Complication Rates Observed in Silicone and Polyurethane Catheters of Totally Implanted Central Venous Access Devices Implanted in the Upper Arm

Multi-Functional Biomaterial for the Treatment and Prevention of Central Line-Associated Bloodstream Infections

Central venous catheters are among the most used medical devices in hospitals today. Despite advances in modern medicine, catheter infections remain prevalent, causing significant morbidity and mortality worldwide. Here, SteriGel is reported, which is a multifunctional hydrogel engineered to prevent and treat central line-associated bloodstream infections (CLABSI). The mechanical properties of SteriGel are optimized to ensure appropriate gelation kinetics, bio-adhesiveness, stretchability, and recoverability to promote durability upon application and to provide persistent protection against infection. In vitro assays demonstrated that SteriGel exhibits long-term antimicrobial efficacy and has bactericidal effects against highly resistant patient-derived pathogens known to be frequently associated with CLABSI. SteriGel outperformed Biopatch, which is a clinically used device for CLABSI, in ex vivo cadaver studies that simulate clinical scenarios. Furthermore, SteriGel has biocompatible, pro-healing, and anti-inflammatory properties in vitro and in a rat subcutaneous injection model, suggesting a potential synergistic effect in the prevention and treatment of CLABSI. SteriGel is a multifunctional adherent biomaterial with potent antimicrobial effects for sustained sterility while promoting healing of the catheter incision site to protect against infection.

A Monocentric Analysis of Implantable Ports in Cancer Treatment: Five-Year Efficacy and Safety Evaluation

BACKGROUND

Daily clinical practice requires repeated and prolonged venous access for delivering chemotherapy, antibiotics, antivirals, parenteral nutrition, or blood transfusions. This study aimed to investigate the performance and the safety of totally implantable vascular access devices (TIVADs) over a 5-year follow-up period through a standardized well-trained surgical technique and patient management under local anesthesia.

METHODS

In a retrospective, observational, and monocentric study, 70 patients receiving POLYSITE® TIVADs for chemotherapy were included. The safety endpoints focused on the rate of perioperative, short-term, and long-term complications. The performance endpoints included vein identification for device insertion and procedural success rate.

RESULTS

The study demonstrated no perioperative or short-term complications related to the TIVADs. One (1.4%) complication related to device manipulation was identified as catheter flipping, which led to catheter adjustment 56 days post-placement. Moreover, one (1.4%) infection due to usage conditions was observed, leading to TIVAD removal 3 years and 4 months post-surgery. Catheter placement occurred in cephalic veins (71.4%), subclavian veins (20%), and internal jugular veins (8.6%). The procedural success rate was 100%. Overall, the implantable ports typically remained in place for an average of 22.4 months.

CONCLUSIONS

This study confirmed the TIVADs' performance and safety, underscored by low complication rates compared to published data, thereby emphasizing its potential and compelling significance for enhancing routine clinical practice using a standardized well-trained surgical technique and patient management.

Central Venous Catheter Consideration in Pediatric Oncology: A Systematic Review and Meta-analysis From the American Pediatric Surgical Association Cancer Committee

BACKGROUND

Tunneled central venous catheters (CVCs) are the cornerstone of modern oncologic practice. Establishing best practices for catheter management in children with cancer is essential to optimize care, but few guidelines exist to guide placement and management.

OBJECTIVES

To address four questions: 1) Does catheter composition influence the incidence of complications; 2) Is there a platelet count below which catheter placement poses an increased risk of complications; 3) Is there an absolute neutrophil count (ANC) below which catheter placement poses an increased risk of complications; and 4) Are there best practices for the management of a central line associated bloodstream infection (CLABSI)?

METHODS

Data Sources: English language articles in Ovid Medline, PubMed, Embase, Web of Science, and Cochrane Databases.

STUDY SELECTION

Independently performed by 2 reviewers, disagreements resolved by a third reviewer.

DATA EXTRACTION

Performed by 4 reviewers on forms designed by consensus, quality assessed by GRADE methodology.

RESULTS

Data were extracted from 110 manuscripts. There was no significant difference in fracture rate, venous thrombosis, catheter occlusion or infection by catheter composition. Thrombocytopenia with minimum thresholds of 30,000-50,000 platelets/mcl was not associated with major hematoma. Limited evidence suggests a platelet count <30,000/mcL was associated with small increased risk of hematoma. While few studies found a significant increase in CLABSI in CVCs placed in neutropenic patients with ANC<500Kcells/dl, meta-analysis suggests a small increase in this population. Catheter removal remains recommended in complicated or persistent infections. Limited evidence supports antibiotic, ethanol, or hydrochloric lock therapy in definitive catheter salvage. No high-quality data were available to answer any of the proposed questions.

