Open Journal of Nephrology, 2013, 3, 152-160 Published Online September 2013 (
Surface Treated Catheters for Vascular Access—Useful?
Rolf Bambauer1*, Ralf Schiel2, Carolin Bambauer3, Reinhard Latza4
1Institute for Blood Purification, Homburg, Germany
2Inselklinik Heringsdorf GmbH, Seeheilbad Heringsdorf, Germany
3Main Hospital Darmstadt, Darmstadt, Germany
4Laboratorium of Medicine, St. Ingbert, Germany
Email: *
Received July 1, 2013; revised July 29, 2013; accepted August 11, 2013
Copyright © 2013 Rolf Bambauer et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Catheter-related infections (CRI), thrombosis, and stenosis are among the most frequent complications
associated with catheters which are inserted in vessels as vascular access. These problems are usually related to the
handling of the staff, the catheter materials, and the surface properties of the catheter. To mitigate such complications
surface treatment process of the outer surface, such as ion beam assisted deposition is investigated in a retrospective
study from 1992 to 2007, to prove if the surface treatment of the catheters is a sufficient solution. Methods: This study
(1992-2007) evaluated silver coated and non-coated implanted large-bore catheters used for extracorporeal detoxifica-
tion. In 159 patients, 54 patients received a silver coated catheter (Spi-Argent, Spire Corporation, Bedford, MA, USA)
and 105 patients, an untreated catheter served as controls. The catheters were inserted into the internal jugular or sub-
clavian veins. After removal, the catheters were cultured for bacterial colonization using standard microbiologic assays.
They were also examined using a scanning electron microscope (SEM). Results: The silver coated catheters showed a
tendency towards longer in situ time. The microbiologic examinations of the catheter tips were in both catheter types
high positive, but not significant. Conclusion: The silver coated catheters showed no significant reduction in infection
rate by evaluation of all collected data in this retrospective study. There was no association between both catheters in
significantly reducing patient discomfort. Other surface treatments which include the outer and inner surface are neces-
sary. New developed catheter materials such as the microdomain structured inner and outer surface, as an example, are
considered more biocompatible because they mimic the structure of natural biological surface.
Keywords: Surface Treated Large Bore Catheters; Hemodialysis; Apheresis; Ion Been Assisted Deposition (IBAD);
Microdomain-Structered Surface (PUR-SMA Coated Catheter)
1. Introduction
Since the first introduction of large-bore catheters for
acute hemodialysis in 1961 by Shaldon et al. [1], many
problems with handling, materials, and contamination of
these catheters have arisen. Nevertheless, vascular cathe-
ters have become essential tools for management of hos-
pitalized or chronically ill patients requiring intensive
medical treatments [2]. The increased insertion of such
devices has been accompanied by a corresponding in-
crease in complications, such as bloodstream infection
and thrombosis [3]. Infections are particular concern, be-
cause they can appear at any time, even years after im-
plantation, and are not material dependent. They are usu-
ally attributed to microbial colonization of the skin or
handling of the catheters by attending staff. Complication
rates due to venous catheter-relates infection are reported
to range from 34 to 40 percent [4,5]. Despite recent tech-
nical innovations in hemodialysis, problems related to
temporary or permanent vascular access have found no
satisfactory solutions. Temporary vascular access is par-
ticularly problematic.
Catheterization of the femoral vessels produces more
complications than the catheterization of the superior
vena cava (SVC). Cannulation of the SVC versus the
subclavian vein is difficult to implement and involves a
high complication rate [6]. Using the infraclavicular
catheterization technique is often difficult to push the
large-bore catheter under the clavicle. Because of the
anatomical position of the subclavian vein, perforation is
more likely with a rigid, large-bore catheter, apart from
the danger of causing a pneumothorax or a hemathorax
*Corresponding author.
opyright © 2013 SciRes. OJNeph
Therefore, Bambauer et al. have introduced the inser-
tion of large-bore catheters in the superior vena cava
rather than in the internal jugular or the subclavian veins
[11,12]. Dialysis catheters are used for vascular access in
65% of incident hemodialysis (HD) patients, and in 25%
of the prevalent HD populations [13]. Today, the first
choice of vascular access is the vena cava superior over
the internal jugular vein.
