-

J Vasc Access 2011; 12 ( 4): 273-279 REVIEW

DOI: 10.5301/JVA.2011.7745

Central venous catheters: legal issues

Maurizio Gallieni1,2, Valentina Martina1,2, Maria Antonietta Rizzo1,2, Luciana Gravellone1,2,
Francesca Mobilia3, Antonino Giordano1, Daniele Cusi2, Umberto Genovese3
1
Nephrology and Dialysis Unit, Hospital San Carlo Borromeo, Milan - Italy
Nephrology and Dialysis Unit, Hospital San Carlo Borromeo, Milan - Italy and Specialist School of Nephrology, DMCO Hospital San Paolo, University of Milan, Milan - Italy
Nephrology and Dialysis Unit, Hospital San Carlo Borromeo, Milan - Italy and Specialist School of Nephrology, DMCO Hospital San Paolo, University of Milan, Milan - Italy
Nephrology and Dialysis Unit, Hospital San Carlo Borromeo, Milan
Nephrology and Dialysis Unit, Hospital San Carlo Borromeo, Milan - Italy and Specialist School of Nephrology, DMCO Hospital San Paolo, University of Milan, Milan - Italy

2
Specialist School of Nephrology, DMCO Hospital San Paolo, University of Milan, Milan - Italy
3
Institute of Forensic Medicine, University of Milan, Milan - Italy
Institute of Forensic Medicine, University of Milan, Milan - Italy

ABSTRACT
In dialysis patients, both central venous catheter (CVC) insertion and CVC use during the dialysis procedure pose important
legal issues, because of potentially severe, even fatal, complications. The first issue is the decision of the kind of vascular ac-
cess that should be proposed to patients: an arteriovenous (AV) fistula, a graft, or a CVC. The second issue, when choosing
the CVC option, is the choice of CVC: nontunneled versus tunneled. Leaving a temporary nontunneled CVC for a prolonged
time increases the risk of complications and could raise a liability issue. Even when choosing a long-term tunneled CVC,
nephrologists should systematically explain its potential harms, presenting them as “unsafe for long-term use” unless there
is a clear contraindication to an AV native or prosthetic access. Another critical issue is the preparation of a complete, infor-
mative, and easy-to-understand consent form. The CVC insertion procedure has many aspects of legal interest, including the
choice of CVC, the use of ECG monitoring, the use of ultrasound guidance for cannulation, and the use of fluoroscopy for
checking the position of the metal guidewire during the procedure as well as the CVC tip before the end of the procedure.
Use of insertion devices and techniques that can prevent complications should obviously be encouraged. Complications of
CVC use are mainly thrombosis and infection. These are theoretically expected as pure complications (and not as malpractice
effects), but legal issues might relate to inappropriate catheter care (in both the inpatient and outpatient settings) rather than
to the event per se. Thus, in the individual case it is indeed very difficult to establish malpractice and liability with a catheter-
related infection or thrombosis. In conclusion, we cannot avoid complications completely when using CVCs, but reducing
them to a minimum and adopting safe approaches to their insertion and use will reduce legal liability.

Key words: Catheter, Complications, Dialysis, Hemodialysis, Liability

Accepted: December 27, 2010

INTRODUCTION their use may be necessary but there is an increased risk

of severe complications) may raise legal issues in the indi-
A well-functioning vascular access is the cornerstone vidual patient having a CVC access who suffers a relevant
of hemodialysis therapy, and timely planning of access complication, such as septicemia or death.
creation is of utmost importance in the care of patients In this article we analyze the main aspects of legal is-
with chronic kidney disease. Clinical practice guidelines sues of tCVC use. In particular, we concentrate on 4 sub-
recommend an arteriovenous fistula (AVF) as the best per- jects: choice of vascular access, the written consent form,
manent vascular access (1-3). In contrast, the prevalence the insertion procedure, and complications of CVC use.
of tunneled central venous catheters (tCVCs) is rising in
most countries (4).
