Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Thrombosis associated with chronic hemodialysis vascular catheters

Gerald A Beathard, MD, PhD
Section Editors
Steve J Schwab, MD
Jeffrey S Berns, MD
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


The use of tunneled catheters for vascular access for hemodialysis is associated with a relatively high incidence of complications, the most frequent of which is thrombosis.

Catheter-related thrombosis specifically affecting chronic hemodialysis catheters is reviewed here. A general discussion of catheter-related upper extremity thrombosis is presented separately, as is a general discussion of the indications and placement of central catheters for acute and chronic hemodialysis. (See "Catheter-related upper extremity venous thrombosis" and "Central catheters for acute and chronic hemodialysis access".)


The detection of catheter dysfunction is important. If not addressed, it can lead to inadequate dialysis. The National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (KDOQI) guidelines define catheter dysfunction as the inability to achieve a volumetric blood flow (Qb) >300 mL/min during the first 60 minutes of HD despite at least one attempt to improve flow [1]. However, this definition is overly simplistic. In evaluating a catheter for dysfunction, there are several issues that should be considered [2].

Measuring catheter flow — Typically, the Qb value that is recorded for the dialysis treatment is taken as the blood pump speed (based on pump revolutions per minute). However, the reading is not a true indicator of the actual blood flow to the catheter. The measurement of Qb depends on having a standardized volumetric blood pump segment of the dialysis tubing. This is the basis for two problems that can occur [3]:

First, the pump relies on the elasticity of the pump segment to expand and refill as the rollers turn. However, despite the manufacturers’ efforts to employ tubing materials with minimal elastic hysteresis (failure to return to original size on the rebound), there is some flattening of the pump segment during dialysis as the tubing becomes warmer. This results in a slight decrease in blood flow late in the dialysis treatment [4].  


