Peripherally Inserted Central Catheters and Other Intravascular Devices: How Safe Are They for Hemodialysis Patients?
2012; Elsevier BV; Volume: 60; Issue: 4 Linguagem: Inglês
10.1053/j.ajkd.2012.07.003
ISSN1523-6838
AutoresRoman Shingarev, Michael Allon,
Tópico(s)Hemodynamic Monitoring and Therapy
ResumoRelated Article, p. 601The growing emphasis on the use of arteriovenous fistulas (AVFs) in hemodialysis patients during the past few years has led to systematic exploration of the myriad barriers to achieving this goal.1Allon M. Fistula first: recent progress and ongoing challenges.Am J Kidney Dis. 2011; 57: 3-6Google Scholar, 2Lee T. Roy-Chaudhury P. Thakar C.V. Improving incident fistula rates: a process of care issue.Am J Kidney Dis. 2011; 57: 814-817Google Scholar Clearly, maintaining the integrity of the vasculature is one critical element in optimizing AVF maturation and patency. The burgeoning use of intravascular devices may promote vascular injury, stenosis, and thrombosis, thereby jeopardizing the success of AVF use in these patients (Table 1). Peripherally inserted central venous catheters (PICCs) are common intravascular devices with growing popularity since the late 1970s and are deemed a safer and simpler alternative to central venous catheters. More than a million PICCs are placed each year in the United States alone.16Moureau N. Vascular safety: it's all about PICCs.Nurs Manage. 2006; 37 (quiz 50): 22-27Google Scholar The major advantages of PICCs include greater patient comfort, simpler catheter care, and possibly long-term dwell time. The most common indication for a PICC is the need for long-term antibiotic administration, particularly in the outpatient setting. Guidelines for the prevention of intravascular catheter–related infections promulgated by the Infectious Diseases Society of America recommend using PICCs for antibiotic administration lasting longer than 6 weeks.17O'Grady N.P. Alexander M. Burns L.A. et al.Healthcare Infection Control Practices Advisory CommitteeSummary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections.Clin Infect Dis. 2011; 52: 1087-1099Google ScholarTable 1Studies Exploring Complications of Intravascular DevicesReferenceStudy DesignMajor FindingsPeripherally Inserted Central CathetersGrove & Pevec3Grove J.R. Pevec W.C. Venous thrombosis related to peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 837-840Google Scholar (2000)Cross-sectionalStepwise increase in PICC-associated thrombosis rate with increasing catheter diameter (1% for 4F, 6.6% for 5F, and 9.8% for 6F)Allen et al4Allen A.W. Megargell J.L. Brown D.B. et al.Venous thrombosis associated with the placement of peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 1309-1314Google Scholar (2000)Retrospective review38% overall PICC-associated thrombosis rate, with 57% found in cephalic, 14% in basilic, and 10% in brachial veinsGonsalves et al5Gonsalves C.F. Eschelman D.J. Sullivan K.L. DuBois N. Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement.Cardiovasc Intervent Radiol. 2003; 26: 123-127Google Scholar (2003)Retrospective review7% incidence of PICC-associated CVSMarnejon et al6Marnejon T. Angelo D. Abu Abdou A. Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters.J Vasc Access. 2012; 13: 231-238Google Scholar (2011)Retrospective case-controlPICC-associated venous thrombosis associated with decreased kidney function, left-sided placement, and use of basilic veinEl Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar (2012)Retrospective case-control3.2-fold higher rate of lack of functioning AVF in patients with PICC historyDialysis CathetersSchillinger et al8Schillinger F. Schillinger D. Montagnac R. Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses.Nephrol Dial Transplant. 1991; 6: 722-724Google Scholar (1991)Prospective cohort32% higher incidence of CVS in patients with subclavian vs internal jugular dialysis cathetersRayner et al9Rayner H.C. Pisoni R.L. Gillespie B.W. et al.Dialysis Outcomes and Practice Patterns StudyCreation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study.Kidney Int. 2003; 63: 323-330Google Scholar (2003)Prospective cohort1.8-fold higher risk of AVF failure with a history of temporary dialysis catheter useMacRae et al10MacRae J.M. Ahmed A. Johnson N. Levin A. Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis.ASAIO J. 2005; 51: 77-81Google Scholar (2005)Cross-sectionalHigher prevalence of CVS with longer catheter dwell time and higher no. of cannulationsShingarev et al11Shingarev R, Barker-Finkel J, Allon M. Association of hemodialysis central venous catheter use with ipsilateral arteriovenous vascular access survival [published online ahead of print July 23, 2012]. Am J Kidney Dis. doi:10.1053/j.ajkd.2012.06.014.Google Scholar (2012)Retrospective case-control2.5-fold higher rate of AVF failure with history of ipsilateral vs contralateral dialysis catheterPacemakers/DefibrillatorsDa Costa et al12Da Costa S.S. Scalabrini Neto A. Costa R. Caldas J.G. Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study.Pacing Clin Electrophysiol. 2002; 25: 1301-1306Google Scholar (2002)Prospective cohort study21% incidence of >70% venous stenosis 6 mo after last pacemaker placementKorkeila et al13Korkeila P. Nyman K. Ylitalo A. et al.Venous obstruction after pacemaker implantation.Pacing Clin Electrophysiol. 2007; 30: 199-206Google Scholar (2007)Prospective cohort study14% incidence of new >50% venous stenosis 6 mo after pacemaker placementDrew et al14Drew D.A. Meyer K.B. Weiner D.E. Transvenous cardiac device wires and vascular access in hemodialysis patients.Am J Kidney Dis. 2011; 58: 494-496Google Scholar (2011)Retrospective case-controlHigher frequency of CVS and catheter-dependence in patients with ipsilateral transvenous cardiac deviceBorsato et al15Borsato G.W. Rajan D.K. Simons M.E. Sniderman K.W. Tan K.T. Central venous stenosis associated with pacemaker leads: short-term results of endovascular interventions.J Vasc Interv Radiol. 2012; 23: 363-367Google Scholar (2012)Prospective cohort study50% primary patency rates of central veins with pacemaker lead-induced stenosis at 120 d postangioplastyAbbreviations: AVF, arteriovenous fistula; CVS, central vein stenosis; PICC, peripherally inserted central venous catheter. Open table in a new tab More recently, there has been enhanced recognition of PICCs' potential to produce venous injury and thrombosis. Symptomatic venous thrombosis occurs in <10% of patients with PICCs,18Aw A, Carrier M, Koczerginski J, McDiarmid S, Tay J. Incidence and predictive factors of symptomatic thrombosis related to peripherally inserted central catheters in chemotherapy patients. Thromb Res., in press.Google Scholar, 19Ong B. Gibbs H. Catchpole I. Hetherington R. Harper J. Peripherally inserted central catheters and upper extremity deep vein thrombosis.Australas Radiol. 2006; 50: 451-454Google Scholar, 20Wilson T.J. Brown D.L. Meurer W.J. Stetler Jr, W.R. Wilkinson D.A. Fletcher J.J. Risk factors associated with peripherally inserted central venous catheter-related large vein thrombosis in neurological intensive care patients.Intensive Care Med. 2012; 38: 272-278Google Scholar but the overall rate of thrombosis, including both symptomatic and asymptomatic, reaches an astounding 38%.4Allen A.W. Megargell J.L. Brown D.B. et al.Venous thrombosis associated with the placement of peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 1309-1314Google Scholar The risk of venous thrombosis associated with PICCs is 2-fold higher in patients with chronic kidney disease (CKD) compared with those with normal kidney function.6Marnejon T. Angelo D. Abu Abdou A. Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters.J Vasc Access. 2012; 13: 231-238Google Scholar PICCs are inserted in the cephalic or basilic vein in the antecubital fossa, with the tip in the superior vena cava or right atrium.Given the deleterious effects of PICCs on the veins that are used to create an AVF, it is likely that PICC placement affects the subsequent ability to create successful AVFs in patients with CKD. This possibility prompted the NKF-KDOQI (National Kidney Foundation's Kidney Disease Outcomes Quality Initiative) guidelines on vascular access to caution against the use of PICCs in patients with CKD,21National Kidney FoundationKDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Vascular Access.Am J Kidney Dis. 2006; 48: S176-S322Google Scholar but to date, these recommendations have been based on anecdotal evidence. The case-control study by El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar reported in the present issue of the American Journal of Kidney Diseases provides compelling evidence for an association between prior PICC