Dialysis Catheter Selection and Management

Hierarchy of Vascular Access Options

The American College of Radiology recommends arteriovenous fistula (AVF) as the vascular access of choice for maintenance hemodialysis due to lower infection rates and better outcomes 1, 2
Arteriovenous graft (AVG) should be considered when an AVF is not possible, as recommended by Praxis Medical Insights 2
Tunneled cuffed venous catheters should be used only when other options are exhausted or as a bridge while waiting for AVF/AVG maturation, according to the Journal of the American College of Radiology 1, 3

Uncuffed hemodialysis catheters (non-tunneled) should only be used in hospitalized patients and for less than 1 week, as recommended by the American Journal of Kidney Diseases 4
Uncuffed femoral catheters should only be used in bed-bound patients and not left in place longer than 5 days, according to the American Journal of Kidney Diseases and the Journal of the American College of Radiology 5, 1
Short-term catheter tips should be positioned in the superior vena cava and confirmed by chest radiograph or fluoroscopy, as recommended by the American Journal of Kidney Diseases 4
Tunneled cuffed catheters (TCCs) are recommended for access lasting more than 3 weeks, according to the Journal of the American College of Radiology 1
Long-term catheter tips should be positioned within the right atrium for optimal flow, confirmed by fluoroscopy, as recommended by the American Journal of Kidney Diseases 4
Catheters capable of rapid blood flow rates (350 mL/min at prepump pressures not more negative than 250 mm Hg) are preferred, according to the American Journal of Kidney Diseases 4

The Journal of the American College of Radiology recommends silicone and polyurethane as the preferred materials for dialysis catheters 1, 6
Silicone is more compatible with infusates but more prone to compression and "pinch-off", while polyurethane is tougher and stiffer but more susceptible to degradation by various drug solvents, as reported by the Journal of the American College of Radiology 1
Antimicrobial-coated catheters (minocycline and rifampin) have shown reduced risk of catheter-related bloodstream infections (CRBSI), according to the Journal of the American College of Radiology 6

The American Journal of Kidney Diseases recommends the following preferences for vein insertion in patients with acute kidney injury (AKI): right jugular vein as the first choice, femoral vein as the second choice, left jugular vein as the third choice, and subclavian vein as the last choice, with preference for the dominant side 7

Ultrasound guidance should be used for all dialysis catheter insertions, as recommended by the American Journal of Kidney Diseases and the Journal of the American College of Radiology 7, 5
Chest radiograph should be obtained promptly after placement and before first use of internal jugular or subclavian dialysis catheters, according to the American Journal of Kidney Diseases 7
Long-term catheters should not be placed on the same side as a maturing AV access, if possible, as recommended by the American Journal of Kidney Diseases 5, 4
Femoral catheters should be of sufficient length to reach the inferior vena cava to deliver adequate blood flow, according to the American Journal of Kidney Diseases 4

Prolonged catheter use is associated with increased mortality (51% increase) and severe infection (130% increase) compared to AVF/AVG, as reported by the Journal of the American College of Radiology 3
Subclavian vein access should be avoided when possible due to risk of central venous stenosis, which may limit future access options, according to the American Journal of Kidney Diseases and the Journal of the American College of Radiology 5, 1
There should always be a plan to either discontinue or convert any short-term catheter to a long-term catheter within 1 week, as recommended by the American Journal of Kidney Diseases 4
Routine replacement of catheters at scheduled intervals is not recommended as it does not reduce infection rates, according to MMWR Recommendations and Reports 8