What is the difference between a permanent catheter (perm cath) and a femoral line for vascular access?

Permanent Catheter vs Femoral Line for Vascular Access

A tunneled cuffed catheter (permanent catheter/PermCath) placed via the right internal jugular vein is superior to a femoral line for hemodialysis access, offering lower infection rates, better blood flow, and longer functional duration, though both should only serve as temporary bridges to arteriovenous fistula or graft creation. 1

Key Differences Between Access Types

Tunneled Cuffed Catheters (PermCath)

• Designed for medium to long-term use (weeks to months), with tunneling under the skin and a subcutaneous cuff that reduces infection risk 1, 2
• Preferred insertion site is the right internal jugular vein, which provides the most direct trajectory to the right atrium and lowest complication rates 1
• Catheter tip must be positioned in the right atrium (confirmed by fluoroscopy) for optimal blood flow rates of 300-350 mL/min 1, 2
• Lower infection rates compared to femoral catheters: exit site infection rate of 5.2 per 1000 catheter-days and septicemia rate of 2.86 per 1000 catheter-days 3
• Actuarial survival rates: 82% at 1 year, 56% at 2 years, 42% at 3 years 3

Femoral Lines (Non-tunneled Femoral Catheters)

• Should only be used in bed-bound hospitalized patients for less than 5-7 days 1, 2
• Associated with significantly higher infection and thrombosis rates compared to internal jugular access 1
• Femoral catheters must be 24-31 cm in length to reach the inferior vena cava and deliver adequate blood flow (≥300 mL/min); shorter catheters frequently cannot achieve this 1
• Higher colonization rates and catheter-related bloodstream infections compared to jugular or subclavian sites in adults 1
• Increased risk of deep venous thrombosis and painful leg swelling requiring catheter removal 1

Clinical Decision Algorithm

When to Use Tunneled Cuffed Catheter (PermCath):

• Bridge access while arteriovenous fistula matures (typically 1-6 months) 1, 2
• Patients with failed or exhausted conventional vascular access options 1, 4
• Patients requiring immediate hemodialysis with no mature permanent access 1, 2
• Elderly patients with cardiovascular disease where fistula creation is not feasible 3
• Maximum acceptable duration: Less than 10% of chronic hemodialysis patients should remain on catheters beyond 3 months 1

When Femoral Access May Be Considered:

• Emergency situations with severe coagulopathy or thrombocytopenia where hemostasis is easier to achieve 1
• Complete occlusion of superior vena cava system with no other options 1
• Bed-bound hospitalized patients requiring access for less than 1 week 1, 2
• Never use femoral access without first considering lower extremity fistula formation 1

Critical Pitfalls to Avoid

Avoid Subclavian Vein Access

• Strongly contraindicated for hemodialysis catheters due to high risk of central venous stenosis that can preclude future permanent access creation 1, 2
• Use only when no other option exists 1

Catheter Placement Errors

• Never place long-term catheters on the same side as a maturing arteriovenous fistula to preserve venous return 1, 2
• Avoid left internal jugular vein due to poor blood flow rates, high stenosis/thrombosis rates, and potential compromise of left arm venous return 1
• Always use ultrasound guidance for catheter insertion 1, 2
• Obtain chest radiograph before first use of internal jugular or subclavian catheters 2

Duration Mistakes

• Any short-term catheter must have a plan for removal or conversion to tunneled catheter within 1 week 1, 2
• Prolonged catheter use increases mortality by 51% and severe infection by 130% compared to arteriovenous fistula/graft 2
• Chronic catheter use (>3 months) compromises dialysis adequacy, leading to increased morbidity and mortality 1

Complications Comparison

Tunneled Cuffed Catheter Complications:

• Sepsis requiring removal: 2-3% of cases 4, 3
• Catheter thrombosis: 6% of dialysis sessions, usually manageable with thrombolytics 3
• Central venous stenosis risk with prolonged use 1
• Lower blood flow rates (300-350 mL/min) compared to fistulas/grafts 1

Femoral Line Complications:

• Higher infection rates (order of magnitude greater than tunneled catheters) 1
• Higher occlusion rates requiring more frequent interventions 1
• Increased deep venous thrombosis risk 1
• Patient discomfort and mobility limitations 5
• High contamination risk at groin exit site 1

Material and Design Considerations

• Silicone and polyurethane are preferred catheter materials 2
• Antimicrobial-coated catheters (minocycline/rifampin) reduce catheter-related bloodstream infections 2
• Catheters must achieve blood flow rates of 350 mL/min at prepump pressures ≤-250 mm Hg 1, 2
• Routine scheduled catheter replacement does not reduce infection rates and is not recommended 2