Recently, it has been suggested that nephrologists Choice Of Vascular Access
have an ethical and legal obligation to avoid the use of
tCVCs as a long-term vascular access in patients who are The first issue is the decision of the kind of vascular
JVA_10_1109_Gallieni

possible candidates for AVFs (5). access that should be proposed to patients: an AVF, a graft,
Recommendations for a limited tCVC use in hemodi- or a CVC (either nontunneled or tunneled). The creation
alysis are based on medical evidence and clinical practice of the vascular access should ideally be planned in ad-
guidelines, suggesting that tCVCs are related to an increased vance of the start of dialysis. In cases where the patient
risk of mortality and morbidity (1, 2). Although it is widely is not a candidate for peritoneal dialysis, an AVF should
accepted that central venous catheters (CVCs) are not the be considered first. An AVF is the optimal vascular access
best type of long-term vascular access, their availability is because it has the longest survival and the lowest infec-
essential for many patients (6), and this contradiction (i.e., tion and thrombosis rates (1, 2, 7). Sometimes, the AVF is

© 2011 Wichtig Editore - ISSN 1129-7298 273

Central venous catheters: legal issues
not a possible option: there are situations which require
an emergency vascular access, such as acute renal failure
and acute obstruction of a previous arteriovenous (AV) ac-
cess. Even in stable patients, some increasingly frequent
conditions, such as the aging of the chronic kidney disease
population and the presence of cardiovascular comorbidi-
ties, can determine an inability to create an autogenous
permanent vascular access.
The second issue right after choosing the CVC option
regards the kind of the CVC to use: nontunneled CVC ver-
sus tunneled CVC. Nontunneled catheters (ntCVCs) can
easily be inserted when urgent dialysis is needed and al-
low a fully functional vascular access. However, using a
temporary ntCVC for a prolonged time increases the risk
of complications, thus raising a liability issue.
The correct clinical indication for a tCVC is their
use as a bridge until AV access maturation, but the
prevalence of permanent tCVCs is rising in patients with
congestive heart failure and severe peripheral vascular
disease, in the very elderly, in those with inadequate
vascular anatomy, in those with limited life expectancy,
and as a last resort in patients with multiple access fail-
ures (1, 2). K/DOQI recommends that use of tunneled-
cuffed catheters be discouraged as long-term vascular
access and that fewer than 10% of patients should be us-
ing them for permanent access (1). Indeed, tCVCs have
been found to be associated with as much as a 2-fold
increased mortality compared with AVFs (8), as well as
with increased risk of serious infection, increased hos-
pitalization, decreased likelihood of adequate dialysis,
and an increased number of vascular access procedures
(5). Conversely, changing from CVC to a fistula or graft
is associated with significantly improved survival (9)
and with significantly lower hospitalization risk relative
to keeping the catheter (10).
Strategies to minimize the use of hemodialysis CVCs
are, besides early referral of patients to the nephrologist,
to increase the number of peritoneal dialysis patients; and
to improve vascular access education, preoperative vascu-
lar mapping, and salvage of early failure and thrombosed
fistulae (11). The best strategies to reduce legal issues re-
garding use of CVCs in the dialysis setting are to practice
a good predialytic follow-up of the patients, to make a
strict preliminary selection for patients really needing a
CVC access, and to replace CVC access with other recom-
mended options as soon as possible.
Written Consent Form And Patient Information
In dialysis patients requiring a CVC access, both
CVC insertion and CVC use during the dialysis proce-
dure pose important legal issues, because of potentially
severe, even fatal, complications. Therefore, placement
of a CVC as vascular access for hemodialysis requires
274 © 2011 Wichtig Editore - ISSN 1129-7298
a specific informed consent (5). The informed consent
should be complete, informative, and easy to under-
stand. The consent form by itself is not sufficient for ei-
ther the patient (needing clinical and practical informa-
tion) or the physician (aiming at good clinical practice):
the nephrologist should talk to the patient, should give
the patient the chance of expressing doubts and asking
questions, and then should clearly inform the patient in
a step-by-step manner of the different medical aspects
regarding the use of CVCs for hemodialysis, as com-
pared with AVFs (Tab. I).
