Central vein stenosis: current concepts.
Adv Chronic Kidney Dis. 2009 Sep;16(5):360-70
Authors: Agarwal AK
Central vein stenosis (CVS) is a common complication of the central venous catheter (CVC) placement. The prevalence of CVS has mostly been studied in those who present with symptoms such as swelling of the extremity, neck and breast. CVS compromises arteriovenous access and can be resistant to treatment. A previous history of CVC placement is the most important risk factor for the development of CVS later. Pacemaker and defibrillator wires are associated with a high incidence of CVS. Increasingly liberal use of peripherally inserted central catheters (PICC) is likely to increase the incidence of CVS. The trauma and inflammation related to the catheter placement is thought to result in microthrombi formation, intimal hyperplasia and fibrotic response, with development of CVS. Treatment of CVS by endovascular procedures involves angioplasty of the stenosis. An elastic or recurrent stenosis may require a stent placement. The long-term benefits of the endovascular procedures, although improved with newer technology, remain modest. Surgical options are usually limited. Future studies to explore the pathogenesis and the use of novel therapies to prevent and treat CVS are needed. The key to reducing the prevalence of CVS is in reducing CVC placement and placement of arteriovenous accesses prior to initiating dialysis. Early referral of the patients to the nephrologists by the primary care physicians is important. Timely vein mapping and referral to the surgeon for fistula creation can obviate the need for a CVC and decrease incidence of CVS.
PMID: 19695504 [PubMed - indexed for MEDLINE]
See http://dx.doi.org/10.1111/j.1525-139X.2007.00242.x for another interesting review.
According to http://dx.doi.org/10.1007/s00270-002-2628-z PICC lines should be avoided in hemodialysis patients because of the difficulties that central vein stenosis can ultimately cause with dialysis access. However, it is not clear that the rate of central vein stenosis is higher with PICC lines than with other types of catheter, particularly subclavian catheters. Very often, central catheters are required in hospitalized hemodialysis patients because of poor peripheral access, and PICC lines represent a less invasive alternative to non-tunneled CVC’s.
Have you encountered institutional policies regarding the use of PICC lines in hemodialysis patients?