placement and lower subsequent frequency of AVF use in hemodialysis patients. The authors compared the frequency of prior PICC use in 120 patients dialyzing with a central venous dialysis catheter or arteriovenous graft (cases) to that observed in 162 patients dialyzing with an AVF (controls). The frequency of prior PICC use was substantially higher in cases (44% vs 20%), and the association between lack of a functioning AVF and prior PICC use was highly significant (odds ratio, 3.2; P < 0.001) even after adjusting for patient sex, artery and vein diameters, and history of a central venous catheter.As the authors acknowledge, this study has several limitations. Most importantly, this was an observational study. As such, it can only show an association between a prior PICC and absence of a functioning fistula, but cannot prove causality. Notwithstanding the authors' attempt to adjust statistically for potential confounders, it still is possible that patients with prior PICCs had vessels of inferior quality that were not identified by preoperative vascular mapping. Nevertheless, given the propensity of PICCs to promote the thrombosis of veins required for the vascular anastomosis, it would be unethical to conduct a randomized clinical trial in which patients with CKD were allocated to receive a PICC prior to AVF creation. Second, the authors did not differentiate between primary AVF failure (AVF nonmaturation) and late AVF failure (AVF failure after successful cannulation). This distinction is important in understanding the link between PICC use and AVF failure and designing strategies to maximize AVF survival. AVF nonmaturation may be attributed to a draining vein that has been exposed to a PICC and became sclerotic, thereby failing to dilate appropriately under increased shear stress, as often happens with mobilized veins.22Badero O.J. Salifu M.O. Wasse H. Work J. Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions.Am J Kidney Dis. 2008; 51: 93-98Google Scholar, 23Falk A. Teodorescu V. Lou W.Y. Uribarri J. Vassalotti J.A. Treatment of “swing point stenoses” in hemodialysis arteriovenous fistulae.Clin Nephrol. 2003; 60: 35-41Google Scholar In contrast, AVF failure subsequent to successful use for dialysis usually indicates a new outflow problem in the proximal draining vein or central vein.24Romero A. Polo J.R. Garcia Morato E. Garcia Sabrido J.L. Quintans A. Ferreiroa J.P. Salvage of angioaccess after late thrombosis of radiocephalic fistulas for hemodialysis.Int Surg. 1986; 71: 122-124Google Scholar, 25Roy-Chaudhury P. Lee T.C. Vascular stenosis: biology and interventions.Curr Opin Nephrol Hypertens. 2007; 16: 516-522Google Scholar Unfortunately, El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar did not provide sufficient information to evaluate whether the deleterious effect of PICCs is due to primary or late AVF failure.If any of the 3 upper-arm veins (brachial, basilic, or cephalic) are exposed to and damaged by a PICC, the other 2 veins remain intact (Fig 1). However, the axillary, subclavian, and brachiocephalic veins, which serve as the common entry route for a PICC into the superior vena cava, are always exposed to the proximal end of a PICC. Two studies examining the incidence of central vein stenosis in association with PICCs reported a 3% rate of subclavian vein stenosis4Allen A.W. Megargell J.L. Brown D.B. et al.Venous thrombosis associated with the placement of peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 1309-1314Google Scholar and a 7% rate of overall central vein stenosis.5Gonsalves C.F. Eschelman D.J. Sullivan K.L. DuBois N. Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement.Cardiovasc Intervent Radiol. 2003; 26: 123-127Google Scholar Patient selection in both studies was limited to those undergoing serial extremity venography, which may have led to underestimation of the true incidence of PICC-associated central vein stenosis. The development of central vein stenosis is not unique to PICCs. Pacemakers that usually are inserted through the left subclavian vein also are associated with an incidence of central vein stenosis ranging from 10%-64%.12Da Costa S.S. Scalabrini Neto A. Costa R. Caldas J.G. Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study.Pacing Clin Electrophysiol. 