Physicians should not use the principle of patient’s
autonomy as a justification for leaving a CVC inserted
in a central vein for a prolonged time. A doctor has the
obligation to offer the best available treatment to patients
and to carefully discuss with them its features and even-
tually its alternatives. To do so, sometimes it may be re-
quired that doctors have to learn to say no (12, 13), when
this avoids a “bad medicine” approach to a disease. Bad
medicine and also clinical malpractice involves, for ex-
ample, choosing a treatment when there is an evidence-
based indication for the cost-effectiveness of alternative
treatments or techniques. In dialysis patients, one simple
example is the choice of tunneled versus nontunneled
CVCs. More challenging is the decision, in the individual
patient, of insisting on AV vascular access creation rather
than relying on a CVC. Good clinical practice nowadays
means good communication with patients too, with spe-
cial efforts at communicating information and giving
explanations, so that the final decision truly reflects the
choice of the patient.
Clinical practice guidelines help the physician to es-
tablish a standard of care (1, 2) and represent an obliga-
tory framework for ex post (as seen after the event) medi-
TABLE I - ELEMENTS TO BE INCLUDED IN AN INFORMED CONSENT
FOR CENTRAL VENOUS CATHETER INSERTION
• Medical indication for the procedure and alternatives to CVC place-
ment.
• Description of the procedure, specifying that it is ultrasound and/or
radioscopically guided. If no guidance is available, detail the reason
and the higher risk compared with a guided technique.
• Risks related to CVC insertion, including management of potential
complications.
• Need for repeated access procedures, due to catheter malfunction.
• Inadequate dialysis.
• Increased risk of infection (5- to 10fold), which might determine severe
complications (septicemia, osteomyelitis, septic arthritis, endocarditis,
or epidural abscess).
• Increased risk of thrombosis of central veins (including the vena cava)
and of the right atrium, which in some cases might require major sur-
gery.
• Increased risk of hospitalization, because of catheter complications.
• Increased risk of death (2 to 3-fold).
CVC = central venous catheter
Gallieni et al
colegal analysis regarding clinical malpractice. The use of
tCVCs as a permanent vascular access exposes nephrolo-
gists to malpractice claims and legal liability, because of
the existing medical evidence of an increased risk of mor-
tality related to the presence of the CVC itself. Sometimes
the patient prefers to continue dialysis using a CVC: in this
situation the physician has theoretically different options.
In a recent article (5), the possible responses of the neph-
rologist were described. In particular, the doctor should
feel obliged to clearly explain the risks of long-term CVC
use and, if the patient is a candidate for an AVF, the physi-
cian should also require an informed refusal of an AVF, to
avoid legal liability. Other possible options proposed by
Rehman et al (5) are that the physician
– refuse to allow the patient to use a CVC and refer him or
her to another physician;
– temporarily yield to the patient’s request, require in-
formed refusal of an AVF, and continue to explain the
importance of using a CVC only as a temporary vascular
access.
The authors believe that in such a complicated cir-
cumstance the crucial points are the careful informing
of the patient, the presence of a never-ending process of
clear communication between the patient and the physi-
cian (from the physician to the patient and vice versa),
and also the full respect of the informed patient choice by
the physician. The official refusal form should be just the
final approach in the situation and not the first goal of the
physician. After the patient’s informed choice of keeping
the CVC access working, the option to refer the patient
to another physician means perhaps not to have fully un-
derstood the cultural shift from patient curing to patient
caring.
Physicians should optimize AVF use and propose it
as standard of care, accepting tCVCs only as temporary
vascular access in all patients where a fistula or graft is
feasible (14). It is then mandatory for the physician deal-
ing with a patient who will receive a CVC access to ex-
plain from the very beginning that the CVC option is just
a temporary procedure and that the final therapeutic goal
is the shift from CVC access to AVF or graft.
Most dialysis units propose to their patients a writ-
ten form of consent regarding CVC and AVF placement,
clearly explaining risks and complications related to the
procedure itself. However, such forms often lack some
crucial information:
– a list of all of the possible types of vascular access that
should be proposed to the patient;
– a statement indicating that the AV fistula is the optimal
form of vascular access because it has the longest sur-
vival, ensures the lowest infection rates and thrombosis
rates, and is better for dialysis;
– correct terminology avoiding the misunderstanding be-
tween permanent and tunneled CVC (the term perma-
nent should not be used, leaving the possibility to con-
© 2011 Wichtig Editore - ISSN 1129-7298
vert a tCVC into an AV access)
– the description of all long-term complications related to
the presence of an ntCVC or tCVC.