CONCLUSIONS

Although over 15,000 tunneled catheters are placed annually in North America into children with cancer, there is a paucity of evidence to guide practice, suggesting multiple opportunities to improve care.

LEVEL OF EVIDENCE

III. This study was registered as PROSPERO 2019 CRD42019124077.

Central venous access device terminologies, complications, and reason for removal in oncology: a scoping review

BACKGROUND

Lack of agreed terminology and definitions in healthcare compromises communication, patient safety, optimal management of adverse events, and research progress. The purpose of this scoping review was to understand the terminologies used to describe central venous access devices (CVADs), associated complications and reasons for premature removal in people undergoing cancer treatment. It also sought to identify the definitional sources for complications and premature removal reasons. The objective was to map language and descriptions used and to explore opportunities for standardisation.

METHODS

A systematic search of MedLine, PubMed, Cochrane, CINAHL Complete and Embase databases was performed. Eligibility criteria included, but were not limited to, adult patients with cancer, and studies published between 2017 and 2022. Articles were screened and data extracted in Covidence. Data charting included study characteristics and detailed information on CVADs including terminologies and definitional sources for complications and premature removal reasons. Descriptive statistics, tables and bar graphs were used to summarise charted data.

RESULTS

From a total of 2363 potentially eligible studies, 292 were included in the review. Most were observational studies (n = 174/60%). A total of 213 unique descriptors were used to refer to CVADs, with all reasons for premature CVAD removal defined in 84 (44%) of the 193 studies only, and complications defined in 56 (57%) of the 292 studies. Where available, definitions were author-derived and/or from national resources and/or other published studies.

CONCLUSION

Substantial variation in CVAD terminology and a lack of standard definitions for associated complications and premature removal reasons was identified. This scoping review demonstrates the need to standardise CVAD nomenclature to enhance communication between healthcare professionals as patients undergoing cancer treatment transition between acute and long-term care, to enhance patient safety and rigor of research protocols, and improve the capacity for data sharing.

Risk factors for peripherally inserted central catheter-related venous thrombosis in adult patients with cancer

PURPOSE

The purpose of this study was to understand and analyze the risk factors of peripherally inserted central catheter (PICC)-related venous thrombosis in adult patients with cancer.

METHODS

This observational cohort study included adult patients with cancer who underwent color Doppler ultrasound at the Xiangya Hospital of Central South University, Hunan Provincial Maternal and Child Healthcare Hospital, and Xiangya Changde Hospital, Hunan Province, from January 1, 2017 to December 31, 2021. Univariate and multivariate logistic regression analyses were performed to determine the risk factors of PICC-related venous thrombosis.

RESULTS

After risk adjustment, multivariate logistic regression analysis revealed statistically significant associations between PICC-related venous thrombosis and age > 65 years old (OR: 1.791, CI: 1.343-2.389), male sex (OR: 1.398, CI: 1.057-1.849), white blood cell count > 9.5 × 109 /L (OR: 1.422, CI: 1.041-1.942), APTT < 25 s (OR: 2.006, CI: 1.431-2.811), gastrointestinal tumor (OR: 2.191, CI: 1.406-3.414), infection (OR:7.619, CI: 5.783-10.037), the use of cisplatin (OR: 2.374, CI: 1.714-3.214), vincristine (OR: 2.329, CI: 1.447-3.749), the use of polyurethane (OR: 2.449, CI: 1.863-3.219) and open-ended catheters (OR:1.660, CI: 1.131-2.439), keeping time of the catheter (days) (OR: 1.003, CI: 1.001-1.005) were associated with PICC-related venous thrombosis.

CONCLUSION

We identified that the presence of age > 65 years old, male sex, white blood cell count > 9.5 × 109 /L, APTT < 25 s, gastrointestinal tumor, infection, the use of cisplatin and vincristine, the use of polyurethane, open-ended catheters and keeping time of the catheter (days), were associated with PICC-related venous thrombosis.

Exploring risk factors for totally implantable venous access devices (TIVADs)-related thrombotic occlusion in the off-treatment period

Totally implantable venous access devices (TIVADs) have been widely used for many years in the management of patients suffering from cancer. Thrombotic occlusion is the most common functional complication in the off-treatment period. This study aims to investigate the incidence of and risk factors for TIVADs-related thrombotic occlusion in patients with breast cancer. The clinical data of 1586 eligible patients with breast cancer with TIVADs at the Fourth Affiliated Hospital of Hebei Medical University from 1 January 2019 to 31 August 2021 were analysed. Thrombotic occlusion was confirmed by angiography with signs of partial or total occlusion. Thrombotic occlusion occurred in 96 (6.1%) cases. Multivariable logistic regression analysis showed that the insertion site of the catheter (P = 0.004), size of the catheter (P < 0.001), and indwelling time (P < 0.001) were significant factors for thrombotic occlusion. Insertion in the right internal jugular vein, smaller catheter size and shorter indwelling time can lower the incidence of thrombotic occlusion in breast cancer patients with TIVADs in the off-treatment period.

