Имплантация туннельного центрального венозного катетера для гемодиализа. Хирургические аспекты: обзор литературы

Обзор посвящен одной из актуальных проблем в создании сосудистого доступа для программного гемодиализа – имплантации туннельных центральных венозных катетеров (тЦВК). Современные конструкции катетеров и новые возможности визуализации за последние годы дали возможность имплантировать тЦВК с минимальным количеством осложнений. Однако существует достаточное количество сложных ситуаций при постановке катетера, требующих индивидуального подхода. В данном обзоре выделены показания и противопоказания к имплантации тЦВК, рассмотрены разновидности катетеров, варианты возможных мест установки; описаны предварительная подготовка пациента к операции и послеоперационное ведение; освещены вопросы осложнений, возникающих в раннем и позднем послеоперационных периодах, и путях их решения. Также представлены дополнительные инструментальные методы, используемые для установки тЦВК. В настоящее время к установке тЦВК применяется стандартизированный подход, который обобщен и представлен в стандартной операционной процедуре (СОП), которая позволяет обеспечивать безопасную имплантацию тЦВК с соблюдением асептики на всех этапах, а также обучение новых членов команды.

1. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024; 105 (4S): S117–S314.

2. Lok CE, Huber TS Lee T et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020. 75 (4): S1–S164. doi: 10.1053/j.ajkd.2019.12.001.

3. United States Renal Data System. 2023 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, 2023.

4. Bernd Schröppel, Lucas Bettac, Lena Schulte-Kemna et al. Placement of tunnelled haemodialysis catheters – interventional standard. Nephrol Dial Transplant. 2025; 40: 264–272. https://doi.org/10.1093/ndt/gfae181.

5. O’Hare AM, Choi AI, Bertenthal D et al. Age affects outcomes in chronic kidney disease. J Am Soc Nephrol. 2007; 18: 2758–2765. https://doi.org/10.1681/ASN.2007040422.

6. Schulte-Kemna L, Künzig M, Dallmeier D et al. [Frailty in renal diseases]. Z Gerontol Geriatr. 2021; 54: 708–716. https://doi.org/10.1007/s00391-021-01953-0.

7. Lyu B, Chan MR, Yevzlin AS et al. Catheter dependence after arteriovenous fistula or graft placement among elderly patients on hemodialysis. Am J Kidney Dis. 2021; 78: 399–408.e1. https://doi.org/10.1053/j.ajkd.2020.12.019.

8. Boubes K, Shaikh A, Alsauskas Z et al. New directions in ensuring catheter safety. Adv Chronic Kidney Dis. 2020; 27: 228–235. https://doi.org/10.1053/j.ackd.2020.02.004.

9. Husameddin El Khudari, Merve Ozen, Bridget Kowalczyk et al. Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications. Semin Intervent Radiol. 2022 Feb 18; 39 (1): 90–102. doi: 10.1055/s-0042-1742346.

10. D M, Trerotola SO, Clark T. Clinical and Regulatory Considerations for Central Venous Catheters for Hemodialysis. Clin J Am Soc Nephrol. 2018; 13 (12): 1924–1932. doi: 10.2215/CJN.14251217.

11. Vesely T M, Ravenscroft A. Hemodialysis catheter tip design: observations on fluid flow and recirculation. J Vasc Access. 2016; 17 (01): 29–39. doi: 10.5301/jva.5000463.

12. Van Der Meersch H, De Bacquer D et al. Hemodialysis catheter design and catheter performance: a randomized controlled trial [published correction appears in Am J Kidney Dis. 2015 May; 65 (5): 810]. doi: 10.1053/j.ajkd.2014.02.017.

13. Hwang HS, Kang SH, Choi SR et al. Comparison of the palindrome vs. step-tip tunneled hemodialysis catheter: a prospective randomized trial. Semin Dial. 2012; 25 (05): 587–591. doi: 10.1111/j.1525-139X.2012.01054.x.

14. Benjamin Lazarus, Kevan R Polkinghorne, Martin Gallagher et al. Tunneled Hemodialysis Catheter Tip Design and Risk of Catheter Dysfunction: An Australian Nationwide Cohort Study. Am J Kidney Dis. 2024 Apr; 83 (4): 445–455. doi: 10.1053/j.ajkd.2023.09.021.

