Ultrasound-Guided Placement of Tunneled Dialysis Catheters Without Fluoroscopic Assistance: A Retrospective Analysis

Introduction

Reliable vascular access is a cornerstone of successful hemodialysis (HD) treatment, particularly for patients with end-stage kidney disease (ESKD). Tunneled cuffed catheters (TCCs) are often utilized for this purpose, especially in cases where arteriovenous fistulas (AVFs) are not yet ready or feasible.¹ Historically, fluoroscopic guidance has been the standard approach for TCC placement, providing precise catheter positioning. However, this method exposes patients to ionizing radiation and can be associated with increased procedural complexity.² In recent years, non-fluoroscopic techniques, notably ultrasound guidance, have emerged as promising alternatives. Ultrasound guidance offers the potential to reduce radiation exposure while simplifying the catheter placement process.³ Despite these advantages, comprehensive data on the outcomes of non-fluoroscopic guided TCCs, particularly within complex tertiary care environments, remains scarce. This study aims to explore the effectiveness of non-fluoroscopic guided TCCs in a tertiary care setting. The objectives are: to evaluate the complication rates associated with these catheters, to determine their overall survival rates, and to identify risk factors linked to catheter dysfunction. By focusing on these areas, we seek to provide a clearer understanding of the benefits and limitations of non-fluoroscopic guidance in HD access. We present our findings of using non-fluoroscopic methods to improve patient safety and procedural efficiency, by emphasizing strategies that minimize radiation exposure while optimizing HD access.

Materials and Methods

This retrospective study was conducted at a public sector, tertiary care center in South India, from January 2022 to January 2024. We identified patients who underwent non-fluoroscopic guided TCC placement for HD access during the study. Inclusion criteria were patients aged ≥18 who had a TCC placed using non-fluoroscopic methods. Exclusion criteria included patients with incomplete medical records or those who had other types of vascular access simultaneously. Data were extracted from medical records using a standardized data collection form. Information collected included patient demographics, including age, sex, comorbidities (e.g., diabetes mellitus, hypertension, coronary artery disease, smoking), primary kidney disease etiology (e.g., chronic interstitial nephritis, diabetic kidney disease, chronic glomerulonephritis, others like chronic thrombotic microangiopathy); catheter details like insertion site (e.g., right and left internal jugular vein (IJV), right and left femoral vein) and duration of catheter use (from day of insertion till removal/death of the patient); complications and outcomes, such as, immediate (within 30 days) and late (after 30 days) complications, including catheter-related bloodstream infections (CRBSI), occlusions, and other adverse events (like kink, arterial puncture, hematoma, minor & major bleeding). Catheter survival was tracked, and reasons for removal were recorded (e.g., AVF maturation, kidney transplantation, catheter-related dysfunction). For outcomes, procedural success was defined as radiologically confirmed appropriate tip position (lower end of the superior vena cava to mid right atrium) and subsequent use of the catheter to achieve adequate HD blood flow (>300 mL/min). An unsuccessful procedure was defined as any outcome that did not meet the criteria for a successful procedure, which included successful cannulation of the intended vessel, unimpeded guide wire advancement, and functional catheter placement with adequate flow. For complications, minor bleeding complications were defined as noticeable bleeding with no escalation in the level of care provided to the patient. These typically resolved with digital pressure to the site of bleeding or an extra suture. Major/severe bleeding complications were defined as a bleeding event that required escalation in the level of care, such as intensive care unit monitoring, transfusion, or transfer from the outpatient to the inpatient setting. CRBSI was defined as the presence of clinical symptoms such as fever and chills, accompanied by a positive blood culture. Catheter occlusion was defined as the inability to withdraw blood or sluggish/absent flow during dialysis. Catheter kinks were identified when there was sluggish or absent blood flow during dialysis, which was subsequently confirmed through radiological imaging. Secondary patency is defined as the successful restoration of blood flow in an initially occluded TCC after intervention. Streptokinase (STK) usage involved administering 250,000 units of STK in a 2 mL solution into the occluded limb of the TCC, followed by a 2-hour wait before reassessment of blood flow. For kink repair, mild kinks, characterized by sluggish blood flow, were corrected either by gently pulling back the catheter or by realigning it using a guide wire. Severe kinks, resulting in absent blood flow, were addressed by exchanging the catheter using a guide wire. Arterially placed TCCs were managed through open surgical repair performed by the endovascular team. Follow-up duration, reasons for loss to follow-up, interventions performed, and outcomes were recorded. A Polyurethane Maxocath long-term dual-lumen catheter (length as per patient’s height) was used.

