Abstract
Background:
Tunneled central venous catheters (TCVCs) remain an important component of hemodialysis vascular access despite recognized complications including infection, thrombosis, and catheter dysfunction. Although multiple catheter designs and technologies are available, there is limited comparative evidence supporting the use of one catheter type over another. Current KDOQI vascular access guidelines acknowledge this lack of evidence and recommend that catheter selection should rely on clinician judgment. This study aimed to explore how clinicians select dialysis catheters in routine practice and identify factors influencing decision-making.
Methods:
A standardized questionnaire was developed to capture clinician perspectives regarding dialysis catheter use. The survey was distributed internationally using SurveyMonkey via QR codes and web links through professional networks including the Vascular Access Society and the Dialysis Catheter Collaborative. Participation was voluntary and anonymous. The survey was open between January and March 2026. Questions addressed respondent characteristics, practice setting, catheter insertion volume, factors influencing catheter selection, perceived complications limiting catheter lifespan, confidence in current catheter technologies, and priorities for future research. Responses were analyzed descriptively.
Results:
A total of 111 clinicians from 37 countries responded. Participants included nephrologists/interventional nephrologist (n = 47; 42.3%), vascular surgeons (n = 44; 39.6%), interventional radiologists (n = 15; 13.5%). Catheter performance (63%), availability (42.3%), and ease of insertion (39.6%) were the most frequently cited factors influencing catheter choice. Thrombosis or fibrin sheath formation was considered the complication most often limiting catheter lifespan (52.3%), followed by infection (29.7%). Confidence in current catheter technologies to prevent complications was generally moderate to low.
Conclusions:
Dialysis catheter selection is primarily influenced by practical considerations rather than strong comparative evidence. These findings highlight a substantial evidence gap and support the need for robust comparative clinical studies to guide catheter choice and improve outcomes for patients requiring TCVC.
Introduction
Tunneled central venous catheters (TCVCs) remain an important component of hemodialysis vascular access despite well-recognized complications. Traditionally considered a “necessary evil,” there has been a more recent shift towards their use being reasonable in certain patients.1,2 TCVC can be considered in patients with needle phobias, low life expectancy, and multiple failed attempts at vascular access.
There are multiple different dialysis catheter designs available yet there is little data to support the use of one configuration of catheter over another. Following extensive review into the evidence, the most recent KDOQI guidelines were unable to make a recommendation regarding TCVC configuration or materials and suggested:
The choice of tunnelled HD CVC type and design be based on the clinicia’s discretion and best clinical judgment. (Conditional Recommendation, Low Quality of Evidence)
2
To further examine the basis of clinicians’ choice of TCVC, a survey of practicing clinicians was performed with an aim of understanding how clinicians select dialysis catheters in clinical practice, including the factors that influence decision-making, device preferences, and perceived barriers or priorities.
Methods
A standardized questionnaire was developed by the authors (NI/BR/JR/TJ) to capture clinician perspectives regarding dialysis catheter use. This was distributed using SurveyMonkey via QR code and web link through professional networks including the Vascular Access Society and the Dialysis Catheter Collaborative group (Supplementary Appendix).
Participation was voluntary and anonymous, (although contributors could waive anonymity based on inclusion in the dialysis catheter collaborative).
The survey remained open for 2 months between January and March 2026.
The questions are included in Table 1 and contain details about the respondents, attitudes to TCVC choice, TCVC features, and confidence in TCVCs in preventing certain complications.
Questions included in survey.
Statistics were collated and summarized descriptively and graphically as responses with percentage. Where a 0–100 sliding scale was used to record confidence, the results were shown as a mean with standard deviation.
Results
A total of 111 responses were received from 37 countries in the Americas, Europe, Africa, Asia, and Australasia (Table 2).
Distribution of respondents: Country (number of respondents)
Respondents (n = 111) represented several specialties involved in vascular access care including nephrologists/interventional nephrologist (n = 47; 42.3%), vascular surgeons (n = 44; 39.6%), interventional radiologists (n = 15; 13.5%), and other (n = 4; 3.6%). Where “other” was chosen the respondents were from general surgery, nurse practitioner, dialysis tech, and VA nurse. One respondent (n = 1; 0.9%) was an acute/critical care medicine practitioner (see Figure 1).
Primary speciality of respondents.
The volume of practice was based on number of TCVC inserted per month with <5 in 30.6% (n = 34), 5–10 in 36% (n = 40), 11–20 in 17.1% (n = 19), and >20 in 16.2% (n = 18; see Figure 2).
Volume of activity (catheters inserted per month).
The TCVC brands used included symmetrical tip and split tip catheters and dual catheters.
The question addressing factors most influencing the choice of TCVC allowed up to three selections. Performance (flow rates, reliability) score most frequently with 63.0% (n = 70) followed by availability (what is on the shelf) 42.3% (n = 47) and ease of insertion 39.6% (n = 44).
Cost or procurement policy (26.1%; n = 29) and personal familiarity (25.2; n = 28) were similar as were thrombosis resistance (24.3%; n = 27) and infection resistance (24.3%; n = 27).
Evidence from studies and guidelines was considered influential by 19.8% (n = 22) and only 10.8% (n = 12) had a manufacturer or brand preference as an influencer (see Figure 3).
Factors influencing coice of catheter.
The responses to the inquiry about the main consideration when comparing TCVC, with a single response from a drop-down list, are shown in Figure 4.
Main considerations when comparing catheters.
In order of responses device handling characteristics (39.6%), was the most common response, published evidence in 16.2%, cost in 10.8%, peer recommendation in 9.9%, guidelines 9.9% and company branding in only 0.9%.
