KDIGO Clinical Practice Guideline for Acute Kidney Injury
When choosing a vein for insertion of a dialysis catheter in patients with AKI: Recommendations and Rationale

• 5.4.2: When choosing a vein for insertion of a dialysis catheter in patients with AKI, consider these preferences (Not Graded):
  • First choice: right jugular vein;
  • Second choice: femoral vein;
  • Third choice: left jugular vein;
  • Last choice: subclavian vein with preference for the dominant side.

Rationale

Although generally associated with the lowest rate of infectious complications, the CDC guideline as well as the KDOQI guideline recommend avoiding the subclavian vein for RRT access,^640,641 because this may lead to central vein stenosis and jeopardize subsequent permanent access. This recommendation is mainly derived from observational data in ESRD patients showing a higher incidence of central vein stenosis with subclavian than with jugular dialysis catheters.^650,651 On the other hand, central vein stenosis has also been described after jugular catheterization.^652,653 Contact of the catheter with the vessel wall is considered a primary initiating event for catheter-related thrombosis and stenosis. Catheters in the right internal jugular vein have a straight course into the right brachiocephalic vein and superior vena cava, and, therefore, the least contact with the vessel wall. A catheter inserted through the subclavian or the left jugular vein has one or more angulations. explaining the higher risk of vessel contact and thrombosis/stenosis with subclavian compared to jugular catheters,^650,651 and with left-sided compared to right-sided jugular catheters.^654-656 The subclavian vein should, therefore, be considered the last choice for insertion of a dialysis catheter in patients with AKI, especially when the risk of nonrecovery of kidney function is substantial. Whether this recommendation should be extended to the left jugular vein remains unclear. In patients where the subclavian vein remains the only available option, preference should be given to the dominant side in order to spare the nondominant side for eventual future permanent access.

Because the subclavian vein should be avoided, the remaining options are the jugular and femoral veins. The use of femoral catheters is thought to be associated with the highest risk of infection, and avoidance of femoral lines is part of many ‘‘central line bundles’’ that intend to reduce the incidence of catheter-related bloodstream infection.⁶⁵⁷ This dogma was questioned in a concealed, randomized, multicenter, evaluator-blinded, parallel-group trial of 750 AKI patients, comparing the femoral with the jugular site for first catheter insertion for RRT. Ultrasound was seldom used, probably explaining the somewhat higher rate of failure on one side and crossover in the jugular group. The rate of hematoma formation was also higher in the jugular group. In both groups, 20% of the catheters were antisepticimpregnated. Mean duration of catheterization was 6.2 days for the femoral and 6.9 days for the jugular group. The major reasons for catheter removal were death or ‘‘no longer required’’. The incidence of catheter colonization at removal (the primary end-point) was not significantly different between the femoral and jugular group. When stratified according to body mass index (BMI), those within the lowest BMI tertile had a higher incidence of colonization with the jugular site, whereas those within the highest BMI tertile had the highest colonization rate with femoral catheters. Bloodstream infection did not differ between the groups (2.3 per 1000 catheter-days for jugular and 1.5 per 1000 catheter-days for femoral) but the study was not powered for this endpoint. This was also the case for thrombotic complications (Suppl Table 34).⁶⁵⁸

Malfunction is another issue that needs to be considered when choosing between a jugular and femoral vascular access. Observational trials show more malfunctioning and a shorter actuarial survival for femoral than for jugular dialysis catheters,^659-661 and more malfunction with left-sided jugular catheters compared to right-sided.⁶⁶² Recirculation has been shown to be more frequent in femoral than subclavian or jugular dialysis catheters, especially with shorter femoral catheters.^642,643 A secondary analysis of the French multicenter trial did not find a difference in catheter dysfunction between jugular and femoral catheters in the intention-to-treat analysis. However, a separate analysis of the right and left jugular catheters showed a trend toward more dysfunction with femoral than with right jugular catheters, but significantly more dysfunction with left jugular compared to femoral catheters.⁶⁶³

Another point to consider is that any patient who has the option of undergoing a kidney transplantation should not have a femoral catheter placed to avoid stenosis of the iliac vein, to which the transplanted kidney’s vein is anatomized. ⁶⁴⁰ The presence of a femoral catheter also reduces the patient’s mobilization, especially when the RRT is continuous.

In summary, the right jugular vein appears to be the best option for insertion of a dialysis catheter. Femoral catheters are preferred over left jugular catheters because of reduced malfunction, and the subclavian vein should only be considered a rescue option. It is evident that individual patient characteristics may require deviations from this order of preferences. Catheter insertion should be performed with strict adherence to infection-control policies, including maximal sterile barrier precautions (mask, sterile gown, sterile gloves, large sterile drapes) and chlorhexidine 2% skin antisepsis.^641,664,665