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Abstract

Objective

To evaluate management strategies of tunneled-cuffed catheters (TCCs) in hemodialysis (HD) patients with hypotension and recurrent central venous thrombosis.

Methods

We retrospectively reviewed HD patients with hypotension treated at the West China Hospital. The initial catheter tip was positioned routinely in the superior vena cava (SVC). In the event of SVC thrombosis, stenosis, or obstruction, the catheter was adjusted to right atrial (RA) or SVC and RA junction, and then inferior vena cava (IVC). If thrombi completely dissolved, catheter tips were returned to the former section. Meanwhile, patients with central venous thrombus were treated with antiplatelet therapy. We analyzed the efficacy of the management strategy in HD with hypotension and recurrent central venous thrombosis.

Results

By adjusting catheter tips following the above procedure, vascular access has persevered in all the patients. Nineteen deaths (90.5%) were recorded during a median follow-up period of 6 years. No fatal pulmonary embolism nor catheter complication-related deaths were observed. The minimal survival period after the procedure was 6 years. The catheter primary patency rates at 3, 6, and 12 months were 90.5%, 66.7%, and 38.1%, respectively. The secondary patency rates were 100.0%, 80.9%, and 57.1% at 3, 6, and 12 months, respectively.

Conclusion

The insertion of the TCCs tips initially in SVC, then adjusting in SVC and RA junction, RA and IVC successively in the event of thrombosis combined with antiplatelet therapy may be considered effective to prolong the HD vintage in patients with hypotension.

Keywords

Hemodialysis hypotension thrombosis catheter central venous stenosis or occlusion

Introduction

Chronic, persistent hypotension is a common complication in hemodialysis (HD) patients. It occurs in approximately 5% of the patients who have been undergoing HD for multiple years.¹ This condition is considered a relative contraindication for arteriovenous fistula (AVF) creation, as it impairs AVF maturation and blood perfusion. Hypotension is also described as a risk predictor of thrombosis in AVF² and adversely affect AVF survival.^3,4 Therefore, catheters are recommended for patients with hypotension who attempt to create or maintain a permanent access.⁵

However, long-term use of tunneled-cuffed catheters (TCCs) is often associated with thrombosis and fibrin sheath formation. Catheter-related thrombosis can result in inadequate and irregular blood flow rates, leading to catheter malfunction, ineffective HD, concomitant infection, and pulmonary embolism (PE).^5,6 Moreover, recurrent thrombosis in the central venous further restricts alternative vascular access, which is essential for the survival of HD patients. Therefore, preserving the TCCs in these patients when catheter-related thrombosis happens is critical.

While HD patients with hypotension usually have a relatively short life expectancy. Hypotension restricts HD patients’ rehabilitation and limits the amount of ultrafiltration, which may further reduce the blood pressure early in the dialysis run. Additionally, contributing factors such as heart disease and impaired left ventricular reserve further increase the risk of mortality in these patients.⁷ In this case, prolonging the HD vintage and improving HD patients’ life quality remains a crucial challenge in the vascular access field. Thus we investigated strategies for managing TCCs in HD patients with hypotension, especially when recurrent thrombi happened in the central venous.

Methods

Study population

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by the Ethics Committee on Biomedical Research at the West China Hospital of Sichuan University (No. 201885). Individual consent for this retrospective analysis was waived. All patient details have been de-identified to ensure that they cannot be identified in any way. The study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.⁸ This retrospective study collected data from HD patients with chronic persistent hypotension from West China Hospital from October 2010 to April 2018. Hypotension was defined as a systolic blood pressure below 100 mmHg, recorded on three consecutive nondialysis days, and sustained for at least one month.⁹ Inclusion criteria: a) Age ≥ 18 years; b) Patients diagnosed with end-stage renal disease (ESRD) undergoing maintenance HD and experiencing persistent hypotension; c) Use of TCCs as the vascular access for HD. The following exclusion criteria were applied: a) Severe organic heart disease; b) Serious bleeding conditions or tendencies; c) Disorders of consciousness, including altered levels of consciousness such as lethargy, confusion, delirium, stupor, or coma; d) Active malignant tumors; and e) Incomplete data or loss to follow-up. Data were collected on each patient to identify causes of ESRD, indications of blood pressure, duration of HD, and duration of catheter use.

