Ponce Daniela, Mendes Marcela, Silva Tricya, Oliveira Rogerio
Internal Medicine, Botucatu School of Medicine, University of São Paulo State, Botucatu, São Paulo, Brazil.
Artif Organs. 2015 Sep;39(9):741-7. doi: 10.1111/aor.12462. Epub 2015 Apr 20.
Thrombosis of tunneled central venous catheters (CVC) in hemodialysis (HD) patients is common and it can lead to the elimination of vascular sites. This study aimed to evaluate the incidence of thrombotic obstruction of tunneled CVC in HD patients and the efficacy of occlusion treatment with alteplase use, and identify factors associated with thrombotic occlusion. It was a prospective cohort study performed in two centers which evaluated the diagnosis and treatment of thrombotic occlusion of CVC in HD patients for 24 consecutive months. The catheter occlusion was defined as the difficulty infusing or withdrawing fluid from their paths. Alteplase dose was infused to fill the lumen of the occluded catheter and remained for 50 min. As there was no obstruction of the catheter, the procedure was repeated. Three hundred and thirty-nine CVC in 247 patients were evaluated and followed, totalling 67,244 CVC-days. One hundred fifty-seven patients had only one CVC, 88 patients had two CVC during the study, and two patients had three CVC. The median age was 58 (47-66) years, patients were predominantly men (54%), with diabetic nephropathy as the main cause of chronic kidney disease (44%), the internal jugular vein as the main site of implantation (82%), and duration of dialysis before CVC implantation of 119 (41.5 to 585.5) days. Eight hundred and fifteen occlusion episodes were diagnosed (12 episodes/1000 CVC-days), with primary success with alteplase in 596 episodes (77%) and secondary in 81 cases (10%). In 99 episodes (13%), success was not achieved after the second dose of alteplase. Two hundred and thirty CVC were removed during the study and the removal causes were arteriovenous fistula use in 88 patients (38.3%), infectious and mechanical complications in 89 (38.7%) and 21 (9.1%), respectively, and others (transplantation, transfer, or death) in 32 patients (13.9%). Adverse effects were also not observed. In the multivariate analysis, we identified the greatest number of days with CVC (OR = 1.02, CI = 1.01-1.04, P = 0.004), the presence of diabetes (OR = 1.560, CI = 1.351-1.894, P = 0.015), and exit site infection (ESI) (OR = 1.567 CI = 1347-1926, P = 0.023) as factors associated with obstruction. Thrombotic occlusion showed frequent mechanical complication in CVC of HD patients. We observed 12 episodes of obstruction per 1000 CVC-days, with a high success rate after alteplase use (87%). In the multivariate analysis, the time with CVC, the presence of diabetes, and ESI were identified as variables associated with thrombotic obstruction.
血液透析（HD）患者的带隧道中心静脉导管（CVC）血栓形成很常见，可能导致血管通路丧失。本研究旨在评估HD患者带隧道CVC血栓性阻塞的发生率、使用阿替普酶进行闭塞治疗的疗效，并确定与血栓性阻塞相关的因素。这是一项在两个中心进行的前瞻性队列研究，连续24个月评估HD患者CVC血栓性阻塞的诊断和治疗。导管闭塞定义为从其通路输注或抽取液体困难。将阿替普酶剂量注入堵塞导管的内腔并保留50分钟。如果导管没有阻塞，则重复该操作。对247例患者的339根CVC进行了评估和随访，共计67244个CVC日。157例患者仅有1根CVC，88例患者在研究期间有2根CVC，2例患者有3根CVC。中位年龄为58（47 - 66）岁，患者以男性为主（54%），糖尿病肾病是慢性肾脏病的主要病因（44%），颈内静脉是主要植入部位（82%），CVC植入前透析时间为119（41.5至585.5）天。共诊断出815次闭塞事件（12次/1000 CVC日），阿替普酶初次治疗成功596次（77%），二次治疗成功81例（10%）。99次（13%）在第二次使用阿替普酶后未成功。研究期间拔除了230根CVC，拔除原因分别为88例患者（38.3%）使用动静脉内瘘、89例（38.7%）出现感染和机械并发症、21例（9.1%）出现其他并发症以及32例患者（13.9%）出现其他情况（移植、转院或死亡）。未观察到不良反应。多因素分析中，我们确定CVC留置天数最多（OR = 1.02，CI = 1.01 - 1.04，P = 0.004）、糖尿病的存在（OR = 1.560，CI = 1.351 - 1.894，P = 0.015）和出口部位感染（ESI）（OR = 1.567，CI = 1.347 - 1.926，P = 0.023）为与阻塞相关的因素。血栓性阻塞在HD患者的CVC中显示出频繁的机械并发症。我们观察到每1000个CVC日有12次阻塞事件，使用阿替普酶后成功率较高（87%）。多因素分析中，CVC留置时间、糖尿病的存在和ESI被确定为与血栓性阻塞相关的变量。