Obtaining an incomplete consent form may be con-
sidered clinical malpractice. If the physician feels that the
consent form is incomplete, she/he must first communi-
cate the patient information orally and then must seek to
improve the consent form itself. When crucial information
is lacking, there is no informed consent from the patient.
In addition, a specific consent form for tCVCs is advis-
able, as well as a specific document for refusal of an AVF
when the patient is a possible candidate for an AVF.
The Insertion Procedure
After choosing the CVC option, recognition of risk fac-
tors for difficult catheterization is essential, and all patients
should be evaluated for conditions that might increase the
difficulty of catheter insertion, such as skeletal deformity,
presence of scars, obesity, previous CVC insertions, vas-
cular abnormalities, or previous surgery at the insertion
site (15).
The CVC insertion procedure has many aspects of le-
gal interest. There are a few points to remember, to avoid
CVC insertion complications and the consequent liabil-
ity (Tab. II). Use of insertion devices and techniques that
can prevent accidents amenable of legal liability must be
encouraged (16). Nephrologists should pay attention to
some aspects of legal interest when they insert CVCs:
– Maximal sterile barriers. For preventing infections, use
wide sterile barriers – cap, mask, gown, gloves, and
wide drape – and wash hands first (15, 17).
– Ultrasound guidance. Ultrasound assisted cannulation
can be considered the standard approach to dialysis
catheter placement in the internal jugular vein (18, 19).
TABLE II - CENTRAL VENOUS CATHETER INSERTION IN DIALYSIS PA-
TIENTS: KEY POINTS
• Always obtain informed consent for elective CVC insertions. Discuss
both the benefits and the risks.
• A specific consent form is not needed in an emergency. However,
the physician must fully document the nature of the emergency in the
progress notes and, if applicable, any attempts to notify the patient’s
family to obtain consent.
• Use wide sterile barriers – cap, mask, gown, gloves, wide drape – and
wash hands first.
• Use ultrasound guidance for internal jugular veins. Avoid subclavian
veins, unless there is no possibility of future AV access in the same
arm.
• Use ECG monitoring during the procedure.
• When placing a CVC in chest central veins, obtain an x-ray following
the procedure and check for line tip placement, pneumothorax, and
hemothorax.
AV = arteriovenous; CVC = central venous catheter
275
Central venous catheters: legal issues
Use of ultrasound guidance for cannulation allows a
better localization of the vein, an evaluation of its depth
beneath the skin, and identifies vascular abnormalities
such as anatomical variations or vein thrombosis; it also
reduces the time of the insertion procedure, the rates
of unsuccessful catheterization, carotid-artery puncture,
hematoma formation, and mechanical complications
(20, 21). After the guidewire insertion, its correct po-
sitioning into the vein can be easily verified by ultra-
sound, excluding the possibility of carotid artery cannu-
lation. Ultrasound guidance is also very effective in the
femoral approach (22, 23), while no clear advantages
have been demonstrated in subclavian vein cannula-
tion. Ultrasound-guided CVC placement has also been
proven to be safe and useful in the hands of surgical
trainees (24).
– ECG monitoring. Use of ECG monitoring during the pro-
cedure is useful to prevent arrhythmia (25).
– Use of fluoroscopy. For tCVC, the use of fluoroscopy
allows checking the position of the metal guidewire as
well as the catheter tip before the end of the procedure.
This is particularly important for left-side placements.
ntCVCs are usually inserted without fluoroscopic guid-
ance.
– Avoiding pneumothorax. The possibility of causing a
pneumothorax while trying to access a central vein
should always be kept in mind. To prevent this com-
plication, it is advisable to use ultrasound guidance.
When choosing the site for central vascular access,
the internal jugular vein is preferable for the lower
frequency of pneumothorax compared with the sub-
clavian site. In symptomatic patients, pneumothorax
can be detected with chest x-ray obtained immediately
after the procedure. A chest x-ray obtained within 4
hours from the procedure can also detect asymptom-
atic pneumothorax (26).
