Central venous access catheters: radiological management of complications

Comparative structural analysis of polyurethane and silicone catheters of totally implantable venous access devices by micro-computed tomography

Objectives:

To investigate microstructural alterations of explanted long-term central venous catheters of totally implantable venous access devices, using micro-computed tomography.

Methods:

A total of 16 catheters (9 made of silicone and 7 made of polyurethane), all non-fractured, have been analyzed in this study. Eight catheters were implanted for an average duration of 994 days (min–max: 98–2731 days), while the remaining eight catheters (four for each material, forming the SIref and PUref control groups) were analyzed before implant and used as a reference. X-ray micro-computed tomography was used to reconstruct the three-dimensional geometry of selected segments of each catheter (ca. 10 cm per sample).

Results:

Morphometric analysis of the catheters revealed increases wall thickness and section area in the polyurethane group as compared with the reference central venous catheters of the same materials (wall thickness: 403 ± 12 μm in the polyurethane (PU) group vs 382 ± 4 μm in PUref, p = 0.014; wall cross-section area: 2.04 ± 0.09 mm² in PU vs 1.91 ± 0.03 mm² in PUref, p = 0.04), whereas implanted silicone catheters showed a larger luminal cross section as compared with their controls (lumen cross-section area = 0.851 ± 0.020 mm² in silicone (SI) group vs 0.811 ± 0.007 mm² in SIref, p = 0.007). All analyzed samples in this study presented some type of alteration in the catheter walls, namely, hyperdense spots (below 0.1 mm size), air gaps/bubbles and displacements of inner and outer axes causing heterogeneous wall thickness. The incidence of air gaps showed no difference with respect to both material type and duration of implant, whereas the SI group revealed more hyperdense spots as compared to all other groups.

Conclusion:

Morphological change and local structural alteration can occur in both silicone and polyurethane catheters. This evidence suggests the need for further studies connecting those morphological changes with modification of mechanical robustness, which ultimately can play a role for patient safety.

Safety in training for ultrasound guided internal jugular vein CVC placement: a propensity score analysis

Background

Central venous catheter (CVC) placement is a routine procedure but is potentially associated with severe complications. Relatively small studies investigated if the use of ultrasound is effective in bridging the skill gap between proficient and not proficient operators, while patient safety during training remains a controversial topic. The first aim of this study was to evaluate if resident proficiency affects the failure rate in CVC positioning under ultrasound guidance. In addition, it aimed to investigate the different rate of complications between proficient and non proficient residents.

Methods

We conducted a cohort study including CVC placed by residents at the University Hospital of Padova, from November 1, 2012 to July 9, 2020 comparing proficient and non proficient residents. To avoid bias the two cohorts were matched using propensity score.

Results

A total of 356 residents positioned 2310 CVC during the 8 year study period. Among them, two groups of 1060 CVCs each were matched with a propensity score analysis. There was no difference in the failure rate among the groups (2.8 vs 2.7%, p-value 0.895).

Moreover, cohorts had the same rate of hematomas, catheter tip malposition, arterial puncture and pneumothorax. No cases of hemothorax were reported.

Conclusions

We found the same rate of success and incidence of adverse complications among cohorts, meaning that the process of skill acquisition is safe as long as appropriate training and direct supervision by a senior consultant are available.

Difference in Computed Tomography Image Quality between Central Vein and Peripheral Vein Enhancement in Treatment Naive Esophageal Cancer Patients

Simple Summary

A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity.

Abstract

The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

A Novel Non-Invasive Device for the Assessment of Central Venous Pressure in Hospital, Office and Home

Background

Venous congestion can be quantified by central venous pressure (CVP) and its monitoring is crucial to understand and follow the hemodynamic status of patients with cardio-respiratory diseases. The standard technique for CVP measurement is invasive, requiring the insertion of a catheter into a jugular vein, with potential complications. On the other hand, the current non-invasive methods, mainly based on ultrasounds, remain operator-dependent and are unsuitable for use in the home environment. In this paper, we will introduce a novel, non-invasive device for the hospital, office and home assessment of CVP.

Methods

After describing the measurement concept, we will report a preliminary experimental study enrolling 5 voluntary healthy subjects to evaluate the VenCoM measurements’ repeatability, and the system’s capability in measuring small elicited venous pressure variations (2 mmHg), as well as an induced venous hypertension within a pathological range (12÷20 mmHg).

Results

The experimental measurements showed a repeatability of ±1mmHg. The VenCoM device was able to reliably detect the elicited venous pressure variations and the simulated congestive status.