Catheter-related bacteremia is a major cause of mor-
bidity among hemodialysis patients. Treatment with sys-
temic antibiotics alone without removal of the catheter
fails to definitely eradicate the infection in most patients
[14]. Catheter-related bacteremia must be managed by
either catheter removal with delayed placement of a new
catheter or management of the infected catheter with a
new catheter over a guide-wire and additional systemic
antibiotic therapy. These catheter-related complications
are contributing factors to increasing cost of medical care.
They are responsible for patient readmissions and longer
hospital stays as well as patient discomfort, morbidity,
and occasional mortality.
The source of catheter-related bacteremia is in most
patients a bacterial biofilm that forms in the catheter lu-
men or on the outer surface. This biofilm, most consist-
ing of staphylococcus aureus, cannot be destroyed or
eliminated by a systemic antibiotic therapy because of
antimicrobial resistance [15]. Bacteriae could most of the
time colonize rough surfaces [16]. The combination of
rough surfaces and protein deposits should be an ideal
situation for the colonization of bacteria. The bacteria
could produce and become covered with a slime layer, in
which case antibiotic drugs have no influence on the
bacteria. The bacteria under the slime layer use the or-
ganic substances of the catheter material for their me-
tabolism. The toxins of the bacteria can penetrate the
slime layer and enter the patient blood provoking a
catheter infection [16]. Biofilm is a microbial derived
sessile community characterized by cells that are irre-
versibly attached to a substratum or interface to each
other, embedded in a matrix of extracellular polymeric
substances that have produced [17]. Such a biofilm can
be the origin of fibrin sheath formations leading to
catheter dysfunction due to blood reducing and to blood
disturbances. The therapy must be to remove the catheter
immediately, or exchange it over a guide-wire with a
new catheter and additional systemic antibiotic therapy.
Biocompatibility of synthetic materials is another ma-
jor problem. The interaction of blood with a synthetic
surface causes coagulation and activation of the com-
plement system. This can lead to the adsorption of vari-
ous proteins and the formation of a layer of protein on
the synthetic surface. Thrombocytes, other cells and bac-
teria adhere to this layer of protein so that thrombi may
form which can lead to blood flow disturbances and
catheter dysfunction [18].
To influence catheter-related bacteremia different new
developments are available today, such as new catheter
materials, coating of the catheter surface with antibiotic-
heparin, or silver and silicone, cuffs on the outer surface,
catheter for tunnelling, installation of an antibiotic-anti-
coagulant lock into the catheter lumen after the HD, etc.
[14,19,20]. The first results with available catheters
which coated on the outer surface with silver or silicone
were encouraged [18,21].
In a retrospective study from 1992 to 2007, outer sur-
face treated catheters with silver versus untreated cathe-
ter in 159 patients, who needed a large-bore catheter, were
investigated. The results of a preliminary study from
2001, which showed 75% decline in the infection rate
with the surface treated catheters cannot be confirmed
with the present study. One reason may be that on the
surface treated catheters only the outer surface was
coated with silver and the possibility of contamination by
the handling during the extracorporeal treatments.
Therefore, new materials and surface treatment tech-
nologies are needed to save health care costs for hemodi-
alysis catheters, to reduce infection rates and thrombus
formations and to help improve the patients’ outcome.
