Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients

Abstract

Background: Although an arteriovenous fistula (AVF) is the hemodialysis access of choice, its prevalence continues to be lower than recommended in the United States. We assessed the association between past peripherally inserted central catheters (PICCs) and lack of functioning AVFs.

Study design: Case-control study.

Participants & setting: Prevalent hemodialysis population in 7 Mayo Clinic outpatient hemodialysis units. Cases were without functioning AVFs and controls were with functioning AVFs on January 31, 2011.

Predictors: History of PICCs.

Outcomes: Lack of functioning AVFs.

Results: On January 31, 2011, a total of 425 patients were receiving maintenance hemodialysis, of whom 282 were included in this study. Of these, 120 (42.5%; cases) were dialyzing through a tunneled dialysis catheter or synthetic arteriovenous graft and 162 (57.5%; controls) had a functioning AVF. PICC use was evaluated in both groups and identified in 30% of hemodialysis patients, with 54% of these placed after dialysis therapy initiation. Cases were more likely to be women (52.5% vs 33.3% in the control group; P = 0.001), with smaller mean vein (4.9 vs 5.8 mm; P < 0.001) and artery diameters (4.6 vs 4.9 mm; P = 0.01) than controls. A PICC was identified in 53 (44.2%) cases, but only 32 (19.7%) controls (P < 0.001). We found a strong and independent association between PICC use and lack of a functioning AVF (OR, 3.2; 95% CI, 1.9-5.5; P < 0.001). This association persisted after adjustment for confounders, including upper-extremity vein and artery diameters, sex, and history of central venous catheter (OR, 2.8; 95% CI, 1.5-5.5; P = 0.002).

Limitations: Retrospective study, participants mostly white.

Conclusion: PICCs are commonly placed in patients with end-stage renal disease and are a strong independent risk factor for lack of functioning AVFs.

Figure 1

Study flowchart. Abbreviations: AKI, acute kidney injury; AVF, arteriovenous fistula; ESRD, end-stage renal disease; PICC, peripherally inserted central catheter.

Figure 2

Indications for peripherally inserted central catheter (PICC) placement in the 85 patients with end-stage renal disease with prior PICC placement as of January 31, 2011. Abbreviations: IV, intravenous; Labs, laboratory tests; TPN, total parenteral nutrition.

Figure 3

Vein diameter differences. (A) Comparison of median vein diameter for patients with no prior peripherally inserted central catheter (PICC; 5.3 mm) versus those with venous mapping pre-PICC insertion (5.6 mm; P = 0.09, Wilcoxon rank sum test) suggests that PICCs may have been preferentially placed in patients with better venous quality. (B) A statistically significant difference in median vein diameter for patients with venous mapping done pre–PICC insertion (5.6 mm) versus post–PICC insertion (4.7 mm with P = 0.03, Wilcoxon rank sum test), possibly indicating a negative impact of PICC use on vein diameter. Data presented as box plot with median and interquartile range.