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 18, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
  2. Moist LM, Hemmelgarn BR, Lok CE. Relationship between blood flow in central venous catheters and hemodialysis adequacy. Clin J Am Soc Nephrol 2006; 1:965.
  3. Besarab A, Pandey R. Catheter management in hemodialysis patients: delivering adequate flow. Clin J Am Soc Nephrol 2011; 6:227.
  4. Schmidt DF, Schniepp BJ, Kurtz SB, McCarthy JT. Inaccurate blood flow rate during rapid hemodialysis. Am J Kidney Dis 1991; 17:34.
  5. Depner TA. Catheter performance. Semin Dial 2001; 14:425.
  6. Beathard GA. Catheter thrombosis. Semin Dial 2001; 14:441.
  7. Fux CA, Uehlinger D, Bodmer T, et al. Dynamics of hemodialysis catheter colonization by coagulase-negative staphylococci. Infect Control Hosp Epidemiol 2005; 26:567.
  8. Sehgal AR, Snow RJ, Singer ME, et al. Barriers to adequate delivery of hemodialysis. Am J Kidney Dis 1998; 31:593.
  9. Lund GB, Trerotola SO, Scheel PF Jr, et al. Outcome of tunneled hemodialysis catheters placed by radiologists. Radiology 1996; 198:467.
  10. Suhocki PV, Conlon PJ Jr, Knelson MH, et al. Silastic cuffed catheters for hemodialysis vascular access: thrombolytic and mechanical correction of malfunction. Am J Kidney Dis 1996; 28:379.
  11. Agraharkar M, Isaacson S, Mendelssohn D, et al. Percutaneously inserted silastic jugular hemodialysis catheters seldom cause jugular vein thrombosis. ASAIO J 1995; 41:169.
  12. Karnik R, Valentin A, Winkler WB, et al. Duplex sonographic detection of internal jugular venous thrombosis after removal of central venous catheters. Clin Cardiol 1993; 16:26.
  13. Köksoy C, Kuzu A, Kutlay J, et al. The diagnostic value of colour Doppler ultrasound in central venous catheter related thrombosis. Clin Radiol 1995; 50:687.
  14. Passman MA, Criado E, Farber MA, et al. Efficacy of color flow duplex imaging for proximal upper extremity venous outflow obstruction in hemodialysis patients. J Vasc Surg 1998; 28:869.
  15. Haire WD, Lynch TG, Lund GB, et al. Limitations of magnetic resonance imaging and ultrasound-directed (duplex) scanning in the diagnosis of subclavian vein thrombosis. J Vasc Surg 1991; 13:391.
  16. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S.
  17. Fuchs S, Pollak A, Gilon D. Central venous catheter mechanical irritation of the right atrial free Wall:A cause for thrombus formation. Cardiology 1999; 91:169.
  18. Forauer AR, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 2003; 14:1163.
  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; 28:59.
  20. Ghani MK, Boccalandro F, Denktas AE, Barasch E. Right atrial thrombus formation associated with central venous catheters utilization in hemodialysis patients. Intensive Care Med 2003; 29:1829.
  21. Ducatman BS, McMichan JC, Edwards WD. Catheter-induced lesions of the right side of the heart. A one-year prospective study of 141 autopsies. JAMA 1985; 253:791.
  22. Hussain N, Shattuck PE, Senussi MH, et al. Large right atrial thrombus associated with central venous catheter requiring open heart surgery. Case Rep Med 2012; 2012:501303.
  23. Stavroulopoulos A, Aresti V, Zounis C. Right atrial thrombi complicating haemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm. Nephrol Dial Transplant 2012; 27:2936.
  24. Jafari J, Reisin LH, Mishael J. Infected right atrial thrombus: serious complication of intravenous fluid replacement catheter. A case report. Angiology 1994; 45:903.
  25. Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002; 121:806.
  26. Kingdon EJ, Holt SG, Davar J, et al. Atrial thrombus and central venous dialysis catheters. Am J Kidney Dis 2001; 38:631.
  27. Kinney EL, Wright RJ. Efficacy of treatment of patients with echocardiographically detected right-sided heart thrombi: a meta-analysis. Am Heart J 1989; 118:569.
  28. The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. Eur Heart J 1989; 10:1046.
  29. Asmarats L, Fernández-Palomeque C, Martínez-Riutort JM, Bethencourt A. Right atrial thrombosis associated with hemodialysis catheter: first description of recurrence in a poorly understood problem. J Thromb Thrombolysis 2015; 39:254.
  30. Dilek M, Kaya C, Karatas A, et al. Catheter-related atrial thrombus: tip of the iceberg? Ren Fail 2015; 37:567.
  31. Gilon D, Schechter D, Rein AJ, et al. Right atrial thrombi are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation. Am Heart J 1998; 135:457.
  32. Ram R, Swarnalatha G, Rakesh Y, et al. Right atrial thrombus due to internal jugular vein catheter. Hemodial Int 2009; 13:261.
  33. Negulescu O, Coco M, Croll J, Mokrzycki MH. Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters. Clin Nephrol 2003; 59:40.
  34. Rotellar C, Sims SC, Freeland J, et al. Right atrium thrombosis in patients on hemodialysis. Am J Kidney Dis 1996; 27:726.
  35. Shah A, Murray M, Nzerue C. Right atrial thrombi complicating use of central venous catheters in hemodialysis. J Vasc Access 2005; 6:18.
  36. Bayón J, Martín M, García-Ruíz JM, Rodríguez C. "We have a tenant" a right atrial thrombus related to a central catheter. Int J Cardiovasc Imaging 2011; 27:5.
  37. Aydogdu S, Celebi OO, Sahin D. Hemodialysis catheter: induced giant right atrial thrombus. Blood Coagul Fibrinolysis 2010; 21:363.
  38. Shah A, Murray M, Nzerue C. Right atrial thrombi complicating use of central venous catheters in hemodialysis. Int J Artif Organs 2004; 27:772.
  39. Hoshal VL Jr, Ause RG, Hoskins PA. Fibrin sleeve formation on indwelling subclavian central venous catheters. Arch Surg 1971; 102:353.
  40. Xiang DZ, Verbeken EK, Van Lommel AT, et al. Composition and formation of the sleeve enveloping a central venous catheter. J Vasc Surg 1998; 28:260.
  41. Grossi C, Mangano S, Zani MB, et al. Tesio catheters: findings in post-mortem examination. Nephrol Dial Transplant 1996; 11:1363.
  42. 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; 20:156.