The handling of the catheter by the attending staff must
be improved and done after the guidelines of different
medical communities [22]. In this study, the authors try
to give an overview of the surface treated catheters and
show a new technique of microdomain-structured surface
catheters (PUR-SMA coated catheters, (Gambro, Ger-
many) as an example if these technologies are useful in
reducing catheter-related infections and thrombogenic-
2. Catheter and Material
All available single-, double-, or triple-lumen catheters
have some deficiencies depending on the material. Not
all catheters are radiopaque. No problem is experienced
with the polyurethane catheters after the incorporation of
contrast media; however, the latter material may affect
catheter durability when using Teflon. This problem was
overcome by making a thicker catheter wall, but this
caused endothelial irritation and early thrombus forma-
tion [23]. Catheters providing radio contrast are not ab-
solutely necessary however, because their position can be
controlled more simply and gently with an intra-atrial
electrocardiogram (ia-ECG) lead [24]. The three most
important criteria of any catheter material are a good
tolerance, a low thrombogenicity, and a low infection
Rarely do the material properties perfectly match
every requirement in a given application and biomaterials
are no exception. Therefore, it often becomes necessary
to strike a compromise so that a material has acceptable
Copyright © 2013 SciRes. OJNeph
properties. For example, in a product such a hemodialy-
sis catheter, which demands both good flexibility and
low surface friction, the best candidate may be a slippery,
less flexible material rather than a more supple one with
unacceptable high friction [25].
The importance of surface-engineered biomaterials has
been recognized by major medical device companies,
because surface modification processes can reduces the
rate of infection, thrombogenicity, and other cathe-
ter-related complications without adversely affecting the
basic design function of catheters.
Although the field of surface-engineered biomaterials
is still essentially in its infancy, the range of services
currently offered by surface treated vendors is varied and
continually expanding. Surface modification processes
can reduces the rate of infection, thrombogenicity, and
other catheter-related complications without adversely
affecting the basic design function of catheters. Exam-
ples include conventional coating process such as de-
pending and spraying: vacuum-deposition techniques
(e.g., sputtering), and surface modification approaches
such as diffusion (e.g., nitriding, carburizing), laser and
plasma processes, chemical plating, grafting or bonding,
and bombardment with energetic particles (as in plasma
immersion or ion implantation). Of the available tech-
niques, those based on ionised particle bombardment
have been particularly successful in biomaterial surface
modification, primarily because they combine versartility
and low-temperatures processing with superior control,
reliability, and reproducibility [25,26].
The ion beam-based technology used for the treatment
of catheters covered herein is ion beam-assisted deposi-
tion (IBAD: Spi-Argent®, Spire corporation, Bedford,
MA, USA) [21,25,27]. The process is typically per-
formed at low temperature under high vacuum. The af-
fected layer in the typical films deposited by the IBAD
process, is in the order of 1 μm or less vacuum- compati-
ble catheter materials may, therefore, be treated without
adversely affecting bulk mechanical properties. The
IBAD is line-of-directly: however, parts with compli-
cated geometries may be manipulated for uniform cov-
erage of all surfaces [26].
Silver has been indicated as a good prospect for an in-
fection-resistant coating material for catheters. The pro-
blem previously preventing the use of silver on catheters
has been the inability to deposit adherent films of silver
on flexible polymeric substances. The IBAD process
permits the formation of silver coatings at a relatively
low temperature with extremely good adhesion that pre-
vents delamination of the film during extended exposure
to bodily fluids. The IBAD silver-deposited film has a
low coefficient of friction, is highly uniform, and has a
cytotoxicity test and the USP Systemic Injection Test.
Excellent results were obtained in both tests [25,26,
Another possibility shows the new developed catheter
material, the microdomain structured surface (PUR-SMA
coated catheter, Gambro Germany) [23]. Microdomain
surfaces are considered the most biocompatible because
the mimic the structure of natural biological surfaces.
Microdomain structures are used to match the multiple
requirements for improved catheter surfaces, that is re-
duced thrombogenicity and improved antimicrobial
properties. An SMA-modified polyurethane coating con-
sists of hydrophobic and hydrophilic microdomain in
range below 50 nmm. Up to 50 percent of the molecule is
presented to the surface and creates microdomain struc-
tured surfaces. If the domains are below a critical dimen-
sion of approximately 100 nmm, theoretical considera-
tions indicate that interaction with proteins, blood cells,
or even bacteria will be unstable and therefore not occur
as frequently as on non-microdomain structured surfaces.
