Both DSA-guided and ultrasound-guided procedures are commonly used for TDC placement. A meta-analysis published in the Cochrane Database concluded that ultrasound-guided procedures are superior to blind puncture. However, unlike ultrasound-guided procedures, there is no clear evidence to support that one of the DSA-guided and ultrasound-guided approaches is superior to the other. The 2019 edition of the KDIGO guidelines states, “Overall, KDOQI cannot suggest the use of image-guided CVC insertion based solely on reducing complication rates, because the complication rates are not significantly different with ultrasound-guided versus traditional placement techniques. Given the strength of the available evidence, further high-quality studies on image-guided CVC insertions and complication rates are needed.”[4]
The existing literature mainly reports on TDC placement under DSA or ultrasound guidance separately. For example, studies by Caridi et al.[11] and Sayani et al.[12] have reported the effectiveness and safety of surgery under DSA guidance. Aurshina et al.[13] reported on 1065 patients who underwent surgery under ultrasound guidance, among whom there were no cases of severe complications such as hemothorax or pneumothorax, with only 2 cases of arterial injury and 3 cases requiring post-operative revision due to incorrect catheter placement. Sohail et al.[14] reported on 25 cases during the COVID-19 pandemic where institutions that routinely used DSA for placement changed their approach to ultrasound guidance, achieving a 100% success rate with post-operative blood flow and ultrafiltration meeting the requirements of dialysis prescriptions.However, there is currently a lack of studies comparing the placement of hemodialysis catheters under DSA and ultrasound guidance. The references for DSA and ultrasound guidance for TDC placement surgery in KDIGO 2019 are sourced from an article published by Yevzlin et al.[15] in 2007, which only reported higher surgical success rates and lower costs under DSA guidance. The studies by Obialo et al.[16] and Chang et al.[17] reported that surgery under DSA guidance does not have an advantage over surgery under ultrasound guidance, and may even be associated with lower catheter patency rates and higher surgical complications such as infection and bleeding. However, the lower catheter patency rate in the DSA group does not align with our clinical knowledge, which may be due to non-random selection of patients for DSA or ultrasound-guided surgery, with patients opting for DSA surgery potentially having worse baseline conditions.Therefore, in our study, we used PSM to balance as many baseline variables as possible, including demographics, laboratory results, surgical information, and hemodialysis information, in order to avoid bias. Previous studies have mainly focused on the success rate of surgery, complications, and patency of the catheter after surgery. However, one major goal of placing a hemodialysis catheter is immediate use, so we included data on the first hemodialysis session post-surgery as the primary outcome measure. Furthermore, previous studies have been conducted in developed countries, but the question of whether surgery guided by DSA is necessary is even more important for developing countries, where there is a shortage of medical resources.
In this study, we compared the effectiveness, safety, and cost of hemodialysis catheter placement using DSA guidance and ultrasound guidance. The results showed that although the DSA guidance group had higher surgical costs, the proportion of catheter tip placement in the appropriate position was significantly higher compared to the ultrasound guidance group. Additionally, the occurrence of premature cessation of dialysis during the first postoperative blood dialysis session was lower in the DSA guidance group.By conducting logistic regression analysis on the occurrence of premature cessation of dialysis, we identified age, catheter type, placement technique, and dialysis anticoagulant type as independent predictive factors. Furthermore, through secondary analysis of patients with different catheter tip positions, we found that the advantage of the DSA group may be based on more accurate catheter tip placement. Some literature reports that intracavitary ECG can guide the insertion of the catheter tip to the appropriate position during the procedure[18–20], and the use of cardiac ultrasound in combination with saline injections has also demonstrated the ability to locate the catheter tip in recent studies[2], suggesting that regardless of the method used, if the surgeon can ensure proper catheter tip placement, DSA may not be necessary.Based on the results of the logistic analysis of adverse events leading to premature discontinuation of hemodialysis, we believe that DSA-guided hemodialysis catheter placement can be considered more preferable in patients who are advanced in age or unable to use anticoagulants in hemodialysis. Additionally, it may also be beneficial to utilize more costly but efficient hemodialysis catheters.
DSA devices are not easily accessible in developing countries, and healthcare funding is also very limited. Even after the introduction of centralized procurement policies for contrast agents used in DSA procedures in China, the costs of DSA-guided surgeries are still significantly higher than those guided by ultrasound[22]. However, our research reveals the advantages of DSA-guided surgeries, providing a basis for determining when to appropriately use DSA procedures. A major strength of this study is the use of PSM to balance between-group differences. Additionally, the selection of DSA and ultrasound procedures in our institution is primarily based on scheduling in the DSA operating room rather than subjective decisions by doctors, which significantly reduces selection bias compared to previous studies. However, this study primarily focuses on immediate postoperative catheter function and lacks long-term data on catheter performance. Furthermore, due to sample size limitations, we did not conduct in-depth research on other catheter placement sites except for the right jugular vein, which requires larger-scale studies for further exploration.