2002; 25: 1301-1306Google Scholar, 13Korkeila P. Nyman K. Ylitalo A. et al.Venous obstruction after pacemaker implantation.Pacing Clin Electrophysiol. 2007; 30: 199-206Google Scholar Central venous catheters inserted through the internal jugular vein are reported to be associated with an alarming 41% central vein stenosis prevalence,10MacRae J.M. Ahmed A. Johnson N. Levin A. Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis.ASAIO J. 2005; 51: 77-81Google Scholar and history of a prior dialysis catheter has been implicated in higher subsequent AVF failure rate.9Rayner H.C. Pisoni R.L. Gillespie B.W. et al.Dialysis Outcomes and Practice Patterns StudyCreation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study.Kidney Int. 2003; 63: 323-330Google Scholar Finally, recent data from our institution suggest that history of a prior dialysis catheter ipsilateral to the AVF is associated with shorter cumulative survival of the AVF.11Shingarev R, Barker-Finkel J, Allon M. Association of hemodialysis central venous catheter use with ipsilateral arteriovenous vascular access survival [published online ahead of print July 23, 2012]. Am J Kidney Dis. doi:10.1053/j.ajkd.2012.06.014.Google ScholarDirect analysis of the relationship between catheter caliber and the diameter of the vein used for PICC placement was not possible in the study by El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar because the authors did not have detailed findings of the preoperative vascular mapping as it related to the ipsilateral PICC. However, at least one prior study reported a higher rate of vein thrombosis with the use of larger PICCs,3Grove J.R. Pevec W.C. Venous thrombosis related to peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 837-840Google Scholar and there is a report of a higher rate of internal jugular vein thrombosis (28%) compared with brachiocephalic vein and superior vena cava thromboses (14% and 2%, respectively).26Oguzkurt L. Tercan F. Torun D. Yildirim T. Zumrutdal A. Kizilkilic O. Impact of short-term hemodialysis catheters on the central veins: a catheter venographic study.Eur J Radiol. 2004; 52: 293-299Google Scholar This leads to a hypothesis that thrombosis is more likely if a greater cross-sectional area of the vessel is occupied by a foreign object, resulting in greater stasis and denudation from greater contact surface area, which is consistent with 2 of Virchow's postulates.Three additional observations in the El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar study are notable. First, 30% of hemodialysis patients in this study had a history of PICC use, a frequency similar to that observed at another medical center.27McGill RL, Lucas JG, Tsukahara T, Marcus RJ. Can a nephrology service protect the veins of hospital patients? Abstract presented at: American Society of Nephrology Meeting, Philadelphia, PA, November 8-13, 2011.Google Scholar Second, in this group, 54% had the PICC placed after initiating dialysis therapy. Finally, 56% of PICCs placed were intended specifically to administer intravenous antibiotics. Given the consensus guidelines that discourage PICCs in patients with CKD, how can we account for these alarming statistics? The authors note that the decision to place PICCs in these patients was determined by non-nephrologists (presumably without consultation with nephrologists). This is a case in which recommendations from medical societies of 2 different subspecialists (infectious diseases and nephrology) are in conflict. Whereas the infectious disease guidelines encourage PICCs for management of long-term intravenous antibiotic therapy, the nephrology guidelines discourage their use in patients with CKD. The overriding incentive for the non-nephrologist treating a hospitalized patient is to accelerate hospital discharge by placing a PICC that permits safe and convenient outpatient intravenous antibiotics. The long-term consequence of inducing venous thrombosis and jeopardizing the success of a future AVF is either not recognized or considered to be of secondary importance.Educational efforts might reduce the use of PICCs in patients with CKD, but one such initiative at a medical center has been reported to be unsuccessful.27McGill RL, Lucas JG, Tsukahara T, Marcus RJ. Can a nephrology service protect the veins of hospital patients? Abstract presented at: American Society of Nephrology Meeting, Philadelphia, PA, November 8-13, 2011.Google