3. Patients
In the retrospective study of a single center from 1992 to
2007, all catheter data of all included patients were col-
lected from the patients´s charts. The inclusion criteria
were patients >18 years of age who required a large-bore
catheter (in-/outpatient), were free of bacteremia and
provided informed consent. The exclusion criteria were a
pregnant or lactating female, a hypersensitivity of silver
and a bacteremia at the time of catheter insertion. An
IRB approval was in 1992 not necessary [30]. After the
patients had given their consent to this study, the physi-
cian chose the catheter which he inserted after a ran-
domization of one surface treated catheter, and than two
untreated catheters, and so on.
In the study a total of 159 patients (age 66.5 ± 13.2
years, female n = 94 (59%)) are involved. Large-bore,
single-lumen catheters were inserted percutaneously in
the internal jugular or subclavian veins. The percutane-
ously catheterization was necessary in renal failure be-
cause of acute kidney injury (AKI) for hemodialysis due
to cardio-vascular disease, postoperative AKI etc., and in
end-stage renal disease (ESRD) because of clotting fis-
tula, septicaemia, abscess and catheter thrombosis and
faults in the catheter material (n = 138 (86.8%)). Further
indications of catheterization were access problems in
patients with familial hypercholesterolemia (n = 12
(7.5%)) under LDL-apheresis treatment, different indica-
tions for plasmapheresis (n = 7 (4.4%)) and in 2 patients
with carcinoma (n =2) (1.3%)).
In 54 patients (34%) a catheter with silver coating on
the outer surface (Spi-Argent®, Spire, Bedford, MA,
USA) was inserted and 105 patients (66%) received un-
treated catheters after a randomization of one treated and
two untreated catheters. Patients with untreated catheters
were younger (62.2 ± 16.2 versus 68.8 ± 10.7, p = 0.003)
Copyright © 2013 SciRes. OJNeph
but there were no differences between the groups re-
garding gender distribution, diagnosis, or extracorporeal
detoxification methods. Catheterization must always be
done under aseptic conditions (wearing sterile gown each
time, sterile gloves, mask etc). The patient should be
correctly positioned, according to the vascular access
point to be used and should be given adequate local an-
The catheters were placed by nephrologists after the
Seldinger technique and/or under fluoroscopic guidance.
Before percutaneous insertion each patient skin was dis-
infected using a consistent method, and a sterile skin
smear was taken for microbiologic examination, and than
the catheter was inserted. Before fixing the catheter with
a suture, its position (particularly the catheter tip) should
be checked with a normal radiological control and/or
with an ia ECG [24]. Before and after the extracorporeal
detoxification procedures, the staff worked under sterile
conditions with disinfection and sterile gloves etc. In
long-term catheters, a blood smear was taken every 4
weeks or earlier if an inflammation was seen on the in-
sertion side of the catheter to screen for bacteria. Cathe-
ters were removed either when other vascular access
routes became available or when serious infections de-
veloped, or if the catheter was not longer necessary.
Before catheter removal, a skin smear was taken. The
catheters were then removed under sterile conditions, and
the tip was examined bacteriologically. The remainder of
the catheter was rinsed in physiological saline solution
and fixed in a solution of phosphate buffer containing
glutaraldehyde and formaldehyde for histological inves-
4. Statistical Analysis
Statistical analysis was performed using the Statistical
Package for Social Sciences (SPSS 13.0). All continuous
data are presented as mean ± standard deviation (SD) or
if the data showed no normal distribution, as median and
range. Dichtomous data were presented as a number (n)
or in percent (%). Univariante, unadjusted analysis were
performed with the independent samples t-test, chi-
square test, Fisher´s exact test for frequencies at or below
5 and the Wilcoxon´s rank sum test. Pearson’s correla-
tion coefficient was calculated and multivaria’s analysis
was used to evaluate the presence of associated variables.
