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Institution: Westmead Hospital - NSW, Australia
Central Venous Catheters (CVC) for Dialysis an established but grossly over & misused modality in ESRF.
CVC morbidity:
1. Destruction of Central Veins: (DVT, Central Vein Occlusion, Arm swelling, SVC Syndrome, AVF malfunction or failure).
2. Line Sepsis & sequelae
3. CVC Malfunction: Fibrin Sheath, occlusion, displacement, fracture
4. CVC Revision: Arterial injury, pneumothorax
Avoiding CVC problems:
a. DON’T Use CVCs! Pre-emptive Dialysis Systems, Urgent Start Seldinger PD (USSPD), forced AVF maturation.
b. Appropriate CVC use:
NO L sided CVCs!!;
DO use temporary femoral lines, R SCV & tunnelled lines.
c. Correct placement (US & Xray guidance), correct care, correct troubleshoot
CVC appropriate when:
1. Life expectancy < 1 year
2. Life expectancy, 1 - 2 years & difficult Access
3. Emergency dialysis
4. Where AVF is contra-indicated: Arterial Steal, poor cardiac reserve, fragile skin & PD not an option.
Inappropriate CVC use:
1. ~all L Sided CVCs!!
2. When PD / USSPD is an alternative
3. When Dialysis Access can be provided / restored by urgent Endovascular fistuloplasty or maturation.
Why no L sided CVCs :
Because of the non-linear anatomy of L sided CVCs, they:
1. Rapidly (days) & reliably destroy L sided Central Veins
2. Morbidity of L upper limb edema,
3. SVC syndrome when R side also damaged,
4. Make L upper limb unsuitable for AVF creation / use
How to keep CVCs on the R hand side when:
1. R Jugular stenosis / occlusion:
Cross the lesion endovascularly OR enter the SVC via the anterior or external Jugular OR use the R SCV.
2. R Jugular CVC sepsis:
Remove CVC, Antibiotics, bridging dialysis thru Femoral line, re-insert R CVC.
3. R Jugular thrombosis:
Anticoagulate, cross thrombus & place a R CVC.