Tunneled femoral catheters and tunneled jugular catheters, our experience, efficacy and complications

Background: The replacement of the arterio-venous fistula with PTFE prostheses or central tunneled catheters is increasing due to the early exhaustion of autologous native accesses. The percentage of patients with tunneled catheters as vascular access for hemodialysis reaches between 15 to 25%, therefore, it is essential to improve the techniques used to avoid early and late complications, and to look for other possibilities due to early venous exhaustion. The use of tunneled femoral catheters is increasingly frequent due to the impossibility of using accesses of the superior venous axis. In this work we study and analyze the evolution and complications of tunneled catheters, both jugular and femoral, placed in the period from January 1, 2017 to May 30, 2018 in the Interventional Nephrology Unit, Nephrology Department of the Clinical Hospital of Santiago de Compostela. We also compared the evolution of femoral tunneled catheters with tunneled jugular catheters.

Other vessels may be the target of percutaneous vascular access, such as the left jugular vein, the subclavian, femoral, iliac, or inferior cava vein.
The use of the subclavian vein for hemodialysis catheters is being set aside due to the high incidence of venous stenosis [4,5].
The use of the femoral, iliac or inferior vena cava is considered as a last resort before the exhaustion of other possibilities, always with a distal to proximal order relative to the heart. In the scientifi c literature, data have been provided that percutaneous accesses have a higher incidence of infections and dysfunctions, being higher in cases of percutaneous accesses of the inferior venous axis [5][6][7][8][9].

Procedures
All tunneled catheters were placed by interventional nephrologists. The catheter placement was performed under real-time ultrasound in the interventional nephrology unit.
We used 15.5F with lengths from 24cm to 28 cm for jugular catheters and 15.5 F TITAN HD with length of 55 cm for femoral catheters. The tip of the catheter was placed in the right atrium for jugular and femoral catheters. The skin exit site for tunneled femoral catheters was towards the side wall of the abdomen.
The administration of prophylactic antibiotic is usually with Cefazolin or in case of not being able to use it, with Vancomycin, single dose after intervention.
All catheters for hemodialysis are managed by nurses specialized in hemodialysis and with training in the management of vascular access.
Nursing care and catheter management is done completely sterile following hospital protocols that include both respiratory and contact isolation, and catheter locking is basically done with heparin except in case of infections, situation which requires locking in addition to heparin with antibiotics.
In the treatment protocol for dialysis patients' infections, treatment is done on an outpatient basis without the need for hospitalization, except in cases of instability or severe infections.  A descriptive analysis of the analyzed variables was carried out using the frequency and percentage for the qualitative variables, and the mean, median, standard deviation and range for the quantitative one. For the comparison of qualitative variables, the Chi-square test was used. The analysis was performed with an IBM SPSS Statistics v20 statistical package.

Materials and methods
Results 22 (37.3%) of the patients studied were women, and 37 (62.7%) men (Table 1).   On the other hand, in the femoral group 2 of the 5 (40%) it was due to AVF creation, 2 (40%) due to dysfunction and (10%) due to deep vein thrombosis.
Bleeding after implantation was considered an immediate complication and was observed in 3/59 patients (5.1%),1 in femoral group and 2 in jugular group, of whom 1 patient did not take any type of anti-platelet treatment, 1 was with acetylsalicylic acid and another patient was anticoagulated with low molecular weight heparin.
Only two patients had venous thrombosis (3.4%) of which one patient was anticoagulated with acenocoumarol and another was not receiving any antithrombotic treatment

Discussion
We start from the basis that patients who have had a femoral catheter are not having adequate access to the jugular axis, either due to exhaustion or complications, for this reason it is understood that the femoral catheter group would have more complications, comorbidities and less quality of the vascular system.
As can be seen in the results obtained, the percentage of male patients is higher than female patients, male patients formed 63% of the sample studied, while women 37%, on the other hand, the patients who required placement of the femoral catheter were more female (63,6%). In some studies, elderly patients have been associated with the increased possibility of AVF failure, although in other studies no differences have been detected between young patients and elderly patients. In our study, it was seen that the mean age is 71 years, and we consider that other factors have more infl uence on the determination of the type and the survival of vascular access. Approximately 30% of patients who acquire catheter implantation had diabetic nephropathy as a cause of chronic kidney disease.
In our study, anticoagulant or anti-platelet therapy intake was not relevant. No relationship has been found between anticoagulation / anti-platelet therapy and the incidence of early or late complications, the two complications related to the procedure detected were venous thrombosis and bleeding, with equal incidences in jugular catheters and femoral catheters.
There were no differences in the incidence of infections between men and women, (22.7%) in women and (29.7%) in men, nor was there a correlation with age since the distribution of infections was homogeneous at all ages.
Tunnelitis was the most frequent infection, observed of equal incidence in the two groups studied, both jugular and femoral, and although the mean time of onset of the fi rst infection was shorter in the femoral group, it was not stylistically signifi cant because of the low frequency number of infections.
In addition they were treated with antibiotherapy and did not require any catheter removal.
There have been 32 catheter removals of the 59 inserted

Conclusion
Due to the advanced age of the patients and the associated pathologies especially cardiovascular pathology, the use of non-native vascular access is increasing, for this reason we must improve the techniques of vascular catheters placement in order to optimize its viability [7][8][9].
We consider that we must investigate further to fi nd easy and safe alternatives to guarantee vascular access, in addition to individualizing the type of access for each patient.