15. Clark TW, Redmond JW, Mantell MP. Initial Clinical Experience: Symmetric-Tip Dialysis Catheter with Helical Flow Characteristics Improves Patient Outcomes. J Vasc Interv Radiol. 2015; 26 (10): 1501–1508. doi: 10.1016/j.jvir.2015.06.033.

16. Nadolski GJ, Redmond J, Shin B. Comparison of Clinical Performance of VectorFlow and Palindrome Symmetric-Tip Dialysis Catheters: A Multicenter, Randomized Trial. J Vasc Interv Radiol. 2020; 31 (07): 1148–1155. doi: 10.1016/j.jvir.2020.02.001.

17. Anil K Agarwal, Stephen R Ash. Maintenance of blood flow rate on dialysis with self-centering CentrosFLO catheter: A multicenter prospective study. Hemodial Int. 2016 Oct; 20 (4): 501–509. doi: 10.1111/hdi.12443.

18. Tal MG, Peixoto AJ, Crowley ST et al. Comparison of side hole versus non side hole high flow hemodialysis catheters. Hemodial Int. 2006; 10 (01): 63–67. doi: 10.1111/j.1542-4758.2006.01176.x.

19. Bulent Arslan, Abdulrahman Masrani. Patency and time to malfunction comparison of BioFlo Duramax to Equistream hemodialysis catheters. Journal of Vascular and Interventional Radiology. 2016; 27 (3): S199–S200. https://doi.org/10.1016/j.jvir.2015.12.514.

20. May RM, Magin CM, Mann EE. An engineered micropattern to reduce bacterial colonization, platelet adhesion and fibrin sheath formation for improved biocompatibility of central venous catheters. Clin Transl Med. 2015; 4: 9. doi: 10.1186/s40169-015-0050-9.

21. David W Sutherland Jr, Zachary D Blanks, Xin Zhang. Relationship Between Central Venous Catheter Protein Adsorption and Water Infused Surface Protection Mechanisms. Artif Organs. 2018 Nov; 42 (11): E369–E379. doi: 10.1111/aor.13274.

22. Koudounas G, Giannopoulos S, Volteas P et al. Arteriovenous fistula maturation in patients with ipsilateral versus contralateral tunneled dialysis catheter: a systematic review and metaanalysis. Ann Vasc Surg. 2024; 103: 14–21. doi: 10.1016/j.avsg.2023.11.048.

23. Engstrom BI, Horvath JJ, Stewart JK et al. Tunneled internal jugular hemodialysis catheters: impact of laterality and tip position on catheter dysfunction and infection rates. J Vasc Interv Radiol. 2013; 24: 1295–302. https:// doi.org/10.1016/j.jvir.2013.05.035.

24. Ali Akbar Beigi, Ali Sharifi, Hafez Gaheri et al. Placement of long-term hemodialysis catheter (permcath) in patients with end-stage renal disease through external jugular vein. Advanced Biomedical Research. 2014 Dec; 3 (1): 252. doi: 10.4103/2277-9175.146381.

25. Pei Wang, Yufei Wang, Yingjin Qiao et al. Retrospective Study of Preferable Alternative Route to Right Internal Jugular Vein for Placing Tunneled Dialysis Catheters: Right External Jugular Vein versus Left Internal Jugular Vein. PLoS One. 2016; 11 (1): e0146411. doi: 10.1371/journal.pone.0146411.

26. Янковой АГ, Зулькарнаев АБ. Хирургическая имплантация туннельного диализного катетера в нижнюю полую вену. Клиническое наблюдение. Нефрология и диализ. 2023; 25 (1): 111–115.

27. Hieu M Vo, Raeeha Syeda, Mohammad Ali. Inferior Vena Cava Placement of a Transhepatic Tunneled Dialysis Catheter in a Patient with Atypical Hepatic Venous Anatomy. A Case Report. 2024 Sep 13; 16 (9): e69365. doi: 10.7759/cureus.69365.

28. Buetti N, Souweine B, Mermel L et al. Concurrent systemic antibiotics at catheter insertion and intravascular catheter-related infection in the ICU: a post hoc analysis using individual data from five large RCTs. Clin Microbiol Infect. 2021; 27: 1279–1284. https://doi.org/10.1016/j.cmi.2020.10.026.

29. Korsten P, Kuczera T, Wallbach M et al. The rapid atrial swirl sign for ultrasound-guided tip positioning of retrogradetunneled hemodialysis catheters: a cross-sectional study from a single center. J Clin Med. 2021; 10: 3999. https://doi.org/10.3390/jcm10173999.