– Avoiding air embolism. Air embolism is a rare but po-
tentially fatal complication caused by the sudden entry
of air through the catheter into the right heart or pul-
monary artery. Death may occur if a large amount of
air enters the heart and pulmonary arteries, stopping
blood flow in the pulmonary circulation. In the United
States, the Agency for Healthcare Research and Quality
of the Department of Health and Human Services has
identified “patient death or serious disability associated
with intravascular air embolism that occurs while being
cared for in a health care facility” as one of the pre-
ventable never events (medical errors that should never
occur) (27). Accordingly, the Center for Medicare and
Medicaid Services stated that reimbursement for air em-
bolism which developed during hospital admission will
be denied (28). Significant factors contributing to this
adverse event include the patient’s body position and
hydration status (29). It has been shown that air embo-
lism usually occurs during insertion of a dialysis tCVC
276 © 2011 Wichtig Editore - ISSN 1129-7298
through a peel-away sheath (29), but the current avail-
ability of valved introducers has greatly reduced the risk
of air embolization. The use of a sheathless technique
for tCVCs has been advocated (30), but in our experi-
ence, this technique carries some technical challenges
during catheter insertion, and we prefer the use of a
valved introducer.
Interesting data from the anesthesiology setting are
available, regarding changing patterns of injury and li-
ability associated with central venous or pulmonary artery
catheters (31). These authors analyzed closed malpractice
claims for central catheter injuries in the American Society
of Anesthesiologists Closed Claims database. All claims for
which a central catheter was the primary damaging event
for the injury were compared with the rest of the claims
in the database. Central catheter complications were de-
fined as being related to vascular access or catheter use
or maintenance. The database included 110 claims for in-
juries related to central catheters (1.7% of 6,449 claims).
Claims for central catheter injuries had a higher severity of
injury, with an increased proportion of death (47%) com-
pared with 29% of the other claims in the database. The
most common complications were wire/catheter embolus,
cardiac tamponade, carotid artery puncture/cannulation,
hemothorax, and pneumothorax. Cardiac tamponade,
hemothorax, and pulmonary artery rupture had a higher
proportion of death compared with the rest of the central
catheter injuries. Important information from this study is
also the increased proportion of claims for vascular ac-
cess injury (47% to 84%) and the decreased proportion of
use/maintenance injury (53% to 16%) in 1994-1999 com-
pared with 1978-1983. The article reports that almost half
of the central catheter claims were judged to be possibly
preventable by ultrasound guidance, pressure waveform
monitoring, or chest radiograph.
Long-Term Complications Of Central Venous Catheters For
Hemodialysis
CVC-related complications are important causes of
hospitalization and mortality in dialysis patients (32, 33).
The rate of CVC complications may vary greatly, depend-
ing on the quality of the insertion procedure and on cath-
eter maintenance. CVCs have very high complication and
fatality rates when not properly inserted and monitored.
The most relevant CVC complications are infections
and thrombosis. Infectious complications are related to
different mechanisms: infection of the exit site; migra-
tion of the pathogen along the external catheter surface;
intraluminal migration, usually due to contamination of
catheter hub, leading to bacteremia and catheter colo-
nization. Catheter-related thrombosis may be associated
with central vein thrombosis and pulmonary embolism.
Thrombosis is a serious complication because it can lead
Gallieni et al
to inefficient dialysis, alter the venous circulation, and fa-
cilitate infections. In many cases, patients with CVC-related
thrombosis are treated with oral anticoagulation. However,
it should be kept in mind that warfarin substantially in-
creases the risk of bleeding in patients on dialysis (34). It is
possible that it may also contribute to accelerated vascular
calcification, due to interference with vitamin K dependent
calcification inhibitors, such as matrix GLA protein (35).
Dialysis CVC care is also of paramount importance in
determining outcomes. Poor CVC care can facilitate infec-
tions and raise nursing liability issues. This has already been
observed in the nondialysis setting (36, 37). Schulmeister
(36) suggests that nurses can reduce the likelihood of being
named in a lawsuit, by maintaining clinical competency;
communicating effectively; adhering to policies, proce-
dures, and standards of care; and thoroughly documenting
care.