  43. Haskal ZJ, Leen VH, Thomas-Hawkins C, et al. Transvenous removal of fibrin sheaths from tunneled hemodialysis catheters. J Vasc Interv Radiol 1996; 7:513.
  44. Oguzkurt L, Ozkan U, Torun D, Tercan F. Does a fibrin sheath formed around a catheter embolize upon removal of the catheter? Nephrol Dial Transplant 2007; 22:3677.
  45. Shanaah A, Brier M, Dwyer A. Fibrin sheath and its relation to subsequent events after tunneled dialysis catheter exchange. Semin Dial 2013; 26:733.
  46. Alomari AI, Falk A. The natural history of tunneled hemodialysis catheters removed or exchanged: a single-institution experience. J Vasc Interv Radiol 2007; 18:227.
  47. Oguzkurt L, Tercan F, Torun D, et al. Impact of short-term hemodialysis catheters on the central veins: a catheter venographic study. Eur J Radiol 2004; 52:293.
  48. Brismar B, Hårdstedt C, Jacobson S. Diagnosis of thrombosis by catheter phlebography after prolonged central venous catheterization. Ann Surg 1981; 194:779.
  49. Little MA, Walshe JJ. A longitudinal study of the repeated use of alteplase as therapy for tunneled hemodialysis catheter dysfunction. Am J Kidney Dis 2002; 39:86.
  50. Eyrich H, Walton T, Macon EJ, Howe A. Alteplase versus urokinase in restoring blood flow in hemodialysis-catheter thrombosis. Am J Health Syst Pharm 2002; 59:1437.
  51. Haire WD, Atkinson JB, Stephens LC, Kotulak GD. Urokinase versus recombinant tissue plasminogen activator in thrombosed central venous catheters: a double-blinded, randomized trial. Thromb Haemost 1994; 72:543.
  52. Zacharias JM, Weatherston CP, Spewak CR, Vercaigne LM. Alteplase versus urokinase for occluded hemodialysis catheters. Ann Pharmacother 2003; 37:27.
  53. Clase CM, Crowther MA, Ingram AJ, Cinà CS. Thrombolysis for restoration of patency to haemodialysis central venous catheters: a systematic review. J Thromb Thrombolysis 2001; 11:127.
  54. Hilleman DE, Dunlay RW, Packard KA. Reteplase for dysfunctional hemodialysis catheter clearance. Pharmacotherapy 2003; 23:137.
  55. Deitcher SR, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol 2002; 20:317.
  56. Ponec D, Irwin D, Haire WD, et al. Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial--the Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J Vasc Interv Radiol 2001; 12:951.
  57. Twardowski, ZJ. Stepwise anticoagulation with warfarin for prevention of intravenous catheter thrombosis. Hemodial Int 2000; 4:37.
  58. Mehta S, Oliveros E, Cohen S, et al. TNK-tPA (tenecteplase). Indian Heart J 2009; 61:422.
  59. Tumlin J, Goldman J, Spiegel DM, et al. A phase III, randomized, double-blind, placebo-controlled study of tenecteplase for improvement of hemodialysis catheter function: TROPICS 3. Clin J Am Soc Nephrol 2010; 5:631.
  60. Macrae JM, Loh G, Djurdjev O, et al. Short and long alteplase dwells in dysfunctional hemodialysis catheters. Hemodial Int 2005; 9:189.
  61. Twardowski ZJ. The clotted central vein catheter for haemodialysis. Nephrol Dial Transplant 1998; 13:2203.
  62. Shaffer D. Catheter-related sepsis complicating long-term, tunnelled central venous dialysis catheters: management by guidewire exchange. Am J Kidney Dis 1995; 25:593.
  63. Savader SJ, Ehrman KO, Porter DJ, et al. Treatment of hemodialysis catheter-associated fibrin sheaths by rt-PA infusion: critical analysis of 124 procedures. J Vasc Interv Radiol 2001; 12:711.
  64. Onder AM, Chandar J, Saint-Vil M, et al. Catheter survival and comparison of catheter exchange methods in children on hemodialysis. Pediatr Nephrol 2007; 22:1355.
  65. Wong JK, Sadler DJ, McCarthy M, et al. Analysis of early failure of tunneled hemodialysis catheters. AJR Am J Roentgenol 2002; 179:357.
  66. Oliver MJ, Mendelssohn DC, Quinn RR, et al. Catheter patency and function after catheter sheath disruption: a pilot study. Clin J Am Soc Nephrol 2007; 2:1201.
  67. Duszak R Jr, Haskal ZJ, Thomas-Hawkins C, et al. Replacement of failing tunneled hemodialysis catheters through pre-existing subcutaneous tunnels: a comparison of catheter function and infection rates for de novo placements and over-the-wire exchanges. J Vasc Interv Radiol 1998; 9:321.
  68. Garofalo RS, Zaleski GX, Lorenz JM, et al. Exchange of poorly functioning tunneled permanent hemodialysis catheters. AJR Am J Roentgenol 1999; 173:155.
  69. Faintuch S, Salazar GM. Malfunction of dialysis catheters: management of fibrin sheath and related problems. Tech Vasc Interv Radiol 2008; 11:195.
  70. Janne d'Othée B, Tham JC, Sheiman RG. Restoration of patency in failing tunneled hemodialysis catheters: a comparison of catheter exchange, exchange and balloon disruption of the fibrin sheath, and femoral stripping. J Vasc Interv Radiol 2006; 17:1011.
  71. Watorek E, Golebiowski T, Letachowicz K, et al. Balloon angioplasty for disruption of tunneled dialysis catheter fibrin sheath. J Vasc Access 2012; 13:111.
  72. Gallieni M, Giordano A, Rossi U, Cariati M. Optimization of dialysis catheter function. J Vasc Access 2016; 17 Suppl 1:S42.
  73. Mokrzycki MH, Jean-Jerome K, Rush H, et al. A randomized trial of minidose warfarin for the prevention of late malfunction in tunneled, cuffed hemodialysis catheters. Kidney Int 2001; 59:1935.
  74. Traynor JP, Walbaum D, Woo YM, et al. Low-dose warfarin fails to prolong survival of dual lumen venous dialysis catheters. Nephrol Dial Transplant 2001; 16:645.
  75. Colì L, Donati G, Cianciolo G, et al. Anticoagulation therapy for the prevention of hemodialysis tunneled cuffed catheters (TCC) thrombosis. J Vasc Access 2006; 7:118.
  76. Abdul-Rahman I, Al-Howaish A. Warfarin versus aspirin in preventing tunneled hemodialysis catheter thrombosis: a prospective randomized study. HKJN 2007; 9:23.
  77. Wilkieson TJ, Ingram AJ, Crowther MA, et al. Low-intensity adjusted-dose warfarin for the prevention of hemodialysis catheter failure: a randomized, controlled trial. Clin J Am Soc Nephrol 2011; 6:1018.
  78. Wang Y, Ivany JN, Perkovic V, et al. Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end-stage kidney disease. Cochrane Database Syst Rev 2016; 4:CD009631.