30. Da Hora Passos R, Ribeiro M, da Conceição LFMR et al. Agitated saline bubble – enhanced ultrasound for the positioning of cuffed, tunneled dialysis catheters in patients with end-stage renal disease. J Vasc Access. 2019; 20: 362–367. https://doi.org/10.1177/1129729818806121.

31. Kächele M, Bettac L, Hofmann C et al. Feasibility analysis of ultrasound-guided placement of tunneled hemodialysis catheters. Kidney Int Rep. 2023; 8: 2001–2007. https://doi.org/10.1016/j.ekir.2023.07.03.

32. Bream PR. Update on insertion and complications of central venous catheters for hemodialysis. Semin Interv Radiol. 2016; 33: 31–38. doi: 10.1055/s-0036-1572547.

33. Sharma M, Tong WL, Thompson D et al. Placing an appropriate tunneled dialysis catheter in an appropriate patient including the nonconventional sites. Cardiovasc Diagn Ther. 2023; 13: 28190–28290. https://doi.org/10.21037/cdt-22-426.

34. Maggiani-Aguilera P, Chávez-Iñiguez JS, Navarro-Gallardo JG et al. The impact of anatomical variables on haemodialysis tunnelled catheter replacement without fluoroscopy. Nephrology (Carlton). 2021; 26: 824–832. doi: 10.1111/nep.13909.

35. Engstrom BI, Horvath JJ, Stewart JK et al. Tunneled internal jugular hemodialysis catheters: impact of laterality and tip position on catheter dysfunction and infection rates. J Vasc Interv Radiol. 2013; 24: 1295–1302. https://doi.org/10.1016/j.jvir.2013.05.035.

36. Practice guidelines for central venous access 2020: an updated report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020; 132: 8–43. https://doi.org/10.1097/ALN.0000000000002864.

37. Rabindranath KS, Kumar E, Shail R et al. Use of real-time ultrasound guidance for the placement of hemodialysis catheters: a systematic review and meta-analysis of randomized controlled trials. Am J Kidney Dis. 2011; 58: 964–970. https://doi.org/10.1053/j.ajkd.2011.07.025.

38. Prasad P, Vachharajani TJ. Non-fluoroscopic techniques to insert a tunneled hemodialysis catheter. Kidney Int Rep. 2023; 8: 2191–2193. https://doi.org/10.1016/j.ekir.2023.09.023.

39. Yevzlin AS, Song GU, Sanchez RJ et al. Fluoroscopically guided vs modified traditional placement of tunneled hemodialysis catheters: clinical outcomes and cost analysis. J Vasc Access. 2007; 8: 245–251. https://doi.org/10.1177/112972980700800405.

40. Hsu JH, Wang CK, Chu KS et al. Comparison of radiographic landmarks and the echocardiographic SVC/RA junction in the positioning of long-term central venous catheters. Acta Anaesthesiol Scand. 2006; 50: 731–735. https://doi.org/10.1111/j.1399-6576.2006.01025.x.

41. Schuepfer AC, Schuepfer G, Mauch J. Three near fatal or fatal complications during implantation of tunnelled hemodialysis catheters learning from experts. Anaesthesiologie. 2022; 71: 541–545.

42. Rattka M, Rottbauer W, Markovic S. Acute chest pain following parenteral infusion. Dtsch Arzteblatt Int. 2021; 118: 841. doi: 10.3238/arztebl.m2021.0094.

43. Jeon Y, Ryu HG, Yoon SZ et al. Transesophageal echocardiographic evaluation of ECG-guided central venous catheter placement. Can J Anaesth. 2006; 53: 978–983. https://doi.org/10.1007/BF03022525.

44. Gibault P, Desruennes E, Bourgain JL. Peroperative electrocardiographic control of catheter tip position during implantation of femoral venous ports. J Vasc Access. 2015; 16: 294–298. https://doi.org/10.5301/jva.5000386.

45. Steinhagen F, Kanthak M, Kukuk G et al. Electrocardiographycontrolled central venous catheter tip positioning in patients with atrial fibrillation. J Vasc Access. 2018; 19: 528–534. https://doi.org/10.1177/1129729818757976.