Procedures

All procedures were performed by interventional nephrologists under local anesthesia. Preoperative chest computed tomography angiography (CTA) or echocardiography was utilized to assess the thrombus and TCCs tips. Intraoperative digital subtraction angiography (DSA) was conducted to confirm the position of TCCs and to adjust the catheter tip position in patients with catheter dysfunction. The procedure adopted in the current study was as follows: Initially, the catheter tip was routinely positioned in the superior vena cava (SVC). In cases of SVC thrombosis, stenosis, or obstruction, the catheter tips were adjusted to the right atrium (RA) or the SVC and RA junction. Catheter tips were then returned to the SVC for patients who experienced complete dissolution of SVC thrombi but developed RA thrombosis or had insufficient blood flow. In patients with only partial dissolution of thrombi of SVC, TCCs tips were replaced in inferior vena cava (IVC) after recanalization of SVC. For patients with IVC thrombosis or obstruction caused by repeated irritation from TCCs tips, interventional surgery was performed to relocate the TCCs tips to the lower section of the obstructed area. As mentioned above, when thrombi in the RA were completely resolved, the catheter tips could be repositioned to the RA or SVC and RA junction (Figure 1). Immediately after TCCs insertion and the completion of the HD session, both ports were locked with unfractionated heparin solution. Lifelong antiplatelet therapy was prescribed to all patients to ensure catheter patency for ongoing HD. Patients continued regular HD sessions were monitored through follow-up echocardiography or CTA.

Figure 1.

The strategy of the management of TCC tips. * Lesion including thrombosis, stenosis, or obstruction.

Outcomes and statistical analysis

The primary outcomes were the incidence of fatal PE and catheter complication–related deaths; the secondary outcomes were catheter patency. Statistical analyses were performed using Stata (version 17.0). The Shapiro–Wilk test assessed the normality of continuous variables. Data with a normal distribution were expressed as mean ± standard deviation, while non-normally distributed data were presented as median and interquartile range. The patency rates were assessed using the Kaplan–Meier method.

Results

Patient characteristics

A total of 21 patients were included in this study, with 8 (38.0%) being male. The mean age was 64.52 ± 12.91 years, and the median duration of HD was 84 months. The median duration of hypotension was 2 months, and the mean systolic blood pressure was 88.38 ± 7.88 mmHg (Table 1 and Supplementary Table 1). All patients underwent right central venous puncture, with the catheter tips initially positioned in SVC. Among them, 19 patients (90.5%) had occlusion of the right brachiocephalic vein and the proximal segment of the right internal jugular vein after prolonged use of TCCs. Additionally, all patients exhibited SVC-related complications, including thrombosis, fibrin sheath formation, severe stenosis, or occlusion caused by recurrent thrombi (Table 2 and Supplementary Table 2). One patient also demonstrated an occlusion at the SVC and RA junction, as shown in Figure 2A.

Figure 2.

(A) Occlusion in the superior vena cava/right atrium junction (see white arrow). (B) Recanalization of the occlusion segment after balloon angioplasty and the catheter tip was replaced in inferior vena cava (see white arrow).

Table 1.

The basic characteristics of the included patients.

Variables	Number of patients
Sample size	21
Male, n (%)	8 (38.0%)
Age (years)	64.52 ± 12.91
BMI (kg/m²)	20.58 (19.02–22.67)
Primary diseases, n (%)
Systolic blood pressure (mmHg)	88.38 ± 7.88
Primary glomerulonephritis	9 (42.8%)
Diabetic nephropathy	5 (23.8%)
Hypertensive kidney disease	4 (19.0%)
Polycystic kidney disease	2 (9.5%)
Gouty nephropathy	1 (4.7%)
Duration of dialysis (months)	84 (48–120)
Duration of TCCs (moths)	57.14 ± 35.17
Duration of hypotension (months)	2 (2–8)
Cause of death, n (%)
AMI	3 (14.2%)
Cerebral hemorrhage	3 (14.2%)
Pneumonia	3 (14.2%)
Heart failure	3 (14.2%)
Gastrointestinal hemorrhage	3 (14.2%)
Other	4 (19.0%)

AMI: acute myocardial infarction; BMI: body mass index; TCCs: tunneled-cuffed catheters.

Table 2.

Adjustment of TCC tips and underlying causes.

Position of TCCs tips	Cause of adjustment	Number of patients
Initial position
SVC	Hypotension	21
Second position
RA, SVC, and RA junction	Insufficient blood flow, SVC occlusion, stenosis, fibrin sheath, or thrombosis	19(90.4%)
IVC	Insufficient blood flow and thrombosis of RA	1(4.8%)
RA and IVC junction	SVC stenosis	1(4.8%)
Third position
SVC	Thrombus in RA and SVC dissolved	1(4.8%)
RA	Insufficient blood flow, or end of catheter adhered to RA wall	3(14.3%)
IVC	Fibrin sheath formation to RA, SVC occlusion, or SVC and RA junction stenosis	5(23.8%)
Fourth position
RA	Insufficient blood flow and thrombosis in IVC, or fibrin sheath formation	2(9.5%)
IVC	catheter infection	1(4.8%)
Fifth position
IVC	Thrombus in RA and IVC dissolved	1(4.8%)

IVC: inferior vena cava; RA: right atrial; SVC: superior vena cava; TCCs: tunneled-cuffed catheters.