Quantification of mechanical properties in long-term in vivo used silicone catheter lines according to DIN 10555-3

BACKGROUND

Totally implantable central venous access port devices are crucial for intravenous application of chemotherapeutics and long-term therapy for chronic disease. Common complications include thrombosis and device fracture related to altered material properties through exposure in situ. This study exhibits whether uniaxial tensile properties (DIN 10555-3) of in vivo used catheters prove inferior to unused catheters.

MATERIAL AND METHODS

5 unused, originally packed silicone catheters were cut into 6 segments of 50 mm: 3 segments each were cleaned via cleaning solution (n = 15) while 3 segments were left unattended (n = 15). Distal segments (50 mm) of long-term in vivo used silicone catheters were cleaned before testing (n = 33). Overall mechanical behavior was tested in a custom-made self-centering, torsion free carrier. Maximum force stress at failure, strain at failure and Young's modulus were determined and statistically analyzed.

FINDINGS

Unused catheters showed no significant difference in testing. in vivo used catheters exhibited 20% lower maximal force than unused catheters (p < 0.001), strain at break (p 〈0,001), and 7% higher elastic modulus (p = 0.004; power: 0.845). Due to a constant cross section area, stress at failure was proportional to maximum force (p < 0.001). Relation between determined parameters and dwell times was non-significant.

INTERPRETATION

In vivo long-term used silicone catheters showed significantly lower ultimate strength than unused ones. It is likely that in situ altering changes the mechanical properties of catheters and may potentially lead to failure.

Infectious complications of radiologically placed upper arm ports: A single center analysis

OBJECTIVES

Infections are common complications in venous access ports. The presented analysis aimed to investigate the incidence, microbiological spectrum, and acquired resistances of pathogens in upper arm port associated infections to provide a decision aid in the choice of therapy.

MATERIALS AND METHODS

In total, 2667 implantations and 608 explantations were performed at a high-volume tertiary medical center between 2015 and 2019. In cases with infectious complications (n = 131, 4.9%), procedural conditions and results of microbiological testing were reviewed retrospectively.

RESULTS

Of 131 port associated infections (median dwell time 103 days, interquartile range 41-260), 49 (37.4%) were port pocket infections (PPI) and 82 (62.6%) were catheter infections (CI). Infectious complications occurred more often after implantation in inpatients compared to outpatients (P < 0.01). PPI were mainly caused by Staphylococcus aureus (S. aureus, 48.3%) and coagulase-negative staphylococci (CoNS, 31.0%). Other gram-positive and gram-negative species were encountered in 13.8% and 6.9%, respectively. CI were caused less frequently by S. aureus (8.6%) than CoNS (39.7%). Other gram-positive and gram-negative strains were isolated in 8.6% and 31.0%, respectively. Candida species were seen in 12.1% of CI. An acquired antibiotic resistance was detected in 36.0% of all significant isolates, occurring especially in CoNS (68.3%) and gram-negative species (24.0%).

CONCLUSIONS

Staphylococci comprised the largest group of pathogens in upper arm port associated infections. However, gram-negative strains and Candida species should also be considered as a cause of infection in CI. Due to the frequent detection of potential biofilm-forming pathogens, port explantation is an important therapeutic measure, especially in severely ill patients. Acquired resistances must be anticipated when choosing an empiric antibiotic treatment.

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience

Introduction

In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed.

Material and methods

Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted.

Results

A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection.

Conclusion

Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late 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.

Does catheter material affect functional performance of intravenous ports via the superior vena cava?

Introduction

The catheter is the only intravascular portion of an implanted port and plays a crucial role in catheter related complications. Both polyurethane and silicone are biocompatible materials which are utilized for catheter manufacturing, but their correlation to complications remains controversial. The aim of this study was to try to analyze the relationship between catheter materials and complications.

Materials and methods

A total of 3144 patients who underwent intravenous port implantation between March 2012 and December 2018 at Chang Gung Memorial Hospital, Linkou, Taiwan were recruited. Of these, 1226 patients received silicone catheter port implantation and 1679 received polyurethane catheter ports. Case matching was done prior to analysis and catheter related complications and cumulative complication incidence for each group were compared.

Results

Intergroup differences were identified in entry vessel (p = 0.0441), operation year (p < 0.0001), operation method (p = 0.0095), functional period (p < 0.0001), patient follow up status (p < 0.0001), operating time for vessel cutdown (p < 0.0001) and wire assisted approach (p = 0.0008). Stratified by specific entry vessel, no statistical difference was found in complication rate or incidence between the silicone and polyurethane groups. We further compared the cumulative complication incidence of the silicone and polyurethane groups, and also found no statistical difference (p = 0.4451).