46. Pereira Junior GM, Souza Alvarenga A, Almeida Felipe CR et al. Use of ultrasound to confirm guidewire position in hemodialysis catheter implantation. J Nephrol. 2022; 35: 1515–1519. https://doi.org/10.1007/s40620-022-01346-5.

47. Kairidibo, Pandey AR, Dwivedi V et al. «Rapid Atrial Swirl Sign»: A Better Tool Than the Landmark Technique for Ensuring Correct Depth of Insertion of Central Venous Catheters. Cureus. 2024 Jul 23; 16 (7): e65211. doi: 10.7759/cureus.65211.

48. Fisher M, Golestaneh L, Allon M et al. Prevention of bloodstream infections in patients undergoing hemodialysis. Clin J Am Soc Nephrol. 2020; 15: 132–151. https://doi.org/10.2215/CJN.06820619.

49. Apata IW, Hanfelt J, Bailey JL et al. Chlorhexidine-impregnated transparent dressings decrease catheter-related infections in hemodialysis patients: a quality improvement project. J Vasc Access. 2017; 18: 103–108. https://doi.org/10.5301/jva.5000658.

50. Hou Y, Griffin L, Bernatchez SF et al. Comparative Effectiveness of 2 Chlorhexidine Gluconate-Containing Dressings in Reducing Central Line-Associated Bloodstream Infections, Hospital Stay, and Costs. Inquiry. 2023 Jan-Dec; 60: 469580231214751. doi: 10.1177/00469580231214751.

51. Gabriele Donati, Alessandra Spazzoli, Anna Laura Croci Chiocchini. Bloodstream infections and patient survival with tunneled-cuffed catheters for hemodialysis: A single-center observational study. Int J Artif Organs. 2020 Dec; 43 (12): 767–773. doi: 10.1177/0391398820917148.

52. Carol L Moore, Anatole Besarab, Marie Ajluni. Comparative effectiveness of two catheter locking solutions to reduce catheter-related bloodstream infection in hemodialysis patients. Clin J Am Soc Nephrol. 2014 Jul; 9 (7): 1232–1239. doi: 10.2215/CJN.11291113.

53. Hongxia Mai, Yuliang Zhao, Stephen Salerno et al. Citrate versus heparin lock for prevention of hemodialysis catheter-related complications: updated systematic review and meta-analysis of randomized controlled trials. Int Urol Nephrol. 2019 Jun; 51 (6): 1019–1033. doi: 10.1007/s11255-019-02150-0.

54. Fadwa Al-Ali, Ahmad F Hamdy, Abdullah Hamad et al. Safety and efficacy of taurolidine/urokinase versus taurolidine/heparin as a tunneled catheter lock solution in hemodialysis patients: a prospective, randomized, controlled study. Nephrol Dial Transplant. 2018 Apr 1; 33 (4): 619–626. doi: 10.1093/ndt/gfx187.

55. Jeffrey L Hymes, Ann Mooney, Carly Van Zandt et al. Dialysis Catheter-Related Bloodstream Infections: A Cluster-Randomized Trial of the ClearGuard HD Antimicrobial Barrier Cap. Am J Kidney Dis. 2017 Feb; 69 (2): 220–227. doi: 10.1053/j.ajkd.2016.09.014.

56. Amy Nau, Troy Richardson, Diana Cardwell et al. Use of ClearGuard HD caps in pediatric hemodialysis patients. Pediatr Nephrol. 2024 Jul; 39 (7): 2171–2175. doi: 10.1007/s00467-023-06273-6.

57. Hemmelgarn BR, Moist LM, Lok CE et al. Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator. N Engl J Med. 2011; 364: 303–312. https://doi.org/10.1056/NEJMoa1011376.

58. Winnicki W, Herkner H, Lorenz M et al. Taurolidine-based catheter lock regimen significantly reduces overall costs, infection, and dysfunction rates of tunneled hemodialysis catheters. Kidney Int. 2018; 93: 753–760. https://doi.org/10.1016/j.kint.2017.06.026.

59. Tran MH, Wilco T, Tran PN. Cather-related right atrial thrombosis. J Vasc Access. 2020; 21 (3): 300–307. doi: 10.1177/1129729819873851.

60. Stavroulopoulos A, Aresti V, Zounis C. Right atrial thrombi complicating haemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm. Nephrol Dial Transplant. 2012; 27 (7): 2936–2944. doi: 10.1093/ndt/gfr739.