Scholar One option to resolve this dilemma would be to implement a hospital policy that mandates a nephrology consultation in any hemodialysis patient prior to scheduling PICC placement. Most systemic infections in hemodialysis patients can be treated with appropriate intravenous antibiotics administered thrice weekly on dialysis days using the hemodialysis access without requiring a separate vascular device,28Allon M. Treatment guidelines for dialysis catheter-related bacteremia: an update.Am J Kidney Dis. 2009; 54: 13-17Google Scholar and routinely involving nephrologists in the decision process likely would eliminate most PICCs in hemodialysis patients. The optimal approach in patients with CKD who have not yet initiated dialysis therapy is more challenging because these patients lack a suitable vascular access for outpatient administration of antibiotics. If there is no alternative to using a PICC in a patient with CKD, there are 2 available measures that may reduce the potential harm. First, using a smaller diameter PICC may reduce the risk of venous injury. Second, preferential use of the brachial vein may minimize injury to the target vessel because most AVFs are created using the cephalic or basilic veins. Another potential alternative is to place a small-caliber tunneled catheter in the right internal jugular vein in lieu of a PICC because the diameter of the internal jugular vein is greater than that of the subclavian vein and no arm veins are disrupted. Prospective clinical trials are needed to determine whether any of these alternative approaches would decrease the likelihood of prolonged hemodialysis catheter dependence in such patients. Related Article, p. 601 Related Article, p. 601 Related Article, p. 601 The growing emphasis on the use of arteriovenous fistulas (AVFs) in hemodialysis patients during the past few years has led to systematic exploration of the myriad barriers to achieving this goal.1Allon M. Fistula first: recent progress and ongoing challenges.Am J Kidney Dis. 2011; 57: 3-6Google Scholar, 2Lee T. Roy-Chaudhury P. Thakar C.V. Improving incident fistula rates: a process of care issue.Am J Kidney Dis. 2011; 57: 814-817Google Scholar Clearly, maintaining the integrity of the vasculature is one critical element in optimizing AVF maturation and patency. The burgeoning use of intravascular devices may promote vascular injury, stenosis, and thrombosis, thereby jeopardizing the success of AVF use in these patients (Table 1). Peripherally inserted central venous catheters (PICCs) are common intravascular devices with growing popularity since the late 1970s and are deemed a safer and simpler alternative to central venous catheters. More than a million PICCs are placed each year in the United States alone.16Moureau N. Vascular safety: it's all about PICCs.Nurs Manage. 2006; 37 (quiz 50): 22-27Google Scholar The major advantages of PICCs include greater patient comfort, simpler catheter care, and possibly long-term dwell time. The most common indication for a PICC is the need for long-term antibiotic administration, particularly in the outpatient setting. Guidelines for the prevention of intravascular catheter–related infections promulgated by the Infectious Diseases Society of America recommend using PICCs for antibiotic administration lasting longer than 6 weeks.17O'Grady N.P. Alexander M. Burns L.A. et al.Healthcare Infection Control Practices Advisory CommitteeSummary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections.Clin Infect Dis. 2011; 52: 1087-1099Google Scholar Abbreviations: AVF, arteriovenous fistula; CVS, central vein stenosis; PICC, peripherally inserted central venous catheter. More recently, there has been enhanced recognition of PICCs' potential to produce venous injury and thrombosis. Symptomatic venous thrombosis occurs in <10% of patients with PICCs,18Aw A, Carrier M, Koczerginski J, McDiarmid S, Tay J. Incidence and predictive factors of symptomatic thrombosis related to peripherally inserted central catheters in chemotherapy patients. Thromb Res., in press.Google Scholar, 19Ong B. Gibbs H. Catchpole I. Hetherington R. Harper J. Peripherally inserted central catheters and upper extremity deep vein thrombosis.Australas Radiol. 