What are the complications of inserting a femoral central line on the same side as a renal transplant graft?

From the Guidelines

Inserting a femoral line on the same side as a transplanted kidney graft should be avoided due to potential complications that could compromise graft function and patient outcomes. The primary concern is the risk of damaging the transplanted kidney's vascular anastomoses, which are typically connected to the external iliac vessels in the ipsilateral pelvis, as noted in the KDOQI clinical practice guideline for vascular access: 2019 update 1. Complications include potential thrombosis of the renal vessels, which could lead to graft loss; inadvertent puncture of the transplant vessels causing hemorrhage; infection that could spread to the immunosuppressed graft; and venous outflow obstruction from the femoral catheter that could compromise graft perfusion.

Key Considerations

• The KDOQI guideline suggests considering the patient's ESKD Life-Plan when choosing the site for a central venous catheter (CVC), with a preference for upper extremity sites before lower extremity sites if choices are equivalent 1.
• The guideline also notes that some experts support the use of a tunneled, cuffed femoral CVC in urgent dialysis start situations under limited use circumstances, but this should be avoided if possible, especially on the same side as a transplanted kidney graft 1.
• Contraindications to femoral vein CVC include femoral or iliac vessel pathology or prior surgery/reconstruction, which would be a concern on the side of a kidney transplant 1.

Recommendations for Practice

• If femoral access is absolutely necessary, the contralateral side should be used whenever possible to minimize risks to the transplanted kidney.
• If ipsilateral access cannot be avoided, ultrasound guidance is essential to visualize the vascular structures and minimize risks, as recommended by expert opinion in the context of vascular access placement 1.
• The procedure should be performed by experienced operators with careful attention to the anatomical relationship between the femoral vessels and the transplanted kidney's vascular connections.
• Post-procedure monitoring should include assessment of kidney graft function through urine output and serum creatinine levels to detect any compromise to the transplanted organ.

From the Research

Complications of Inserting a Femoral Line on the Same Side as a Transplanted Kidney Graft

• The insertion of a femoral line on the same side as a transplanted kidney graft can lead to several complications, including:
  • Iliofemoral deep venous thrombosis (DVT), which can cause graft dysfunction 2
  • Catheter-related bloodstream infections, although the risk is not significantly different from subclavian and internal jugular venous catheters 3
  • Vascular thrombosis, which can sensitize the recipient for human leukocyte antibodies, reducing the chance for a second transplant 4
  • Transplant renal vein thrombosis, a devastating event that ultimately leads to graft loss in almost all cases 5
• The risk of catheter-related infection or bacteremia is not significantly different between femoral and nonfemoral sites for double-lumen vascular catheters during continuous renal replacement therapy 6
• However, the risk of catheter-related colonization is higher in patients older than 65 years and weighing >90kg, especially with femoral sites 6
• Mechanical factors, such as multiple renal veins and organ retrieval surgery complications, are considered the most common causes of transplant renal vein thrombosis 4
• The diagnosis of transplant renal vein thrombosis depends on a high index of clinical suspicion and duplex ultrasonographic scans, with venography remaining the criterion standard 5