Discussion and Conclusion

The proposed non-invasive VenCoM device is able to provide a fast and repeatable CVP estimate, having a wide spectrum of potential clinical applications, including the monitoring of venous congestion in heart failure patients and in subjects with renal and hepatic dysfunction, as well as pulmonary hypertension (PH) that can be extended to pneumonia COVID-19 patients even after recovery. The device needs to be tested further on a large sample size of both healthy and pathological subjects, to systematically validate its reliability and impact in clinical setting.

IJV collapsibility index vs IVC collapsibility index by point of care ultrasound for estimation of CVP: a comparative study with direct estimation of CVP

Purpose

To compare the bedside ultrasound estimation of internal jugular vein (IJV)-collapsibility index with inferior vena cava (IVC)-collapsibility index and invasively monitored central venous pressure (CVP) in ICU patients.

Design

prospective observational study.

Setting

The study was carried out in the ICU of Al Wakra and Al Khor hospitals of the Hamad Medical Corporation, Qatar. The patients were enrolled from November 2013 to January 2015.

Patients

Patients admitted to the ICU with central venous catheter were included.

Material and methods

The A-P diameter, cross-sectional area of the right IJV, and diameter of IVC were measured using bedside USG, and their corresponding collapsibility indices were obtained. The results of the IJV and IVC indices were compared with CVP. The sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic and predictive accuracy of the IJV collapsibility index in predicting the CVP.

Results

Seventy patients were enrolled, out of which 12 were excluded. The mean age was 54.34±16.61 years. The mean CVP was 9.88 mmHg (range =1-25). The correlations between CVP and IJV-CI (collapsibility index) at 0° were r=-0.484 (P=0.0001), r=-0.416 (P=0.001) for the cross-sectional area (CSA) and the diameter, respectively, and, at 30°, the most significant correlation discovered was (r=-0.583, P=0.0001) for the CSA-CI and r=-0.559 (P=0.0001) for the diameter-CI. In addition, there was a significant and negative correlation between IVC-CI and CVP (r=-0.540, P=0.0001).

Conclusion

The IJV collapsibility index, especially at 30° head end elevation, can be used as a first-line approach for the bedside non-invasive assessment of CVP/fluid status in critical patients. IVC-CI can be used either as an adjunct or in conditions where IJV assessment is not possible, such as in the case of a neck trauma/surgery.

Sudden hypotension occurring after 4 days of left-sided central catheter placement

Central venous catheters (CVCs) have an important role in the management of critically ill patients. In contrast to the immediate complications after CVC insertion, the late complications were difficult to be noticed without high suspicion despite their life-threatening outcome. We report a rare but fatal delayed vascular perforation occurring after 4 days of left-sided hemodialysis catheter insertion. A 74-year-old male with septic shock was treated with continuous renal replacement therapy (CRRT) and recovered smoothly during hospitalization. Refractory hypotension occurred abruptly on the fourth hospital day. Chest X-ray and computed tomography revealed that the catheter tip perforated the innominate vein and located the mediastinum. He finally died despite the emergent radiologic intervention.

Cateteres venosos totalmente implantáveis: histórico, técnica de implante e complicações

O acesso ao sistema venoso, seja para coleta de amostras de sangue ou para infusão de soluções, é de vital importância para o diagnóstico e tratamento de pacientes com as mais variadas condições clínicas. Desde que Harvey, em 1616, descreveu o sistema circulatório a partir de estudos em animais e que Sir Christopher Wren, 4 décadas depois, realizou a primeira infusão endovenosa em seres vivos, a evolução na técnica de acesso e nos dispositivos para infusão tem sido constante. Merece destaque a criação dos cateteres de longa duração na década de 1970, em especial os totalmente implantáveis, que revolucionaram o tratamento do câncer, aumentando a segurança e o conforto dos pacientes oncológicos. Este artigo tem como objetivo a revisão de dados históricos relativos ao acesso vascular e a discussão da técnica de implante e das principais complicações associadas ao procedimento de colocação e ao uso dos cateteres totalmente implantáveis.

Analysis of chest X-ray plain film images of intravenous ports inserted via the superior vena cava

PURPOSES

The optimal tip position for an intravenous port and the angle between the locking nut and the catheter are still debatable. This study evaluates the use of chest X-ray plain films for screening patients with potential intravenous port complications.