2006; 50: 451-454Google Scholar, 20Wilson T.J. Brown D.L. Meurer W.J. Stetler Jr, W.R. Wilkinson D.A. Fletcher J.J. Risk factors associated with peripherally inserted central venous catheter-related large vein thrombosis in neurological intensive care patients.Intensive Care Med. 2012; 38: 272-278Google Scholar but the overall rate of thrombosis, including both symptomatic and asymptomatic, reaches an astounding 38%.4Allen A.W. Megargell J.L. Brown D.B. et al.Venous thrombosis associated with the placement of peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 1309-1314Google Scholar The risk of venous thrombosis associated with PICCs is 2-fold higher in patients with chronic kidney disease (CKD) compared with those with normal kidney function.6Marnejon T. Angelo D. Abu Abdou A. Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters.J Vasc Access. 2012; 13: 231-238Google Scholar PICCs are inserted in the cephalic or basilic vein in the antecubital fossa, with the tip in the superior vena cava or right atrium. Given the deleterious effects of PICCs on the veins that are used to create an AVF, it is likely that PICC placement affects the subsequent ability to create successful AVFs in patients with CKD. This possibility prompted the NKF-KDOQI (National Kidney Foundation's Kidney Disease Outcomes Quality Initiative) guidelines on vascular access to caution against the use of PICCs in patients with CKD,21National Kidney FoundationKDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Vascular Access.Am J Kidney Dis. 2006; 48: S176-S322Google Scholar but to date, these recommendations have been based on anecdotal evidence. The case-control study by El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar reported in the present issue of the American Journal of Kidney Diseases provides compelling evidence for an association between prior PICC placement and lower subsequent frequency of AVF use in hemodialysis patients. The authors compared the frequency of prior PICC use in 120 patients dialyzing with a central venous dialysis catheter or arteriovenous graft (cases) to that observed in 162 patients dialyzing with an AVF (controls). The frequency of prior PICC use was substantially higher in cases (44% vs 20%), and the association between lack of a functioning AVF and prior PICC use was highly significant (odds ratio, 3.2; P < 0.001) even after adjusting for patient sex, artery and vein diameters, and history of a central venous catheter. As the authors acknowledge, this study has several limitations. Most importantly, this was an observational study. As such, it can only show an association between a prior PICC and absence of a functioning fistula, but cannot prove causality. Notwithstanding the authors' attempt to adjust statistically for potential confounders, it still is possible that patients with prior PICCs had vessels of inferior quality that were not identified by preoperative vascular mapping. Nevertheless, given the propensity of PICCs to promote the thrombosis of veins required for the vascular anastomosis, it would be unethical to conduct a randomized clinical trial in which patients with CKD were allocated to receive a PICC prior to AVF creation. Second, the authors did not differentiate between primary AVF failure (AVF nonmaturation) and late AVF failure (AVF failure after successful cannulation). This distinction is important in understanding the link between PICC use and AVF failure and designing strategies to maximize AVF survival. AVF nonmaturation may be attributed to a draining vein that has been exposed to a PICC and became sclerotic, thereby failing to dilate appropriately under increased shear stress, as often happens with mobilized veins.22Badero O.J. Salifu M.O. Wasse H. Work J. Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions.Am J Kidney Dis. 2008; 51: 93-98Google Scholar, 23Falk A. Teodorescu V. Lou W.Y. Uribarri J. Vassalotti J.A. Treatment of “swing point stenoses” in hemodialysis arteriovenous fistulae.Clin Nephrol. 2003; 60: 35-41Google Scholar In contrast, AVF failure subsequent to successful use for dialysis usually indicates a new outflow problem in the proximal draining vein or central vein.24Romero A. Polo J.R. Garcia Morato E. Garcia Sabrido J.L. Quintans A. Ferreiroa J.P. Salvage of angioaccess after late thrombosis of radiocephalic fistulas for hemodialysis.Int Surg. 1986; 71: 122-124Google Scholar, 25Roy-Chaudhury P. Lee T.C. Vascular stenosis: biology and interventions.Curr Opin Nephrol Hypertens. 