Informed consent was taken. The required catheter length was estimated by measuring the external distance from the venous entry point (usually right IJV) to the fourth intercostal space as the anatomical landmark for the mid-right atrium. Under ultrasound guidance, a guide wire was used to facilitate catheter placement. Using a tunneller tool, a subcutaneous tunnel from the exit site to the venous entry site was created. Using a peel-away sheath, the catheter was secured over the guide wire. After inserting the catheter, post-procedural flow was checked, and a chest X-ray (pelvic/lower chest X-ray in femoral TCC) was performed to confirm the catheter’s position and assess for any complications (like hemothorax, pneumothorax, kink). Azygos vein entry was suspected if the catheter curved upward along the right mediastinum on X-ray, and it was corrected by withdrawing the catheter and guidewire slightly and redirecting under anatomical guidance, sometimes using saline flush and gentle wire manipulation. The catheter was then reinserted and rechecked by X-ray. Standard infection control practices were followed. Antibiotic catheter lock solution prepared in-house by combining 1 mL of gentamicin (10 mg/mL) with 4 mL of heparin (1000 U/mL), yielding a final concentration of 2 mg/mL gentamicin and 800 U/mL heparin per milliliter was used during hospital stay.

Results

The demographic data has been shown in Table 1. Most patients (44%) were aged 41-60 years, 40% were ≤40 years, and 16% were >60 years old. There were 72.7% males and 27.3% females. TCCs were primarily inserted as a temporary bridge to AVF creation (62%), with the right IJV being the most frequently used insertion site, accounting for 92% of cases. The catheter survival data has been shown in Table 2. The overall mean duration of TCC use was 7.19 months, with a median of 6 months. Survival rates declined over time, with 98%, 78%, 41%, and 16% of catheters functional at 1, 3, 6, and 12 months, respectively. By 15 months, all catheters had either been removed or patients were lost to follow-up [Figure 1]. Catheter survival varied significantly by purpose: those used as a bridge to living kidney transplantation had the shortest mean duration at 3.6 months, while those used for permanent access had the longest at 8.7 months [Figure 2]. During the study, 63.3% of catheters were removed. The most common reason for catheter removal was AVF maturation, representing 41.3% of cases, followed by kidney transplantation (11.3%) and catheter-related problems (10.7%). Overall, 36.7% were lost to follow-up due to reasons unrelated to the catheter (deaths in 33.3%). Only 3.3% of catheters were lost due to catheter-related issues like catheter-related bloodstream infection (CRBSI), leading to sepsis. Patients with coronary artery disease (CAD) and multiple access failures, those with catheters used for >6 months, and those with femoral insertion sites experienced higher rates of catheter-related dysfunction, leading to increased catheter removal rates compared to other groups (p < 0.001) [Table 3]. Complications were observed in 44.6% cases [Figures 3 and 4], including CRBSI in 25.3%. Middle-aged patients (44.7%), those with comorbidities (76.3%), especially diabetes (47.4%), and long-term catheter use (73.7%) experienced higher risk for CRBSI (as a part of late complications). Fibrin sheath or thrombus affected 12% of patients, while other complications, like catheter kink or improper tip position, were seen in 4.7% of cases; 17.3% required additional interventions post-insertion. STK (2.5 lakh IU) was the most common intervention used in 12% of cases. Other interventions included catheter kink repair (4%) and, rarely, reinsertion (for cuff extrusion) and surgical removal (0.7%). Interventions had a secondary patency success rate of 54%. STK interventions had a 44% success rate in restoring catheter function. A significant proportion of patients, particularly those with CAD (66.7%) and diabetes mellitus (DM) (55.6%), multiple access failures (77.8%), and femoral insertion sites (55.6%), did not achieve restoration of catheter function.

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Figure 1:

Outcomes of TCC insertion. TCC: Tunneled cuffed catheters, AVF: Arteriovenous fistula, CRBSI: Catheter-related bloodstream infections.

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Figure 2:

Complications of TCC and interventions. TCC: Tunneled cuffed catheters, STK: Streptokinase, CRBSI: Catheter-related bloodstream infections.

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Figure 3:

TCC survival analysis. TCC: Tunneled cuffed catheters.