METHODS

We reviewed, retrospectively, 1505 patients who had an intravenous port implanted between January 1 and December 31, 2006 at Chang Gung Memorial Hospital, and were followed up until June 30, 2010. Of the 1119 patients with an intravenous port implanted via the superior vena cava (SVC), 279 underwent re-interventions for complications. There were four different types of single lumen port, and entry vessels on the right side were utilized as the predominant entry sites through the vessel cut-down method for catheter cannulation. The anatomic catheter tip was confirmed on the postero-anterior view of plain chest X-ray films. We used the Picture Arching and Communicating System (PACS) (GE, Fairfield, CT, USA) to record the angle and distance in degrees and centimeters, respectively.

RESULTS

The tracheal carina was seen easily on the chest X-ray plain film and the location of the catheter tip and the angle between the locking nut and the catheter were identified. The location of the catheter tip was significantly related to migration (p < 0.0001). The cut-off value of the receiver operating characteristic (ROC) curve for location and migration was 0.68 cm below the carina. The area under the curve (AUC) was 0.8385 and had favorable predictive power.

CONCLUSION

The ideal position of an intravenous port to avoid migration is 0.68 cm below the carina. For surgeons, a quantified reference may minimize technical errors. Patients with shallow tip location should be followed up regularly and aggressive intervention initiated for any intravenous port malfunction.

A single-center study of vascular access sites for intravenous ports

PURPOSE

This study evaluated the use of intravenous ports and provides a guide related to clinical decision making.

METHODS

This study retrospectively reviewed 1505 patients who had received intravenous ports at Chang Gung Memorial Hospital in 2006. The relationships between the complications and entry routes were assessed. The intervention-free periods were also determined and compared. The patients were followed up until June 2010.

RESULTS

Of the 1543 procedures performed, 412 were reinterventions to treat complications, most of which corresponded to fewer than 0.1 episodes per 1000 catheter-days; these were not associated with any particular entry route. There was a higher catheter fracture rate when the right subclavian vein was chosen as the entry vessel (p < 0.05). The intervention-free period ranged from 207 to 533 days.

CONCLUSION

The subclavian vein is not recommended for the use of intravenous ports. There is not only a higher risk of iatrogenic pneumothorax or hemothorax using this entry route but also a higher fracture rate, which may be caused by pinch-off syndrome. The greater saphenous vein should only be considered when the patient has superior vena cava syndrome. However, a higher incidence of infection and a lower device survival rate should be expected with this location.

Catheter fracture of intravenous ports and its management

BACKGROUND

Intravenous ports are widely used for oncology patients. However, catheter fractures may lead to the need for re-intervention. We aimed to identify the risk factors associated with catheter fractures.

METHODS

Between January 1 and December 31, 2006, we retrospectively reviewed the clinical data and plain chest films of 1,505 patients implanted with an intravenous port at Chang Gung Memorial Hospital. Different vascular sites were compared using the chi-square or Fisher's exact test for categorical variables, and the t test was used for continuous variables with normal distribution; P < 0.05 was considered statistically significant.

RESULTS

There were 59 and 1,448 procedures in the fracture and non-fracture groups, respectively. Monovariate analysis revealed that the risk factors for catheter fracture were as follows: large angle (P < 0.0001), female gender (P < 0.0008), subclavian route (P < 0.0001), and port type Arrow French (Fr.) 8.1 (P < 0.0001). Because these risk factors showed no interaction effects, they were all considered independent risk factors. When all factors were considered together, all risk factors, except angle and age, retained their statistical significance.

CONCLUSIONS

Most catheter fractures were caused by material weakness. If catheter fracture is confirmed, further intervention for port and catheter removal is recommended. Female gender, intravenous port implantation via the subclavian route, and the Arrow Fr. 8.1 port were found to be risk factors. Patients with these risk factors should be monitored closely to avoid catheter fractures.

[How should urologists perform implantation of subcutaneous central venous port systems? A single center experience of 347 cases]

BACKGROUND

Since 1999 urologists at the University of Essen in Germany have performed subcutaneous implantation of venous port systems, controlled by intravasal ECG.

METHODS

Between December 1999 and June 2011 implantation of venous port systems was performed in 241 male (69.5%) and 106 (30.5%) female patients. The port systems were implanted subcutaneously above the pectoralis major muscle under local anesthesia. If it was not possible to isolate the cephalic vein or safe catheter implantation was not feasible, puncture of the subclavian vein was performed.

