Thrombosis associated with chronic hemodialysis vascular catheters
- Gerald A Beathard, MD, PhD
Gerald A Beathard, MD, PhD
- Clinical Professor
- University of Texas Medical Branch
- Section Editors
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Steve J Schwab, MD
Steve J Schwab, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- University of Tennessee Health Science Center
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".)
CATHETER DYSFUNCTION AND FAILURE
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 . However, this definition is overly simplistic. In evaluating a catheter for dysfunction, there are several issues that should be considered .
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 :
●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 .
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- CATHETER DYSFUNCTION AND FAILURE
- Measuring catheter flow
- Indicators of catheter dysfunction
- - Early catheter failure
- - Late catheter failure
- EXTRINSIC THROMBUS
- Axillosubclavian thrombosis
- Mural thrombus
- Catheter-related atrial thrombus
- INTRINSIC THROMBUS
- Intraluminal thrombus
- Catheter tip thrombus
- Fibrin sheath thrombus
- Treatment approach
- - In the dialysis unit
- Forceful saline flush
- Intraluminal lytic enzyme
- Infusion of lytic enzyme
- - Referral for intervention
- SUMMARY AND RECOMMENDATIONS