Significance was defined at the 0.05 level.
5. Results
The median in situ period untreated and silver coated
catheters were 138.9 (range, 1 - 1,845) and 115.0 (range,
4 - 1,348) days respectively (p = 0.653). Calculating the
in situ times after classification for different age groups,
it will be overt, that in patients older than 45 years in situ
times were significantly longer (p < 0.01). Comparing
the in situ times of untreated catheters after classification
for in situ times, there was a tendency towards longer in
situ times for the silver coated catheters. In the median
catheters were used for 44 (range, 1 - 670) treatment ses-
sions. Untreated catheters were used for 51 (range, 1 -
625) treatments, silver coated catheters for 39 (range, 1 -
670, p = 0.849) treatment sessions [30].
Performing microbiologic examinations of the catheter
tips some differences were overt. Of the untreated cathe-
ter tips 55 % cultured positive for bacteria. Of the cul-
tures in patients with surface treated catheters 52 % were
positive, not significantly lower. Although untreated
catheters showed a lower infection rate with Staphylo-
coccus aureus, in treated catheters the infection rate with
Staphylococcus epidermidis, pseudomonas, and others
such as saphrophytes was not significantly lower (Table
1). A catheter thrombosis rate was not proved in the re-
moved catheters.
Performing multivariante analysis there was a strong
association between catheters’ in situ period (R-square =
0.96), the number of treatment sessions (ß = 0.97, p <
0.001) and patients’ age (ß = 0.095, p = 0.002). There
was no association between the in situ time and silver
coated/untreated catheters, results of the bacteriological
examination, and patients diagnosis outcome. Catheter
malfunction or fibrin sheath formation as an outcome of
both groups was not investigated.
The decrease of the infection rate in surface treated
catheter in the preliminary study from 2001 cannot be
seen in this presented study from 1992 to 2007. An ex-
planation could be that all and more available data are
now evaluated. The untreated catheters showed a higher
positive culture for bacteria of 55% versus 52% to the
surface treated catheters, but without significance. The
procedure for both studies was the same.
The PUR-SMA coating prevents contact of blood
components with barium sulphate, possibly leading to
leaching as particles or dissolved in the surrounding me-
dia. The advantage of the PUR-SMA surface treatment is
the coating of the inner and the outer surface in contrast
to the ion beam-based surface treatment technologies in
which can be treated only the outer surface of the cathe-
ters. The preliminary results with these PUR-SMA
coated catheters showed a good biocompatibility without
any blood deposits and a low thrombogenicity and co-
agulation activity. The microbiological results were low
and of those from the Spi-Argent® catheters [30].
6. Discussion
Catheter-related infections are the most dangerous com-
plications of large-bore catheter aside from accidential
puncture of an artery. In addition to colonization, bio-
compatibility of a catheter material is an important con-
Copyright © 2013 SciRes. OJNeph
Copyright © 2013 SciRes. OJNeph
Table 1. Microbiological examinations of 105 untreated and 54 surface treated catheters.
Microorganism Untreated (n) % Treated (n) % p-value
Negative 47 45 26 48 n.s
S. aureus 31 29 21 38 n.s
S.epidermidis 7 7 1 2 n.s.
Pseudomonas 1 1 0 0 n.s.
Enterobacter 1 1 1 2 n.s.
Others 18 17 5 10 n.s.
tributing factor to a successful clinical outcome, particu-
larly in catheters that remain in situ for several weeks or
months. Although improved since the use of centrally
placed catheters, the incidence of catheter clotting was
previously very high.
Infection rates range from 5% to 30 % and the most
bacteria found is the Staphylococcus aureus. These rates
do not depend on the route of vascular access [31].
Catheter-related Staphylococcus aureus bacteremiae are
one of the main causes of morbidity and preventable
cause of death in hemodialysis. Patients on dialysis are at
a high risk of Staphylococcus aureus bacteremia and they
have a four times higher mortality from central venous
catheter-related Staphylococcus aureus bacteremia than
other patients [15,32,33].