Clinical policies within the dialysis unit are also im-
portant, as good clinical care can be the best preventive
measure to avoid infections (15, 17). A correct clinical
policy should state that nursing care should follow stan-
dard, high-quality procedures. These include hand decon-
tamination (by washing with an antimicrobial liquid soap
and water or by using an alcohol handrub) and aseptic
nontouch techniques for catheter handling (17). In the in-
tensive care setting, wearing sterile gloves and disinfecting
the skin with 2% chlorhexidine–based preparations reduce
catheter-related infections most effectively. Skin disinfec-
tion before insertion of a CVC should also be performed
with 2% chlorhexidine, rather than 10% povidone-iodine
or 70% alcohol, as it can reduce the incidence of device-
related infection (38).
In the dialysis setting, an infection-preventing approach
should also be adopted, particularly in children (39), al-
though it is not yet clear which measures are truly safe and
cost-effective.
Establishing liability with a catheter infection and/or
thrombosis may be difficult. When investigating if clinical
care was appropriate, it should be easy to assess the fol-
lowing:
– the CVC was inserted in an appropriate room, with sterile
technique;
– established catheter management procedures in the di-
alysis setting were followed;
– how long the CVC has been in place (especially for
ntCVC).
The presence of an access coordinator taking care
of access problems in the dialysis unit should allow their
prompt recognition and treatment, reducing the possibility
of adverse outcomes.
A recent case report (40) has raised the issue of the po-
tential use of a CVC as an easily accessible method to com-
mit suicide, by cutting the CVC tube and bleeding to death
or dying because of air embolism. These authors highlight
the requirement to assess carefully the patient’s mental state,
© 2011 Wichtig Editore - ISSN 1129-7298
and if there are signs of depression and suicidal thoughts,
they should be reported to the relatives and to all members
of the renal dialysis team, to prevent suicide. However, re-
ports of suicide through incision of an AV fistula have also
been reported (41). Therefore, the issue here is not the type of
vascular access but rather the identification of the individual
patient at risk for depression and suicidal thoughts.
Patient Negligence
If present, patient negligence can be an important as-
pect to consider in case of a medical malpractice lawsuit.
Three aspects are particularly relevant to the dialysis set-
ting:
1. The patient refused AV fistula surgery and asked to start
or continue dialysis with a CVC. To claim that there was
patient negligence, it is very important to document that
the patient was correctly and repeatedly informed.
2. The patient carried out inadequate CVC care, in particu-
lar of dressings, which should not be opened in the in-
terdialytic period.
3. The patient failed to disclose important information to
the doctor.
CONCLUSION
We can not avoid complications using CVCs, but re-
ducing them to a minimum and adopting safe approaches
to their insertion and use will reduce legal liability. Pa-
tients should be adequately informed about the choice
of dialysis (peritoneal vs. hemodialysis), about the choice
of vascular access, and about complications related to
CVCs. Long-term dialysis with CVC increases the risk
of serious complications and mortality – a good reason
to present catheters as temporary vascular access only.
The main questions in many vascular access malpractice
cases concerning CVCs should be kept in mind: was the
indication to insert a CVC clinically justified? Were the
informed consent and the whole information communica-
tion process adequate? How did the insertion technique
compare with the standard, state-of-the-art methodology?
Was catheter management in the dialysis unit correct? A
complete description of what has been done and of the
reasons specific decision were made will help in demon-
strating good clinical practice, despite the occurrence of
a complication.
Abbreviations
AVF = arteriovenous fistula
ntCVC = nontunneled central venous catheter
tCVC = tunneled central venous catheter
277
Central venous catheters: legal issues
ACKNOWLEDGEMENTS
The authors thank Dr. Luc Turmel Rodrigues for his suggestion to
convert a meeting presentation into this article.
Financial support: Writing of this manuscript was supported in
part by a grant (PUR 10%) from the University of Milan for in-
ternal research.
Meeting presentation: The content of this article has been pre-
sented in part at the scientific meeting of the French Society for
Vascular Access (SFAV), Tours, France, 16 June 2010.
Conflict of interest: The authors do not have any proprietary in-
terests to disclose regarding the issue of the present manuscript.