RESULTS

The median follow-up was 491.6 days (2-2568), and 163.254 catheter days (mean 239 days, range 2-2604) were documented. During the follow-up period 191 (55.1%) patients died. The mean surgical implantation and explantation time was 36.5 min (14-85 min) and 25.4 min (10-46 min), respectively; 79.7% were implanted and controlled by ECG. Altogether, 390 devices were used in 379 surgical procedures, 355 implantations (91.1%) and 35 explantations (8.9%). Implanted vessels were the cephalic vein in 303 patients (85.6%) and the subclavian vein in 51 (14.4%) patients. Of 35 explanted devices, the explantation was necessary due to complications in 28 (8.0%) cases: infection n=6 (1.7%, 0.036 per 1,000 catheter days), occlusion n=8 (2.3%, 0.049 per 1,000 catheter days), dislocation n=7 (2.0%, 0.042 per 1,000 catheter days), deep vein thrombosis of the upper extremity n=6 (1.7%, 0.037 per 1,000 catheter days), and clotting n=1(0.3%, 0.006 per 1,000 catheter days). Premature catheter removal (<30 days post-op) was required in six cases (1.9%, 0.036 per 1,000 catheter days) due to complications: three catheter dislocations/malfunctions (0.9%, 0.019 per 1,000 catheter days), one port-related infection, one pocket port infection, and one deep vein thrombosis of the upper extremity (0.3%, 0.006 per 1,000 catheter days). Other problems described in the literature like pneumothorax, vein perforation, or pinch-off syndrome did not occur.

CONCLUSIONS

Implantation of port systems with ECG control of the catheter tip position is related to a few cases of adverse events and good surgical outcomes. Furthermore, it has also shown great advantages in offering immediate support and early therapy initiation with a fast learning curve for the training urologists. The results of the presented analysis are comparable to those of surgical or radiological departments reported in the literature and provide good evidence that this procedure should be extended to urological centers with a high volume of chemotherapy patients.

Central venous port systems as an integral part of chemotherapy

BACKGROUND

Port systems are easy to implant on an in- or outpatient basis and provide reliable, long-lasting central venous access. They are used mainly for cancer patients.

METHODS

This article is based on a selective literature review, the guidelines of the German Society for Nutrition Medicine and of the European Society for Clinical Nutrition and Metabolism, and the recommendations of the German Society for Pediatric Oncology and Hematology.

RESULTS

In modern oncology, central venous port systems are increasingly replacing short-term and permanently tunneled central venous catheters. They are indicated for patients who need long-term intravenous treatment involving, e.g., the repeated administration of chemotherapeutic drugs, parenteral nutrition, transfusions, infusions, injections, and/or blood sample collection. Port systems can markedly alleviate the burden of intravenous therapy and thereby improve these patients' quality of life. The planning, preparation, and performance of port system implantation require meticulous attention to detail. The rate of implantation-associated complications is less than 2% in experienced hands; overall complication rates have been reported from 4.3% to as high as 46%. The proper postoperative use and care of the port system are of decisive importance to the outcome. Reported infection rates during port system use range from 0.8% to 7.5% in current clinical studies.

CONCLUSION

The treatment, follow-up care, and rehabilitation of cancer patients are interdisciplinary tasks. Optimal treatment and complication avoidance require a collaborative effort of all of the involved specialists-not just the physician implanting the port system, but also the oncologists, nutritionists, visiting nurses, and other home health care providers. Continuing medical education, too, plays a role in improving outcomes.

(Mis)placed central venous catheter in the left superior intercostal vein

Background

Chest X-ray is routinely performed to check the position of the central venous catheter (CVC) inserted through the internal jugular or subclavian vein, while the further evaluation of CVC malfunction is usually performed by contrast venography. In patients with superior vena cava obstruction, the tip of the catheter is often seen in collateral mediastinal venous pathways, rather than in the superior vena cava. In such cases detailed knowledge of thoracic vessel anatomy is necessary to identify the exact location of the catheter.

Case report.

We report a case of 32-year-old female patient with relapsing mediastinal lymphoma and previous superior vena cava obstruction with collateral azygos-hemiazygos venous pathways. The patient had CVC inserted through the left subclavian vein and its position was detected by CT to be in the dilated left superior intercostal vein and accessory hemiazygos vein. Considering that dilated accessory hemiazygos vein can tolerate infusion, the CVC was left in place and the patient had no complaints related to CVC (mal)position. Furthermore, we present anatomical and radiological observations on the azygos-hemiazygos venous system with the special emphasis on the left superior intercostal vein.

Conclusions

Non-contrast CT scans can be a valuable imaging tool in the detection of the CVC position, especially in patients with renal insufficiency and contrast media hypersensitivity.