Recent data have suggested that methicillin-resistant S.
aureus (MSRA) and vancomycin intermediate S. aureus
(VISA) organisms may have increased [34]. One of the
proposed mechanisms of vancomycin resistance is the
bacterial cell wall thickening following vancomycin ex-
posure [35]. Vancomycin´s activity may be decreased
due to the thickness of the bacterial cell, the results are
MSRA and VISA [36].
To reduce infection rates and thrombogenicity, coated
catheters and cuffs were investigated [37-40]. The clini-
cal results of our preliminary investigations showed a
significantly reduced infection rate in treated versus un-
treated catheters, a reduction of more than 75% [18].
With the silver surface treatment, a very smooth metallic
surface was obtained which was responsible for a lower
thrombogenicity rate. The activation of coagulation fac-
tors at the catheter surfaces, and the catheter thrombosis
rate was not investigated. Silver ions are bactericidal,
therefore, no bacteria growth is possible on the treated
catheter surface. The positive association between the in
situ time of the catheters and the patients’ age may be
because of an alteration of the immune system in elderly
patients, especially in hemodialysis patients.
But in our retrospective study of all silver coated
catheters no significantly reduction in infection rate, im-
provement, or life expectancy of silver coated versus
untreated catheters, which were inserted during 1992 and
2007, was observed. One reason can be that with the
IBAD technology only the outer surface is coated with
silver. The postulated penetration of silver ions from the
outer to the inner surface cannot be shown with these
results. The only outer surface treated surface catheters
with silver have no advantage in point of view of reduc-
ing infection rate and improvement of patients versus the
untreated catheters. The handling of the catheters under
sterile conditions before, during and after the extracor-
poreal treatments probably cannot prevent the contami-
nation with bacteria, especially the untreated inner side.
Based on these results, new materials must be devel-
oped, which should have better biocompatibility to re-
duce side effects so that they can be left in situ for a long
time, because the part of dialysis patients with vascular
problems is increasing in the last decade, and now about
30 % of all hemodialysis patients [41], because the age of
HD patients is permanent growing up. As the require-
ment for more and more artificial organs and/or organ
replacement increases, especially in elderly patients,
there will be a definite need for new materials with better
biocompatibility and for suitable technologies to solve
these infection, thrombosis and medical problems to re-
duce the costs and get better improvement of patients. A
disadvantage of drugs such as antibiotics in the catheter
surfaces or administration to patient or disinfection sub-
stances is that they can develop resistance by mutation or
other mechanisms. Therefore the need of new surgical
techniques and materials are necessary [42].
More new materials must be developed, which should
have better biocompatibility to reduce side effects so that
they can be left in situ for a long time, because the part of
dialysis patients with vascular problems is increasing in
the last decade. As the requirement for more and more
artificial organs and/or organ replacement increases,
there will a definite need for new materials with better
biocompatibility and for suitable technologies to solve
these infection, thrombosis and medical problems to re-
duce the costs and get a better improvement of patients.
But it appears impossible to create a surface with an ab-
solute “zero” adherence due to thermal-dynamical rea-
sons and due to the fact that a modified material surface
is in vivo rapidly covered by plasma and connective tis-
sue proteins.
Therefore other concepts of the prevention of implant-
associated infections must involve the impregnation of
the devices the inner and outer surface with antibiotics,
antimicrobial substances and/or metals [43,44]. Another
point is to understand the processes leading to the devel-
opment of catheter-related bacteremia in order to can
offer effective preventive and therapeutic possibilities
[45] such as new polymer-antibiotic systems in inhibiting
bacterial biofilm formation and in reducing neutrophil
activation after surface contact on different biomaterials,
thus reducing the risk for biomaterial-mediated inflam-
matory reactions [46-48], or the development of new
biofilm to serve in a communication system termed quo-
rum sensing [49], or molecules that inhibit quorum sens-
ing signal generation among organism could block mi-
crobial biofilm formation [50].