Address for correspondence:
Maurizio Gallieni, MD
Nephrology and Dialysis Unit
Ospedale San Carlo Borromeo
Via Pio II 3
20153 Milano, Italy
maurizio.gallieni@fastwebnet.it
REFERENCES
1. National Kidney Foundation. KDOQI clinical practice
guidelines and clinical practice recommendations for
2006 updates: hemodialysis adequacy, peritoneal dialysis
adequacy and vascular access. Am J Kidney Dis 2006; 48
(Suppl 1): S1-322.
2. Tordoir J, Canaud B, Haage P, et al. EBPG on vascular
access. Nephrol Dial Transplant 2007; 22 (Suppl 2): ii88-
117.
3. Konner K, Hulbert-Shearon TE, Roys EC, Port FK. Tailoring
the initial vascular access for dialysis patients. Kidney Int
2002; 62: 329-38.
4. Ethier J, Mendelssohn DC, Elder SJ, et al. Vascular access
use and outcomes: an international perspective from the
Dialysis Outcomes and Practice Patterns Study. Nephrol
Dial Transplant 2008; 23: 3219-26.
5. Rehman R, Schmidt RJ, Moss AH. Ethical and legal
obligation to avoid long-term tunneled catheter access.
Clin J Am Soc Nephrol 2009, 4: 456-60.
6. Schwab SJ, Beathard G. The hemodialysis catheter
conundrum: hate living with them, but can’t live without
them. Kidney Int 1999; 56: 1-17.
7. Davidson IJ, Gallieni M, Saxena R, Dolmatch B. A patient
centered decision making dialysis access algorithm. J Vasc
Access 2007; 8: 59-68.
8. Polkinghorne KR, McDonald SP, Atkins RC, Kerr PG.
278 © 2011 Wichtig Editore - ISSN 1129-7298
Vascular access and all-cause mortality: a propensity score
analysis. J Am Soc Nephrol 2004; 15: 477-86.
9. Lacson E Jr, Wang W, Lazarus JM, Hakim RM. Change in
vascular access and mortality in maintenance hemodialysis
patients. Am J Kidney Dis 2009; 54: 912-21.
10. Lacson E Jr, Wang W, Lazarus JM, Hakim RM. Change
in vascular access and hospitalization risk in long-term
hemodialysis patients. Clin J Am Soc Nephrol 2010; 5:
1996-2003.
11. Asif A, Merrill D, Leon C, Ellis R, Pennell P. Strategies to
minimize tunneled hemodialysis catheter use. Blood Purif
2006; 24: 90-4.
12. Brett AS, McCullough LB. When patient received specific
interventions: defining the limits of the physician’s
obligation. N Engl J Med 1986; 315: 1347-51.
13. Thurow LC. Learning to say “no”. N Engl J Med 1984; 311:
1569-72.
14. Lacson E Jr, Lazarus JM, Himmelfarb J, Ikizler TA, Hakim
RM. Balancing fistula first with catheters last. Am J Kidney
Dis 2007; 50: 379-95.
15. Gallieni M, Pittiruti M, Biffi R. Vascular access in oncology
patients. CA Cancer J Clin 2008; 58: 323-46.
16. McGee DC, Gould MK. Preventing complications of central
venous catheterization. N Engl J Med 2003; 348: 1123-33.
17. Pratt RJ, Pellowe CM, Wilson JA, et al. EPIC2: national
evidence-based guidelines for preventing healthcare-
associated infections in NHS hospitals in England. J Hosp
Infect 2007; 65 (Suppl 1): S1-64.
18. Denys BG, Uretsky BF, Reddy PS. Ultrasound assisted
cannulation of the internal jugular vein: a prospective
comparison to the external landmark guided technique.
Circulation 1993; 87: 1557-62.
19. Kwon TH, Kim YL, Cho DK. Ultrasound guided cannulation
of the femoral vein for acute hemodialysis access. Nephrol
Dial Transplant 1997; 12: 1009-12.
20. Randolph AG, Cook DJ, Gonzales CA, Pribble CG.
Ultrasound guidance for placement of central venous
catheters: a meta-analysis of the literature. Crit Care Med
1996; 24: 2053-8.