61. Chen L, Chen B, Lai Q et al. Management of catheter-related right atrial thrombus in hemodialysis: a systematic review. BMC Cardiovasc Disord. 2024 Nov 20; 24 (1): 656. https://doi.org/10.1186/s12872-024-04330-y.

62. Sun J, Liu Y, Chen J et al. Catheter replacement combined with antiplatelet therapy in hemodialysis catheter-related right atrial thrombus: a potential treatment approach. BMC Cardiovasc Disord. 2025 Jan 16; 25 (1): 26. https://doi.org/10.1186/s12872-025-04485-2.

63. Yang H, Chen F, Jiao H et al. Management of tunneled-cuffed catheter-related right atrial thrombosis in hemodialysis patients. J Vasc Surg. 2018; 68 (5): 1491–1498. doi: 10.1016/j.jvs.2018.02.039.

64. Rossi L, Libutti P, Casucci F et al. Is the removal of a central venous catheter always necessary in the context of catheter-related right atrial thrombosis? J Vasc Access. 2018; 20 (1): 98–101. doi: 10.1177/1129729818774438.

65. Kruger PC, Eikelboom JW, Douketis JD et al. Pulmonary embolism: update on diagnosis and management. Med J Aust. 2019 Jul; 211 (2): 82–87. doi: 10.5694/mja2.50233.

66. Ahmed R, Chapman SA, Tantrige P et al. TuLIP (Tunnelled Line Intraluminal Plasty): An Alternative Technique for Salvaging Haemodialysis Catheter Patency in Fibrin Sheath Formation. Cardiovasc Intervent Radiol. 2019; 42: 770–774. https://doi.org/10.1007/s00270-019-02189-7.

67. Lizhu Jin, Hui Wang, Tianlei Cui et al. [Catheter Replacement Methods in Hemodialysis Patients With Dysfunctional Tunneled-Cuffed Catheters With Fibrin Sheaths]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2023 Nov 20; 54 (6): 1283–1287. doi: 10.12182/20231160201.

68. Nayak-Rao S, Ramanna B, Subramanyam K et al. Endovascular intervention for central venous stenosis in hemodialysis patients: A single-center experience. Indian J Nephrol. 2020; 0 (0): 0. doi: 10.4103/ijn.IJN_343_19.

69. Kitrou PM, Papadimatos P, Spiliopoulos S et al. Paclitaxel-Coated Balloons for the Treatment of Symptomatic Central Venous Stenosis in Dialysis Access: Results from a Randomized Controlled Trial. J Vasc Interv Radiol. 2017 Jun; 28 (6): 811–817. doi: 10.1016/j.jvir.2017.03.007.

70. Panagiotis M Kitrou, Tobias Steinke, Rami El Hage et al. Paclitaxel-Coated Balloons for the Treatment of Symptomatic Central Venous Stenosis in Vascular Access: Results from a European, Multicenter, Single-Arm Retrospective Analysis. J Endovasc Ther. 2021 Jun; 28 (3): 442–451. doi: 10.1177/15266028211007471.

71. David M Tabriz, Bulent Arslan. HeRO Graft: Indications, Technique, Outcomes, and Secondary Intervention. Semin Intervent Radiol. 2022 Feb 18; 39 (1): 82–89. doi: 10.1055/s-0042-1742391.

72. Leclaire C, Lobbedez T, Henri P et al. A new procedure for guidewire exchange of tunneled hemodialysis catheters in chronic hemodialysis patients: a pilot study. Blood Purif. 2023; 52: 91–100. https://doi.org/10.1159/000525436.

73. Wang J, Nguyen TA, Chin AI et al. Treatment of tunneled dialysis catheter malfunction: revision versus exchange. J Vasc Access. 2016; 17: 328–332. https://doi.org/10.5301/jva.5000533.

74. Lazarus B, Kotwal S, Gallagher M et al. Effect of a multifaceted intervention on the incidence of hemodialysis catheter dysfunction in a national stepped-wedge cluster randomized trial. Kidney Int Rep. 2023; 8: 1941–1950. https://doi.org/10.1016/j.ekir.2023.07.013.

75. Niyyar VD, Beathard G. Interventional nephrology: opportunities and challenges. Adv Chronic Kidney Dis. 2020; 27: 344–349.e1. https://doi.org/10.1053/j.ackd.2020.05.013.