Conclusion

As long as external stress forces generated by surrounding structures and focused on potential weak points are avoided, both silicone and polyurethane materials provide sufficient structural stability to serve as reliable vascular access for patients.

Favorable Antibacterial, Antibiofilm, Antiadhesion to Cells, and Biocompatible Polyurethane by Facile Surface Functionalization

It is of paramount importance to prohibit biofilm formation in a wide range of implant devices, such as thermoplastic polyurethane (PU)-based catheters. It is possible only by means of a multifunctional material that provides fast and effective antibacterial activity, proper biocompatibility, and low bacterial and cell adhesion. In this paper, a facile chemistry approach has been developed to modify biomedical-grade PU with PU species, containing reactive uretdione functional groups for functionalization with the contact-type polyguanidine bactericidal agent and oxidized dextran as an antifouling polymer without sacrificing the thermal and mechanical properties. The resulting PU possesses broad-spectrum contact-active antibacterial activity against Gram-negative and Gram-positive bacteria with fast kinetics. The excellent antifouling capacity was confirmed by low nonspecific protein adsorption and reduced adhesion of fibroblast cells by ≥ 90%. In addition to antiadhesive and antibiofilm properties, high cell viability (>90%) and low hemolysis rate (HR < 1%) verified favorable cytocompatibility. Hence, the strategy followed to functionalize PUs in this paper might be considered to modify PU-based biomedical devices.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases

BACKGROUND

Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients.

METHODS

A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis.

RESULTS

The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060).

CONCLUSION

MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Chinese expert consensus and practice guideline of totally implantable access port for digestive tract carcinomas

Totally implantable access port is a fully implantable drug delivery system that is implanted subcutaneously and can be retained for a long time. Advantages of ports include a simple nursing process, low risk of infection and embolism, and high patient comfort. In order to promote the standardized application of ports in the treatment of digestive tract tumors and reduce port-related complications, the Chinese Research Hospital Association Digestive Tumor Committee, the Chinese Association of Upper Gastrointestinal Surgeons, the Chinese Gastric Cancer Association, and the Gastrointestinal Surgical Group of Chinese Surgical Society Affiliated to Chinese Medical Association have organized multidisciplinary expert discussions at the General Hospital of the People’s Liberation Army and nation-wide expert letter reviews and on-site seminars, and formulated an expert consensus of the operation guidelines.

Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications

Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.

X(-rays) sometimes mark the spot: A case of occult central venous catheter embolization

INTRODUCTION

Breakage and fragment embolization is a rare but feared complication of peripherally inserted central catheter use. While chest radiographs are no longer the gold standard for determining peripherally inserted central catheter tip position, their use in diagnosing complications is still warranted. We report a case of occult catheter embolization discovered by routine chest X-ray.

CASE DESCRIPTION

A patient with a right brachial vein peripherally inserted central catheter was admitted to our Emergency Department for palpitations and dyspnea. The peripherally inserted central catheter was not visible at presentation, and she was unclear as to what had happened; she left the Emergency Department before workup was performed. Catheter embolization was discovered upon implantation of a new peripherally inserted central catheter.

CONCLUSION

Although routine chest radiographs are no longer necessary after peripherally inserted central catheter implantation, they are in diagnosing peripherally inserted central catheter-related complications even in asymptomatic patients. We discuss their use and the possible role of securement devices in preventing some instances of catheter embolization.

Preparation of ordered mesoporous and macroporous thermoplastic polyurethane surfaces for potential medical applications

Thermoplastic polyurethanes are widely used in medical devices. In order to limit some of their shortfalls, like microbial attachment, surfaces modifications can be required. In this work, a two-step replication method was used to create ordered macroporous and mesoporous thermoplastic polyurethane surfaces using anodic aluminum oxide as master template. The intermediate mould materials that were tested were polystyrene and a polyacrylate resin with inorganic filler. All obtained surfaces were characterized by scanning electron microscopy. The initial anodic aluminum oxide surfaces possessed macro or mesopores, function of anodization conditions. The intermediate mould structure correctly replicated the pattern, but the polystyrene surface structures (pillars) were less resistant than the polyacrylate resin ones. The thermoplastic polyurethane pattern possessed macropores or mesopores of about 130 nm or 46 nm diameter and of about 300 nm or 99 nm interpore distances, respectively, in accordance with the initial pattern. Thermoplastic polyurethanes pore depth was however less than initial anodic aluminum oxide pore depth, linked to an incomplete replication during intermediate mould preparation (60 to 90% depth replication). The correct replication of the original pattern confirms that this novel fabrication method is a promising route for surface patterning of thermoplastic polyurethanes that could be used for medical applications.