PROLONGED USE OF A TUNNELEDCUFFED CENTRAL VENOUS ACCESS DEVICE

AUTHORS: JOANNE DALUSUNG & SARAH PALYA

In the post-acute space, unique situations arise in the care of long-term vascular access devices. In this article, AVA’s Beyond Acute Care Special Interest Group (BAC-SIG) members investigate the challenges in the care and maintenance of a 5.5-year-old Broviac.

Background

Over a decade ago, my son, Gus, then age 7, had his first central line placed due to dysmotility that led to intestinal failure. “Functionally short gut,” he has several medical and behavioral complications that make it exceptionally difficult to keep a central line safe and operative. As someone with autism and is non-verbal, Gus often communicates his wants and emotions physically. One of the greatest challenges of his care is managing his self-injurious actions when he experiences abdominal pain from intestinal failure. At the time his first central line was placed, these behaviors were incessant and heartbreaking to endure. More than that, they were very difficult to prevent, putting his central line in certain danger. Since Gus will need central access for the rest of his life, keeping his catheter safe became my mission. I ultimately want Gus to have the best quality of life possible, and I know that vascular access is at the heart of making that possible. There is tremendous gravity in the knowledge that every decision we make regarding his central access has the potential to shape his long-term outcome.

Thus far, Gus has been very fortunate to have only 4 central catheters placed in over 11.5 years of use, varying from 14-18 hours a day. To the best of our knowledge today, all his access is still viable. Our success in these demanding circumstances can be attributed to how his lines have been secured and protected. His current line is a single-lumen tunneled Left IJ, 6.5Fr catheter. This 5.5-year-old line continues to work well and is utilized 14 hours a day for parenteral nutrition, bi-weekly blood draws, and periodically for iron infusions.

After the 5-year birthday of his catheter, serious questions arose about the potential for adverse events like catheter fracture during removal:

• Are we increasing the risk of an adverse event by not proactively replacing his aging line?

• Do the risks of a conservative approach outweigh the potential benefits to his long-term vascular access?

• Is there an existing framework or protocol for evaluating this situation?

Gus’s team and I are in a fortunate position to be able to weigh the risks and benefits and consider the best course of action (or in-action) for his catheter. Knowing what an important decision this is, I brought the question to Joanne Dalusung, one of my counterparts in BAC-SIG, for her assessment of our options.

Discussion

Guidelines on appropriate vascular access devices (VADs) of choice according to the intended duration of use are well-defined.1-3 On the contrary, there appears to be a lack of information about how many years tunneled catheters can remain in place and functional. Tunneled vascular access devices, like Broviac, are recommended for use if needed for more than three months or longer, like for parenteral nutrition. The most common complications include infection, thrombosis, and catheter fracture, which are widely published and may result in catheter removal. Catheter-related bloodstream infection (CRBSI) is the most common complication of home parenteral nutrition, associated with mortality.4,5 A study by Dibb and colleagues in 2014 showed how implementing catheter care protocols and training nurses, patients, and caregivers help minimize the occurrence of CRBSI.5 Additionally, the study emphasized VAD salvage, if infected, can be achieved by an initial standardized protocol tailored to the patient's clinical condition and microbiological sensitivities.4, 5

How long is too long?

Removing a functional catheter after five years of indwelling time lacks evidence and is not widely recommended. However, available evidence on the risk of keeping tunneled lines too long is related to the difficulty of removing the line when no longer needed. Published reports of calcification around the catheter, fractured catheter, or stuck catheter are found in the literature. Vellanki and colleagues found that only 0.92% of all permanent hemodialysis catheters removed in a ten-year period resulted in a “stuck catheter” requiring invasive removal.6 A study by Kojima and colleagues reported that implanted vascular access devices connected to Groshong silicone catheters accessed using the internal jugular vein have a greater fracture risk than ports connected to polyurethane catheters.7 It is unclear if the findings of these two studies can be generalized to a patient using a long-term Broviac for PN. The decision to keep the catheter should be discussed if keeping the VAD outweighs the risks of removal after long-term use between the vascular access specialist, a surgeon, the patient, and the caregivers.

The Infusion of Nursing Society and Association of Vascular Access guidelines do not recommend routine replacement of tunneled catheters within a certain period. There appears to be a lack of existing framework or protocol for evaluating this situation. A review of the literature did not show any results for duration of a long-term Broviac or other VAD. However, a wealth of evidence is provided on circumstances under which it should be removed. Vessel health preservation and patient preference are recommended in vascular access device selection. Standards of practice such as catheter salvage with antibiotics and anticoagulation for catheter-related thrombosis are used to avoid the need for removal and reinsertion of new VAD if vascular access is still needed.4, 5, 8 There should be an equal emphasis on patient education about insertion and removal of a VAD. In the absence of indications for removal, like treatment completion and infection, the patient's preference is suggested as the primary consideration, as in the case presented above.

Conclusion

Currently, the available evidence supports keeping a functional vascular access device and only removing it when clinically indicated. To better understand the useful lifespan of a longterm vascular access device, one needs to weigh the cost and benefit of maximizing the dwell time of the device versus the risk of complications. The authors recommend conducting additional longitudinal research to understand better the risks and benefits of proactive replacement versus maximizing the useful lifespan of a long-term CVAD. There is limited data on how long a VAD can remain in place after insertion, placing the burden of decision-making regarding removal on the patient, caregiver, and managing clinical team.

References

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2. Association for Vascular Access. Resource guide for vascular access, 2nd ed. Herriman, UT: Association for Vascular Access; 2021.

3. Chopra V, Flanders SA, Saint S, Woller SC, O'Grady NP, Safdar N, Trerotola SO, Saran R, Moureau N, Wiseman S, Pittiruti M, Akl EA, Lee AY, Courey A, Swaminathan L, LeDonne J, Becker C, Krein SL, Bernstein SJ. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a multispecialty panel using the RAND/UCLA appropriateness method. Annals of Internal Medicine. 2015; 163(6): S1– S24. https://doi. org/10.7326/m15-0744.

4. Edakkanambeth Varayil J, Whitaker JA, Okano A, Carnell JJ, Davidson JB, Enzler MJ, Kelly DG, Mundi MS, Hurt RT. (2017). Catheter salvage after catheter‐related bloodstream infection during home parenteral nutrition. Journal of Parenteral and Enteral Nutrition. 2017; 41(3): 481-448. https://doi.org/10.1177/0148607115587018.

5. Dibb MJ, Abraham A, Chadwick PR, Shaffer JL, Teubner A, Carlson GL, Lal S. (2014). Central venous catheter salvage in home parenteral nutrition catheter-related bloodstream infections. Journal of Parenteral and Enteral Nutrition. 2014; 40(5): 699–704. https://doi. org/10.1177/0148607114549999.

6. Vellanki VS, Watson D, Rajan DK, Bhola CB, Lok CE. The stuck catheter: a hazardous twist to the meaning of permanent catheters. J Vasc Access. 2015; 16(4): 289-93. https://doi. org/10.5301/jva.5000392.

7. Kojima S, Hiraki T, Gobara H, Iguchi T, Fujiwara H, Matsui Y, Mitsuhashi T, Kanazawa S. Fracture of totally implanted central venous access devices: A propensity-score-matched comparison of risks for groshong silicone versus polyurethane catheters. The Journal of Vascular Access. 2016; 17(6): 535–541. https://doi.org/10.5301/jva.5000606.

8. Naik V, Mantha S, Rayani B. Vascular access in children. Indian Journal of Anaesthesia. 2019; 63(9): 737. https://doi.org/10.4103/ija.ija_489_19.