Treatment

Tunneled-cuffed catheters were replaced over a guidewire under DSA by an experienced nephroradiologist in all patients following the detection of diseased SVC. In patients with right internal jugular vein entry site catheters, TCCs were replaced in situ. The right brachiocephalic vein was chosen as the puncture site to allow for convenient revascularization of SVC for patients with SVC occlusion or obstruction and without a diseased right brachiocephalic vein. When the right brachiocephalic vein and SVC were occluded, the SVC stump was used as the puncture site, and the recanalization of SVC by balloon angioplasty (Cordis Corporation, Milpitas, Calif) was performed. The procedure of the adjustment of catheter tips was followed as described in “Methods” section. The location of the new catheter tips was confirmed by DAS.

Follow-up

The median follow-up time was 6 years (60–96 months). The outflow of the catheter and oxygen saturation of blood was recorded. None of the patients were found to have reduced blood oxygen saturation. Patients with a reduced outflow of the catheters were readmitted to the hospital. The adjustment of the catheter tip for each patient is listed in Table 2 and Supplementary Table 2. Nineteen (90.4%) patients suffered from thrombus/fibrin sheath formation in SVC or insufficient blood flow, and catheters were replaced in RA or SVC and RA junction. Among them, two patients (patient #2 and #7) had insufficient blood flow, and one patient (patient #13) had the end of the catheter adhere to the RA wall. Catheters were exchanged in situ and remained in RA in the abovementioned three patients. In one patient (patient #5) who had insufficient blood flow with the catheter tip in RA and SVC thrombus dissolved, the catheter was repositioned back to SVC. Five patients had SVC or RA lesion, and recanalization of SVC or RA was conducted, and catheter tips were finally adjusted in IVC (Figure 2B). Among them, one patient (patient #1) failed to maintain sufficient blood flow in the IVC, necessitating the catheter tip to be returned to the RA. However, thrombi formed in RA, thus the catheter was finally adjusted back to IVC due to IVC thrombus’ dissolution. When the tips of TCCs were adjusted to the RA following pathological changes in the SVC, all patients experienced reduced outflow from the arterial port of the catheter. This was attributed to their shorter anatomical stature, resulting in relatively smaller RA volumes. The arterial and venous lines of the catheter were inversed during the dialysis session. All patients were on regular dialysis without thrombolysis or thrombectomy. Nineteen deaths were observed during the follow-up period (Table 1). The minimal survival period after procedure was 60 months. Neither fatal PE nor catheter complication–related deaths occurred during the follow-up period. The catheter primary patency rates at 3, 6, and 12 months were 90.5%, 66.7%, and 38.1%, respectively. The secondary patency rates were 100.0%, 80.9%, and 57.1% at 3, 6, and 12 months, respectively (Figure 3).

Figure 3.

The catheter primary and secondary patency rates.

Discussion

The management of TCCs in HD patients with hypotension in the condition of repeated thrombosis in central venous is critical to explore. Therefore, the current article gives a proof of concept on successful maintenance of HD by adjusting the TCCs tips following this process: Placing the tips of TCCs originally in SVC, followed by SVC and RA junction, RA or IVC when thrombosis, stenosis, or obstruction in the above central venous. When the thrombi completely dissolved, catheter tips can be returned to the former location. Recanalization of the occluded vein by balloon angioplasty was performed where required for smoother insertion of the new TCC. Vascular access was preserved in these patients who had very limited alternative access sites. All the patients maintained satisfactory blood flow. No fatal PE or catheter-related deaths occurred, and catheter patency rates were well-maintained during the follow-up period. This article is perhaps among the first to report the management of TCCs and clinical outcomes of HD patients with hypotension.

