left-sided catheterization, 13 longer indwelling time, more frequent catheterization, , more dialysis sessions,  and associated infections.  They also demonstrated possible effects of catheter properties , and catheter tip position  on the development of stenosis. These factors can accentuate either initial injury or facilitate evolution of the lesions. On the other hand, the prevalence of stenosis is about 20% shortly after catheterization with temporary catheters, which showed no difference in the rate of stenosis between SCV and IJV catheterization. 
The role of ASA as a protective factor may be explained by its anti-inflammatory and anticoagulation effects. Although timing of changes of the lesions in animals cannot be extended to explain human changes, the animal studies demonstrated necessity of at least few months before the development of stable lesions. In our study, the mean time after the indwelling of catheters was only one month, which is not a short time for chronic changes to develop, since a few days have been adequate for the initial injury in animal models. Differences due to the absence or presence of catheters and time interval from catheter removal may be explained by the process of resolution noted in the histological studies indicated above.
Following the patients for a longer period could enable us to comment on different views of chronic dynamic pattern, which requires a longer time to occur than that achieved in our study. Moreover, as previous studies have shown, sensitivity of color doppler sonography in detecting stenosis is about 80%, and we have probably missed some cases of stenosis in our study. 
We conclude that the insertion of catheters in central veins induces a pathological process that can result in venous stenosis. Using aspirin may have a preventive role of stenosis.
| References|| |
|1.||Forauer AR, Theoharis CG, Dasika NL. Jugular vein catheter placement: Histologic features and development of catheter-related (fibrin) sheaths in a swine model. Radiology 2006;240 (2):427-34. |
|2.||Forauer AR, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 2003;14(9 Pt 1):1163-8. |
|3.||Schwab SJ, Beathard G. The hemodialysis catheter conundrum: hate living with them, but can't live without them. Kidney Int 1999;56 (1):1-17. |
|4.||Oguzkurt L, Tercan F, Torun D, Yildirim T, Ziimrutdal A, Kizilkilic O. Impact of shortterm hemodialysis catheters on the central veins: a catheter venographic study. Eur J Radiol 2004;52(3):293-9. |
|5.||Beathard, GA. Percutaneous transvenous angioplasty in the treatment of vascular access stenosis. Kidney Int 1992;42:1390. |
|6.||Schwab SJ, Quarles LD, Middleton, JP, et al. Hemodialysis-associated SCV stenosis. Kidney Int 1988;33:1156. |
|7.||Xiang DZ, Verbeken EK, Van Lommel ATL, Stas M, De Wever I. Intimal hyperplasia after long-term venous catheterization. Eur Surg Res 2000;32(4):236-45. |
|8.||Kalso E. A short history of central venous catheterization. Acta Anaesthesiol Scand Suppl 1985;81:7-10. [PUBMED] |
|9.||Brismar B, Hardstedt C, Jacobson S. Diagnosis of thrombosis by catheter phlebography after prolonged central venous catheterization. Ann Surg 1981;194(6):779-83. |
|10.||O'Farrell L, Griffith JW, Lang CM. Histologic development of the sheath that forms around long-term implanted central venous catheters. JPEN J Parenter Enteral Nutr 1996;20(2):156-8. |
|11.||Sigel B, Swami V, Can A, et al. Intimal hyperplasia producing thrombus organization in an experimental venous thrombosis model. J Vasc Surg 1994;19(2):350-60. |
|12.||Usui Y, Wu HD, Goff SG, Sauvage LR, Walker M. A comparative experimental study of the organization of arterial and venous thrombi. Ann Surg 1987;205(3):312-7. |
|13.||Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterization vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular acesses. Nephrol Dial Transplant 1991;6(10):722-4. |
|14.||Vanherweghem JL, Yassine T, Goldman M, et al. Subclavian vein thrombosis: a frequent complication of subclavian vein cannulation for hemodialysis. Clin Nephrol 1986;26(5): 235-8. |
|15.||MacRae JM, Ahmed A, Johnson N, Levin A, Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 2005;51(1):77-81. |
|16.||Hernandez D, Diaz F, Rufino M, et al. Subclavian vascular access stenosis in dialysis patients: natural history and risk factors. J Am Soc Nephrol 1998;9(8):1507-10. |
|17.||Grove JR, Pevec WC. Venous thrombosis related to peripherally inserted venous catheters. J Vasc Interv Radiol 2000;11(7):837-40. |
|18.||Di Costanzo J, Sastre B, Choux R, Kasparian M. Mechanism of thrombogenesis during total parenteral nutrition: role of catheter composition. JPEN J Parenter Enteral Nutr 1988;12 (2):190-4. |
|19.||Kohler TR, Kirkman TR. Central venous catheter failure is induced by injury and can be prevented by stabilizing the catheter tip. J Vasc Surg 1998;28(1):59-65 |
|20.||Hernandez D, Diaz F, Suria S, et al. Subclavian catheter related infection is a major risk factor for the late development of subclavian vein stenosis. Nephrol Dial Transplant 1993;8(3):227-30. |
|21.||Rose, SC, Kinney, TB, Bundens, WP, et al. Importance of Doppler analysis of transmitted atrial waveforms prior to placement of central venous access catheters. J Vasc Interv Radiol 1998;9(6):927-34. |
Department of Radiology, Iran University of Medical Sciences, P.O. Box 13185-1678, Tehran