21. Gallieni M. Central vein catheterization of dialysis patients
with real time ultrasound guidance. J Vasc Access 2000; 1:
10-4.
22. Pecorari M. The suitability of the femoral vein for permanent
vascular access. J Vasc Access 2004; 5: 116-8.
23. Prabhu MV, Juneja D, Gopal PB, et al. Ultrasound-
guided femoral dialysis access placement: a single-center
randomized trial. Clin J Am Soc Nephrol 2010; 5: 235-9.
24. Hameeteman M, Bode AS, Peppelenbosch AG, van der
Sande FM, Tordoir JH. Ultrasound-guided central venous
catheter placement by surgical trainees: a safe procedure? J
Vasc Access 2010; 11: 288-92.
25. da Silva PS, Waisberg J. Induction of life-threatening
supraventricular tachycardia during central venous catheter
placement: an unusual complication. Pediatr Surg 2010;
45: E13-6.
Gallieni et al
26. Giacomini M, Iapichino G, Armani S, Cozzolino M,
Brancaccio D, Gallieni M. How to avoid and manage a
pneumothorax. J Vasc Access 2006; 7: 7-14.
27. US Department of Health and Human Services, Agency for
Healthcare Research and Quality, Patient Safety Network.
Patient safety primer: never events. Available at: http://psnet.
ahrq.gov/primer.aspx?primerID=3. Accessed November
19, 2010.
28. US Medicare Program. Changes to the hospital inpatient
prospective payment systems and fiscal year 2009 rates:
preventable hospital-acquired conditions (HACs) including
infections. 73 Federal Register 161. Revised 19 Aug 2008.
pp. 48471-90.
29. Vesely TM. Air embolism during insertion of central venous
catheters. J Vasc Interv Radiol 2001; 12: 1291-5.
30. Patel A, Hofkin S, Ball D, Cohen G, Smith DC. Sheathless
technique of Ash Split-Cath insertion. J Vasc Interv Radiol
2001; 12: 376-8.
31. Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA,
Cheney FW. Injuries and liability related to central vascular
catheters: a closed claims analysis. Anesthesiology 2004;
100: 1411-8.
32. Allon M, Daugirdas J, Depner TA, Greene T, Ornt D, Schwab
SJ; for the HEMO Study Group. Effect of change in vascular
access on patient mortality in hemodialysis patients. Am J
Kidney Dis 2006; 47: 469-77.
33. Lee T, Barker J, Allon M. Tunnelled catheters in hemodialysis
© 2011 Wichtig Editore - ISSN 1129-7298
patients: reasons and subsequent outcomes. Am J Kidney
Dis 2005; 46: 501-8.
34. Holden RM, Clase CM. Use of warfarin in people with low
glomerular filtration rate or on dialysis. Semin Dial 2009;
22: 503-11.
35. Mandolfo S, Gallieni M. Use of oral anticoagulants to
prevent central venous catheter-related thrombosis in
hemodialysis. G Ital Nefrol 2010; 27: 490-7.
36. Schulmeister L. A complication of vascular access device
insertion: a case study and review of subsequent legal
action. J Intraven Nurs 1998; 21: 197-202.
37. Masoorli S. Legal issues related to vascular access devices and
infusion therapy. J Infus Nurs 2005; 28 (3 Suppl): S18-21.
38. Maki DG, Ringer M, Alvarado CJ. Prospective randomised
trial of povidone-iodine, alcohol, and chlorhexidine for
prevention of infection associated with central venous and
arterial catheters. Lancet 1991; 338: 339-43.
39. Stefanidis CJ. Prevention of catheter-related bacteremia in
children on hemodialysis: time for action. Pediatr Nephrol
2009; 24: 2087-95.
40. Edirisinghe PA, Busuttil A. Suicide by severing the arterio-
venous subclavian dialysis catheter. J Clin Forensic Med
2006: 13, 86-8.
41. Marc B, Baudry F, Latifa Z, Ghaith A, Garnier M. Suicidal
incised wound of a fistula for haemodialysis access in an
elderly woman: case report. Am J Forensic Med Pathol
2000; 21: 270-2.
279