Other was the response for 12.6%. This varied in the free text responses but included referring clinician preference and recommendation from dialysis units.
Responses to the question about complications limiting TCVC use included thrombosis/fibrin sheath in over half (52.3%), followed by infection (29.7%), malposition/technical issues (15.3%), and patient factors including comorbidities in 2.7% (see Figure 5).
Complications limiting catheter lifespan.
Using a linear scale from 0 to 100 (not confident to fully confident), questions were asked regarding confidence in the current catheter technology to prevent complications (mean ± SD).
The scores were 53.8 ± 25.7 for preventing line infection, for CLBSI50.6% ± 26.4, 52.2 ± 26.7 for dysfunction, 45.5 ± 24.7 for prevention of thrombosis, and 38 ± 21.9 for prevention of fibrin sheath (see Figure 6).
Confidence in current cathter technology.
The survey invited an opinion on what types of studies are required to compare the features of TCVC.
Multi center randomized controlled trials scored highest at 65.4% with almost equal response to real world comparative studies (64.5%). Lower ranks were registries 37.3%, Observational series 16.4%, single center randomized studies 9.0%. Non-clinical studies such as animal studies and benchtop/in vitro studies scored low at 6.4% and 4.6%, respectively. Free text (see Figure 7) responses were: all types of studies from two respondents and none from one respondent.
Studies required to compare catheters.
Discussion
The survey was designed to be simple and practical to get a sense of current real-world consideration for TCVC use. Over the 2-month period the online survey was completed by 111 clinicians internationally representing all continents and wide geographic spread.
The clinicians’ responses represented the target group providing care to patients needing dialysis access, being largely composed of nephrologists, vascular and transplant surgeons, and interventional radiologists with a reasonable spread of monthly activity using available types and brands of TCVC.
Guidelines were only considered by a fifth and catheter performance (flow rates, reliability) was the most common answer. Although thrombosis resistance and infection resistance were assessed lower, they were considered the complications that limited catheter lifespan subsequently.
Not surprisingly, device availability scored highly and reflects that choice is likely limited for many clinicians. This is supported by a quarter of respondents considering cost or procurement policy as a factor.
Ease of insertion as factor in choice of catheter may reflect differences in responsibility for inserting catheters rather than maintaining catheters. Likewise for comparisons of TCVC the high response of device handling characteristics would support the priorities of experience with catheters at insertion rather than longer term management.
The survey was unable to distinguish between the duration of involvement or continuity of care by the respondents, both issues that could alter choice of catheter.
Brand preference or manufacturer preference was not a major influence.
Consistent with KDOQI guidelines, the low rates of considering published evidence in comparing TCVC most likely reflects the lack of suitable evidence rather than ignoring or disregarding available evidence.
The confidence of current technology to prevent complications was low, with most responding as “neither confident nor not confident.” This points to dissatisfaction with current catheter technology to address factors that respondents had rated as important in previous questions about influences, comparators, and complications limiting catheter lifespan (i.e. dysfunction, line infection, CLABSI, thrombosis, and fibrin sheath formation).
As thrombosis and fibrin sheath were seen as the main complications that limit TCVC lifespan it is not surprising that respondents felt the least confidence in available devices in addressing this common issue.
It would seem from this survey that this is an area requiring the most attention for catheter research and innovation.
There are limitations of this study. The respondents may be a subset of clinicians with an active interest in the area and not fully representative. In addition, single respondents from a country or region are unlikely to represent all views and may have different practices to others. The purpose of this survey was to get a broad idea of these issues and further studies with more stringent methodology (e.g. Delphi process) will be required to examine these responses further.
In addition, choice may be limited based on health system factors such as procurement policies and resource constraints that affect availability of different catheters.
Overall, the survey pointed to a deficit in evidence to allow informed decisions making in TCVC choice. Respondents not surprisingly felt that high quality studies were required with multi-center RCTs rating highly although real world comparative studies scored almost as highly.
Unfortunately, national registries do not report catheter type or brand so retrospective comparative analysis cannot be performed.
Innovation in catheter design and function has been stymied as catheters are maligned for having bad outcomes and strategies are in place mainly to reduce catheter use rather than to improve outcomes. The lack of quality data on dialysis catheters is somewhat surprising based on the global hemodialysis market having an estimated value of $736 million in 2020 and predicted to reach $1.16 billion in 2023. 3
Even though catheters have been vilified, their use has not declined over time, and >75% of patients will require a dialysis catheter during their dialysis lifetime. Therefore, the use of TCVCs may be an underestimate based on changes in the approach to dialysis access advocated by the philosophy of “right access for the right patients at the right time for the right reasons” rather than historic fistula first approaches. 4
Likewise, a recent study highlighted that current practice regarding central venous catheter management across the UK is not standardized and called for studies generating evidence in the field. 5
The goal of research to generate more meaningful data that will support clinicians in which type of TCVC to use is required and rather than simply aiming to reduce complications by reducing use the shift should be to improve the outcomes when a TCVC is used.
Supplemental Material
sj-docx-1-jva-10.1177_11297298261451044 – Supplemental material for Decision making in vascular access: International perspectives on dialysis catheter choice
Supplemental material, sj-docx-1-jva-10.1177_11297298261451044 for Decision making in vascular access: International perspectives on dialysis catheter choice by Nicholas Inston, Brian Rifkin, Joris Rotmans, Tamara Jemcov and on behalf of the Dialysis Catheter Collaborative in The Journal of Vascular Access
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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References
Supplementary Material
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