These catheters related complications are contributing
factors to the increasing cost of medical care. They are
responsible for patient readmissions and longer hospital
stays as well as patients discomfort, morbidity, and occa-
sional mortality. Feldman et al. calculated in 1996 the
costs of the morbidity due to catheter infections will soon
exceed $ 1 billion per year [51]. Therefore he demanded
to reduce vascular access-related morbidity, that strate-
gies must be developed not only to prevent and detect
appropriately early synthetic vascular access dysfunction,
but to better identify the patients in a whom radial arte-
rio-venous fistula is a viable clinical option. The repre-
sentative health care cost savings for hemodialysis cathe-
ters, given specific infection rates and potential infection
rate reductions achieved by treated catheters [23].
The cost analysis was calculated using the literature
and the available costs of different companies which dis-
tribute these catheters [52]. Potential health care cost
reductions that could be achieved through the use of sur-
face treated-catheters by an annual usage of 125,971 he-
modialysis catheter devices and an infection rate of 5% -
20%, savings per year of $ 17.7 million, reduction about
40% [52]. Besides a high number of patients who die to
CRI, the costs of these infections are increasingly steady.
After Schwebel et al. the costs are $ 2118/intensive care
unit day, and after Pronovost et al. $ 45,000 per each
infection [53,54]. Tacconelli et al. estimated in 2009 the
costs associated with CRI in four European countries
(France, Germany, Italy, and UK) between € 35.9 and €
163.9 million per year [55].
Due to these tremendous high costs it must be possible
of scientists, physicians, bioengineers and others to de-
velop new techniques and new materials to reduce these
high costs and to increase the improvement of patients.
But besides the high costs due catheter-related infec-
tions, the patients´ longer hospital stays, and patients
discomfort, mortality, and occasionally mortality are the
most important problems which must be resolved. To
reduce these complications it is necessary that the han-
dling of the catheters must be done first after the numer-
ous recommendation and guidelines available in the lit-
erature [22,56,57].
Surface treatment of catheter is necessary, but of the
inner and the outer surface. Therefore new technology
must be developed for the surface treatment with antibi-
totics, antimicrobial substances and/or metal. New mate-
rial and new-polymer-antibiotic systems are demanded.
The developed of new biofilm to serve in a communica-
tion system termed quorum sensing [49], or molecules
which inhibit quorum sensing signal generation among
organism could block microbial biofilm formation [50].
This reqirement shows perhaps the new developed cathe-
ter material, the microdomain-structured surface [PUR-
SMA-coated catheters, Gambro, Germany) [18]. Micro-
domain surfaces are considered the most biocompatible
because they mimic the structure of natural biological
surfaces. Microdomain structures are used to match the
multiple requirements for improved catheter surfaces,
that is reduced thromgenecity and improved antimicro-
bial properties. First results with these catheters are very
Most important is the improvement of the handling of
the catheters by the attending staff which is recommend-
ed in numerous available guidelines to reduce the tre-
mendous high costs to treat the CRI and the discomfort
and morbidity of the patients.
7. Conclusion
The results showed that catheters which were surface
treated only on the outside had no advantages versus un-
treated catheters. In a retrospective study from 1992 to
2007, outer surface treated catheters with silver versus
untreated catheters in 159 patients, who needed a large
bore catheter, were investigated. There was no associa-
tion between the in situ time and silver coated/uncoated
catheters, resulting in the bacteriological examination, and
patients’ diagnosis or outcome. Reasons may be that on
the surface treated catheters only the outer surface was
coated with silver and the possibility of contamination by
the handling during the extracorporeal treatments. There-
fore, new materials and surface treatment on both sur-
faces, the inner and outer surface, are needed to save the
tremendous high health costs for hemodialysis catheters,
to reduce infection rates, and thrombus formations and to
improve the patients’ outcome.
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