Vascular Access Considerations for Therapeutic Apheresis Procedures

Abstract

The success of therapeutic apheresis (TA), similar to hemodialysis, depends on the integrity of the extracorporeal circuit as well as a reliable vascular access. However, unlike hemodialysis, which requires high flow of blood around 400 mL/minute through the extracorporeal circuit for effective clearance, TA is usually carried out with much lower blood flow rates (<100 ml/minute). Therefore, even peripheral venous access can be considered for TA. The main determinants of the choice of vascular access for TA is the duration of the planned treatment and, to a certain degree, the indication for its use. While peripheral venous access and temporary central venous catheters are sufficient for short-term TA, tunnelled catheters and arteriovenous fistulae (AVF) are usually used for long-term treatments. Because of the large body of evidence in the hemodialysis literature on the advantages of AVF over tunnelled catheters and AV grafts, they should be considered as the preferred access for chronic TA as well. However, advance planning for the care of AVF after creation is of critical importance especially since many of the healthcare providers dealing with TA are less familiar with caring for AVF than nephrologists and dialysis nurses. In this article we first review the similarities and differences between HD and TA procedures. The pros and cons of different vascular access options are discussed next. Finally, we have included a list of recommendations on maintenance of AVF created for TA based on our own experience.

Vascular access for therapeutic plasma exchange

“…Thus, the latter is only used when there is not an option for two vascular access sites. In addition, the urgency of the procedure, the total procedural time, the plasma volume(s) exchanged, the frequency of the procedure, and the duration of the treatment (days or months) also will impact the choice of vascular access …”

Is peripheral access for apheresis procedures underutilized in clinical practice?—A single centre experience

“…These include access via a peripheral vein, temporary central venous catheter (CVC) access (via subclavian, jugular or femoral veins), placement of indwelling double‐lumen ports (e.g. Vortex), or the creation of arteriovenous fistulas . A broad consensus is that, where possible, a peripherally placed device should be the first choice for elective therapeutic apheresis procedures (TAs).…”

Performance characteristics of the PowerFlow apheresis port: Early experience

“…Our nursing staff were able to access the port on the first attempt in all TPE procedures. Inlet and plasma flow rates are comparable to flow rates obtained using conventional apheresis catheters, and all TPE were completed with a minimum of alarms or interruptions. We have not had to use a thrombolytic agent to maintain the patency of this new device.…”

“…A second generation catheter‐over‐needle implantable venous access port performs as well as conventional large‐bore catheters in therapeutic plasma exchange . The potential advantages of an implantable device for outpatient therapeutic apheresis have been well described.…”