论血透导管的选择

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SelectingOptimalHemodialysisCatheters:

Material,Design,AdvancedFeatures,andPreferences

MichaelG.Tal,MD,MBAandNinaNi,AB

Hemodialysiscathetersareanecessaryevil.Theyprovideanimmediateandeffectivelifelineforhemodialysispatients,andtheiruseissteadilyincreasing.Thisincreasinglyimportantrolehasleadtothedevelopmentofmanygenerationsofdialysiscatheters.Someaspectsofnoveldesignshaveshownpotentialtoreducecomplications,whileothersprovideoptionsforphysicianinsertionpreference.Thetwomajorbiomaterialsforcatheterconstructionarecurrentlypolyurethaneandsilicone,whilecopolymerssuchascarbothanearebecomingmorewidespread.Cathetercoatingssuchasheparin,antibiotics,andsilverionaredesignedtominimizethrombosisandinfection.Finally,manylumenandtipdesignsarealsoavailable.Thesenewfeaturesweredesignedtoaddresscommonproblems,includingmaintenanceofadequate owrateandpreventionofthrombosis, brinsheath,andcatheter-relatedinfection.However,reliabledatadirectlycomparingthesedifferentdesignsandcoatingsarecurrentlylacking.Thiscommunicationreviewscurrenthemodi-alysiscatheters,includingmaterials,design,andadvancedfeatures.

TechVascInterventionalRad11:186-191©2008ElsevierInc.Allrightsreserved.KEYWORDShemodialysis,dialysiscatheters,cathetercomplications

ntheUnitedStates,approximately25%ofhemodialysispatientsusecathetersforhemodialysis,upfrom13%over10yearsago.1,2Ithasbeenreportedthatasmanyasonein venewdialysispatientsstartstheirtreatmentwithtunneledcuffedcatheters.3Dialysiscathetersareusedeitherastempo-rarysolutionswhilepatientswaitfor plicationsassociatedwithdialysisaccessareontherise,aspatientsdiagnosedwithend-stagerenaldiseasearein-creasingbothinageandinthenumberandseverityofco-morbidities.

Hemodialysispatientscurrentlyhavehighratesofmorbid-ityandmortalityandvascularaccesscathetersareacontrib-utingfactortotheseclinicaloutcomes.Themainproblemsassociatedwithlong-termcatheterizationincludethrombosis,vascularstenosis,andinfection.4,5Consequently,newercatheterdesignsoftenaimtoaddresstheseissueswithinnovationsoverexistingproducts.

Thrombosisand brinsheathcanleadtoinadequatehe-modialysisbydisrupting ow.Catheterexchangeor brinsheathstrippingcanimprove ow,butalsointroducefurtherriskforfuturecomplications.6Acatheter’santithrombogenicpropertiesareimportantforlongevity,consideringthat

I

YaleUniversitySchoolofMedicine,NewHaven,CT,USA.MichaelG.TalisaconsultanttoCovidien,Inc.

AddressreprintrequeststoMichaelTal,MD,MBA,YaleUniversitySchoolofMedicine,P.O.Box208042(SP2-323),NewHaven,CT06520-8042.E-mail:

michael.tal@yale.edu

thrombusand brinsheathformationbeginasearlyas24hoursafterinsertion.7Thecontinuingdevelopmentofcath-eterbiomaterials,coatings,andtipdesignsre ectstheneedforbetterdurability,asthecurrentmediandwellingtimeislittlemorethan2months.Themajorityofunplannedcath-eterremovalsareduetoinfectionandpoorfunction.8Poorfunctionisgenerallyrelatedto owproblemsthataccountforoverhalfoftheseremovals,with76%ofcasesexhibiting brinsheathformation.8,9

Inadditiontocausing owproblems,catheterthrombosisand brinsheathformationhavealsobeenimplicatedinthehighratesofcatheter-relatedinfectionseenindialysispa-tients.Infectionscanbeintroducedintocathetersextralumi-nallyviaskinorintraluminallyviathecatheterhub.Bacteriacanmovethroughtheskininsertionsitealongthedermaltunnelandreachthetipofthecatheter.10Fibrinsheathcanexacerbatebacterialcolonizationbyprovidingahabitableenvi-ronment.Indialysispatientswhoarealreadyimmunocompro-mised,bacteriacanbecometrappedwithinthe bronectincoat-ing,renderingtheminaccessibletoimmunecells.11-15Bacteriacanalsoadheretothecathetermaterialitself,formingaprotec-tiveglycocalixbio lm.14,15Thecombinationofbreakingtheskinbarriertoinsertacatheter,exposuretocontaminants,andformationofpathogen-trapping brinsheathscancauseappre-ciablebacteremiarisk,translatingtouptothreefoldrelativemortalityrisk.2,16Newcatheterdesignandcoatingsareoftenemphasizedfortheireffectsonreducing brinsheathformationandinfectionrates,whichcanultimatelyleadtodecreasedmor-bidityandcostofcare.

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1089-2516/08/$-seefrontmatter©2008ElsevierInc.Allrightsreserved.doi:10.1053/ir.2008.09.006