Femoral versus Jugular, part two

I have always been told that the jugular veins are preferable over the femoral veins when inserting temporary dialysis catheters. Various reasons are put forward for this including increased risk of infection and poor function of femoral catheters due to factors such as recirculation and frequent clotting. A previous post by Nate discussed the Cathedia study in which 750 bed-bound patients were randomized to receive a femoral catheter or a jugular catheter for dialysis. There was no difference in rates of infection as measured by catheter tip colonization or documented line-related bacteremia in the two groups. The authors’ only reservation was that in patients with a higher BMI, a jugular catheter was preferable. In contrast, in patients with a BMI less than 24.2, the use of a femoral catheter was associated with less infections. So much for the first complaint.

So, what about the risk of poor function associated with femoral catheters? In order to determine whether catheter site had any influence over dialysis performance, a paper was recently published in which the authors performed a secondary analysis of the data in the Cathedia trial. The primary endpoints were catheter dysfunction – defined as an inability to achieve adequate blood flow requiring catheter replacement, dialysis sessions delivered, URR and CRRT downtime. Overall, catheter dysfunction occurred in 10.3% of the femoral group and 11.1% of the jugular group. Comparing LIJ to RIJ, the risk of dysfunction was 6.6% on the right as opposed to 19.5% on the left, significantly higher then in the femoral group. There was no difference in URR, number of sessions or CRRT downtime between the two groups. The authors suggested that when choosing a site for vascular access, you should think – RIJ → Femoral → LIJ.

Nate in his previous post came to the conclusion that the original study would not necessarily change his practice although it made it easier to justify the use of femoral lines. This new paper seems like one more piece of evidence that might make me change mine