Comparison of catheter patency between surgical inside-out technique and conventional femoral approach for tunneled cuffed catheter placement in patients with thoracic central venous occlusion

OBJECTIVE: Femoral tunneled cuffed catheters (TCCs) can provide long-term hemodialysis access for patients with exhausted upper extremity access sites due to thoracic central venous occlusion. However, the use of femoral vein catheters (FVCs) has reportedly been associated with the risk of infection, malfunction, and discomfort. An inside-out technique will facilitate chest TCC placement by intentional retrograde extravascularization of the proximal occluded venous stump into the mediastinum. Next, the wire and small catheter are exteriorized to the skin at the base of the neck with a small skin incision. Then, the hemodialysis catheter is railed back down to the right atrium. With this technique, we placed the tip of the catheter into intrathoracic superior vena cava or brachiocephalic vein. In the present study, we compared the catheter patency of the inside-out technique vs a standard approach for FVC placement. METHODS: The present randomized controlled trial was conducted from May to December 2020. We included 22 patients requiring long-term hemodialysis with failed recanalization of thoracic central venous occlusion. The patients were randomized into the surgical inside-out (S-inside-out) group and FVC group. RESULTS: The S-inside-out and FVC groups included 10 and 12 patients, respectively. All 22 patients had undergone successful catheter placement. Catheter survival function was significantly higher for the S-inside-out group than for the FVC group (100% vs 50%, respectively; P = .017). In addition, the EQ-5D utility score was significantly better for the S-inside-out group (P = .008). Four cases of catheter infection occurred in the FVC group, but no catheter infection was found in the S-inside-out group. Procedural-related complications occurred in two patients; one case each of hemothorax and stroke in the S-inside-out group. CONCLUSIONS: Use of the S-inside-out technique facilitated upper chest TCC placement for hemodialysis patients with exhausted access sites. This technique provided better catheter survival function, a better quality of life, and a lower infection rate, which outweighed the procedure risk.