To date, the optimal location for the long-term TCCs tip remains controversial.^5,10,11 The placement of catheter tips in the RA can achieve a higher blood flow. In contrast, placing catheter tips in the SVC is associated with a lower incidence of RA thrombosis, thus recommending to avoid potential cardiac-related complications.^12,13 Regardless of catheter tip location, thrombosis still remains the most common complication in the long-term use of TCCs and occurs in access loss in 30–40% of patients.^14,15 The potential pathogenesis of catheter-related thrombosis involves mechanical irritation of the vessel wall caused by the catheter tip or the high-flow rates facilitated by the catheter. This irritation can result in endothelial damage, triggering coagulation, platelet aggregation, and subsequent thrombus formation.⁵ Adjusting catheter tip positions during catheter exchanges may help reduce irritation to the vessel wall, thereby minimizing thrombus expansion and preventing further complications. Drawing from our previous experience, catheter-related RA thrombi can often be resolved following catheter exchange and tip adjustment, combined with oral anticoagulation or antiplatelet therapy.¹⁶ In the present study, we prioritized reserving vascular access when thrombi recurred in the central venous. Thus, the position of the catheter tip was adjusted successively rather than removing catheters. Additionally, while the catheter patency rate was acceptable, it was slightly lower than previously reported,^17,18 possibly due to the inclusion of patients with persistent hypotension.

Regarding the catheter tip adjustment, we do not recommend following the strict “SVC-RA-IVC” strategy. Relatively, we suggest that the catheter tip could be replaced back to SVC when RA lesion occurs and thrombus dissolves in SVC; likewise, back to RA when IVC lesion occurs and RA thrombus dissolves. Similarly, we do not focus on how to choose the puncture site. Wherever the puncture site is selected, it is expected to face the problem of thrombosis with the extension of TCCs. Thrombosis and vascular occlusion may happen in SVC, RA, and SVC extended into RA, and even in IVC. Thus, in our strategy, the right internal jugular was routinely chosen as the puncture site, and the tip of TCCs was preferentially placed in SVC, RA, or SVC and RA junction. Both the puncture entry site and the TCCs tips’ location were adjusted according to the condition of central venous.

The study has some limitations. First, the limited sample size, retrospective design, and absence of a control group highlight the need for larger-scale prospective randomized controlled trials to further validate the efficacy of the proposed strategy. Second, during the interventional procedure, there may be unpredictability, and discrepancies between preoperative ultrasound/CTA findings and actual vasculopathy severity can arise. Therefore, the selection of the puncture site and TCC tip location is based on the specific situation. The experience of the nephroradiologist and timely decision-making is critical. This strategy based on our 8 years of experience still requires optimization in certain circumstances.

Conclusion

To preserve the limited vascular access and address the repeated central venous thrombosis in HD patients with hypotension, it may be effective to place the tips of TCCs originally in SVC, followed by SVC and RA junction or RA, IVC in the event of thrombosis, stenosis, or obstruction. When thrombi are completely dissolved, catheter tips can be returned to the former location. Additionally, patients with central venous thrombus should be treated with antiplatelet therapy. These findings require validation through future prospective studies.

Supplemental Material

sj-docx-1-sci-10.1177_00368504251323761 - Supplemental material for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study

Supplemental material, sj-docx-1-sci-10.1177_00368504251323761 for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study by Jibo Sun, Hong Fan and Tianlei Cui in Science Progress

Supplemental Material

sj-docx-2-sci-10.1177_00368504251323761 - Supplemental material for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study

Supplemental material, sj-docx-2-sci-10.1177_00368504251323761 for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study by Jibo Sun, Hong Fan and Tianlei Cui in Science Progress

Supplemental Material

sj-docx-3-sci-10.1177_00368504251323761 - Supplemental material for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study

Supplemental material, sj-docx-3-sci-10.1177_00368504251323761 for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study by Jibo Sun, Hong Fan and Tianlei Cui in Science Progress

Supplemental Material

sj-pdf-4-sci-10.1177_00368504251323761 - Supplemental material for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study

Supplemental material, sj-pdf-4-sci-10.1177_00368504251323761 for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study by Jibo Sun, Hong Fan and Tianlei Cui in Science Progress

Supplemental Material

sj-pdf-5-sci-10.1177_00368504251323761 - Supplemental material for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study

Supplemental material, sj-pdf-5-sci-10.1177_00368504251323761 for Management of tunneled-cuffed catheters in hemodialysis patients with hypotension and recurrent central venous thrombosis: A single-center retrospective cohort study by Jibo Sun, Hong Fan and Tianlei Cui in Science Progress

Footnotes

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Author contributions

Conception and design: Tianlei Cui and Jibo Sun; Administrative support: Tianlei Cui; Provision of study materials: Tianlei Cui; Collection and assembly of data: Tianlei Cui, Jibo Sun, and Hong Fan; Data analysis and interpretation: Tianlei Cui, Jibo Sun, and Hong Fan; Manuscript writing: All authors; and Final approval of manuscript: All authors.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval and consent to participate

The study was approved by the Ethics Committee on Biomedical Research at the West China Hospital of Sichuan University (No. 201885). Individual consent for this retrospective analysis was waived.

ORCID iDs

Hong Fan

Tianlei Cui

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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