2007; 16: 516-522Google Scholar Unfortunately, El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar did not provide sufficient information to evaluate whether the deleterious effect of PICCs is due to primary or late AVF failure. If any of the 3 upper-arm veins (brachial, basilic, or cephalic) are exposed to and damaged by a PICC, the other 2 veins remain intact (Fig 1). However, the axillary, subclavian, and brachiocephalic veins, which serve as the common entry route for a PICC into the superior vena cava, are always exposed to the proximal end of a PICC. Two studies examining the incidence of central vein stenosis in association with PICCs reported a 3% rate of subclavian vein stenosis4Allen A.W. Megargell J.L. Brown D.B. et al.Venous thrombosis associated with the placement of peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 1309-1314Google Scholar and a 7% rate of overall central vein stenosis.5Gonsalves C.F. Eschelman D.J. Sullivan K.L. DuBois N. Bonn J. Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement.Cardiovasc Intervent Radiol. 2003; 26: 123-127Google Scholar Patient selection in both studies was limited to those undergoing serial extremity venography, which may have led to underestimation of the true incidence of PICC-associated central vein stenosis. The development of central vein stenosis is not unique to PICCs. Pacemakers that usually are inserted through the left subclavian vein also are associated with an incidence of central vein stenosis ranging from 10%-64%.12Da Costa S.S. Scalabrini Neto A. Costa R. Caldas J.G. Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study.Pacing Clin Electrophysiol. 2002; 25: 1301-1306Google Scholar, 13Korkeila P. Nyman K. Ylitalo A. et al.Venous obstruction after pacemaker implantation.Pacing Clin Electrophysiol. 2007; 30: 199-206Google Scholar Central venous catheters inserted through the internal jugular vein are reported to be associated with an alarming 41% central vein stenosis prevalence,10MacRae J.M. Ahmed A. Johnson N. Levin A. Kiaii M. Central vein stenosis: a common problem in patients on hemodialysis.ASAIO J. 2005; 51: 77-81Google Scholar and history of a prior dialysis catheter has been implicated in higher subsequent AVF failure rate.9Rayner H.C. Pisoni R.L. Gillespie B.W. et al.Dialysis Outcomes and Practice Patterns StudyCreation, cannulation and survival of arteriovenous fistulae: data from the Dialysis Outcomes and Practice Patterns Study.Kidney Int. 2003; 63: 323-330Google Scholar Finally, recent data from our institution suggest that history of a prior dialysis catheter ipsilateral to the AVF is associated with shorter cumulative survival of the AVF.11Shingarev R, Barker-Finkel J, Allon M. Association of hemodialysis central venous catheter use with ipsilateral arteriovenous vascular access survival [published online ahead of print July 23, 2012]. Am J Kidney Dis. doi:10.1053/j.ajkd.2012.06.014.Google Scholar Direct analysis of the relationship between catheter caliber and the diameter of the vein used for PICC placement was not possible in the study by El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar because the authors did not have detailed findings of the preoperative vascular mapping as it related to the ipsilateral PICC. However, at least one prior study reported a higher rate of vein thrombosis with the use of larger PICCs,3Grove J.R. Pevec W.C. Venous thrombosis related to peripherally inserted central catheters.J Vasc Interv Radiol. 2000; 11: 837-840Google Scholar and there is a report of a higher rate of internal jugular vein thrombosis (28%) compared with brachiocephalic vein and superior vena cava thromboses (14% and 2%, respectively).26Oguzkurt L. Tercan F. Torun D. Yildirim T. Zumrutdal A. Kizilkilic O. Impact of short-term hemodialysis catheters on the central veins: a catheter venographic study.Eur J Radiol. 2004; 52: 293-299Google Scholar This leads to a hypothesis that thrombosis is more likely if a greater cross-sectional area of the vessel is occupied by a foreign object, resulting in greater stasis and denudation from greater contact surface area, which is consistent with 2 of Virchow's postulates. Three additional observations in the El Ters et al7El Ters M. Schears G.J. Taler S.J. et al.Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients.Am J Kidney Dis. 2012; 60: 601-608Abstract Full Text Full Text PDF Scopus (52) Google Scholar study are notable. First, 30% of hemodialysis patients in this study had a history of PICC use, a frequency similar to that observed at another medical center.27McGill RL, Lucas JG, Tsukahara T, Marcus RJ. Can a nephrology service protect the veins of hospital patients? Abstract presented at: American Society of Nephrology Meeting, Philadelphia, PA, November 8-13, 2011.Google Scholar Second, in this group, 54% had the PICC placed after initiating dialysis therapy. Finally, 56% of PICCs placed were intended specifically to administer intravenous antibiotics. Given the consensus guidelines that discourage PICCs in patients with CKD, how can we account for these alarming statistics? The authors note that the decision to place PICCs in these patients was determined by non-nephrologists (presumably without consultation with nephrologists). This is a case in which recommendations from medical societies of 2 different subspecialists (infectious diseases and nephrology) are in conflict. Whereas the infectious disease guidelines encourage PICCs for management of long-term intravenous antibiotic therapy, the nephrology guidelines discourage their use in patients with CKD. The overriding incentive for the non-nephrologist treating a hospitalized patient is to accelerate hospital discharge by placing a PICC that permits safe and convenient outpatient intravenous antibiotics. The long-term consequence of inducing venous thrombosis and jeopardizing the success of a future AVF is either not recognized or considered to be of secondary importance. Educational efforts might reduce the use of PICCs in patients with CKD, but one such initiative at a medical center has been reported to be unsuccessful.27McGill RL, Lucas JG, Tsukahara T, Marcus RJ. Can a nephrology service protect the veins of hospital patients? Abstract presented at: American Society of Nephrology Meeting, Philadelphia, PA, November 8-13, 2011.Google Scholar One option to resolve this dilemma would be to implement a hospital policy that mandates a nephrology consultation in any hemodialysis patient prior to scheduling PICC placement. Most systemic infections in hemodialysis patients can be treated with appropriate intravenous antibiotics administered thrice weekly on dialysis days using the hemodialysis access without requiring a separate vascular device,28Allon M. Treatment guidelines for dialysis catheter-related bacteremia: an update.Am J Kidney Dis. 2009; 54: 13-17Google Scholar and routinely involving nephrologists in the decision process likely would eliminate most PICCs in hemodialysis patients. The optimal approach in patients with CKD who have not yet initiated dialysis therapy is more challenging because these patients lack a suitable vascular access for outpatient administration of antibiotics. If there is no alternative to using a PICC in a patient with CKD, there are 2 available measures that may reduce the potential harm. First, using a smaller diameter PICC may reduce the risk of venous injury. Second, preferential use of the brachial vein may minimize injury to the target vessel because most AVFs are created using the cephalic or basilic veins. Another potential alternative is to place a small-caliber tunneled catheter in the right internal jugular vein in lieu of a PICC because the diameter of the internal jugular vein is greater than that of the subclavian vein and no arm veins are disrupted. Prospective clinical trials are needed to determine whether any of these alternative approaches would decrease the likelihood of prolonged hemodialysis catheter dependence in such patients. Financial Disclosure: The authors declare that they have no relevant financial interests. Association of Hemodialysis Central Venous Catheter Use With Ipsilateral Arteriovenous Vascular Access SurvivalAmerican Journal of Kidney DiseasesVol. 60Issue 6PreviewCentral venous catheters frequently are used for hemodialysis vascular access while patients await placement and maturation of an arteriovenous fistula or graft. Catheters may cause central vein stenosis, which can adversely affect vascular access outcomes. We compared vascular access outcomes in patients with a history of ipsilateral and contralateral dialysis catheters. Full-Text PDF
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