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Figure 4:

TCC survival and indications for TCC. AVF: Arteriovenous fistula, LKT: Live kidney transplant, TCC: Tunneled cuffed catheters.

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Discussion

Tunneled catheters placed under fluoroscopic guidance constitute an important option for vascular access for hemodialysis. However, fluoroscopy may not be universally employed due to cost and radiation exposure. Our study aimed to evaluate if non-fluroscopically placement of tunneled catheters could provide a safe, effective and viable option.

This study demonstrated a high success rate (98.6%) for non-fluoroscopic tunneled cuffed catheter (TCC) placement in a predominantly middle-aged population with a marked male predominance (72.7%), possibly reflecting either a higher ESKD prevalence in males or reduced dialysis access for females, consistent with Pisoni et al.⁴ The prevalence of diabetes mellitus (32.7%) and hypertension (27.3%) aligns with established chronic kidney disease risk factors. A strong preference for the right internal jugular vein (IJV) (92%) was noted, consistent with Beathard’s report of its anatomical benefits and lower complication rates.⁵ More than half of patients (55.4%) experienced no complications; however, catheter-related bloodstream infection (CRBSI) occurred in 25.3%, reflecting late complications likely due to suboptimal infection control, aligned with Allon et al.’s reported rates of 2.5–5.5 episodes per 1000 catheter days, which corresponds to a 20–60% annual risk.⁶ The mean catheter duration was 7.19 months (median 6 months), comparable to Maya and Allon’s median survival of 6.5 months⁷ but shorter than Develter et al. (20.2 months)⁸ and Hu et al. (26.2 ± 19.8 months).⁹ Infections were the leading cause of catheter loss, with AVF maturation (41.3%) as the primary reason for catheter removal, underscoring TCC use mainly as a bridge to permanent vascular access. Interventions were necessary in 17.3% of cases, primarily involving streptokinase (2.5 lakh IU) for catheter clearance, consistent with Saad’s 15–20% intervention rate.¹⁰ The secondary patency rate of 44% indicates that while many issues were addressable, a significant proportion required additional management. Comparative analysis against historical fluoroscopic data reveals that non-fluoroscopic TCC insertion in this study achieved similar success rates [Table 4]. Konnepati et al. reported 100% success and Zi Yun Chang 98.1%, demonstrating comparable effectiveness.^11,12 Non-fluoroscopic procedures were shorter (30–40 minutes vs. 47.7 minutes fluoroscopic), improving efficiency and reducing costs. Major bleeding was notably lower at 0.6% vs. 6.5% and 4.6% in fluoroscopic series (Konnepati et al. and Chang et al., respectively).^11,12 CRBSI rates were 0%, lower than fluoroscopic rates of 12.6% and 2.2%.^11,12 Immediate catheter dysfunction was minimal (0.66%), slightly better than Konnepati et al. (1.1%), though long-term dysfunction requiring intervention was higher (17.3% vs. 12.9%), highlighting scope for improvement in maintenance care. Cost savings of approximately $1,529 per procedure (Yevzlin et al.) further support non-fluoroscopic methods, especially in resource-limited settings.¹³ This study’s findings have important implications: in LMIC settings where fluoroscopy might be unavailable or cost-prohibitive, ultrasound-guided non-fluoroscopic TCC placement is a safe, effective, and economically advantageous alternative. However, late complications, particularly infection and dysfunction, remain challenges, emphasizing the critical need for rigorous infection control and catheter care protocols. The study supports the 2019 KDOQI Clinical Practice Guideline for Vascular Access endorsement of ultrasound as the primary imaging modality for vascular access, reserving fluoroscopy for complex cases.^14,15 Limitations include potential selection bias due to demographics and underlying diseases, a retrospective design with moderate sample size, loss to follow-up, and reliance on historical fluoroscopic data for comparison, which may affect the robustness of outcome assessments. Future prospects include prospective comparative studies between fluoroscopic and non-fluoroscopic approaches, targeted interventions to reduce infections and dysfunction, and enhanced protocols for catheter maintenance and transition to permanent vascular access. Such efforts will further optimize outcomes and expand safe, affordable dialysis access in LMIC environments. This comprehensive assessment highlights the balance of safety, efficacy, cost-effectiveness, and clinical outcomes, advancing support for adopting non-fluoroscopic TCC techniques with focused strategies to improve long-term care and reduce infection-related morbidity.