Techniques for peripheral insertion of central venous catheters

Jugular versus subclavian totally implantable access ports: catheter position, complications and intrainterventional pain perception

PURPOSE

To determine the safest and most tolerable method for totally implantable access ports (TIAPs) particularly in regard to patient's pain perception and catheter-related complications.

MATERIALS AND METHODS

From January 2007 to October 2008 a subcutaneous TIAP (Bardport, Bard Access System, UT, USA) was implanted in 138 oncological patients (60 male, 78 female; 18-85 years old; mean age of 56 ± 6 years) by experienced interventional radiologists. 94 TIAP were implanted through the subclavian vein (subclavian group) and 44 TIAP were implanted through the internal jugular vein (jugular group). Intrainterventional pain perception (visual analogue scale from 1 to 10), postinterventional catheter tip migration and radiation dose were documented for each method and implantation side and differences were compared with Wilcoxon t-test. For ordinal variables, comparison of two groups was performed with the Fisher's exact test.

RESULTS

No severe periinterventional complication occurred. Inadvertent arterial punctures without serious consequences were reported in one case for the jugular group versus four cases in the subclavian group. Significantly (p<0.05) lower pain perception, radiation dose and tip migration rate were observed in the jugular group. Catheter occlusions occurred in 4% (n=4) of the subclavian group versus 2% (n=1) of the jugular group. The corresponding values for vein thrombosis and catheter dislocation were 3% (n=3) and 1% (n=1) in the subclavian group, while none of those complications occurred in the jugular group.

CONCLUSION

Both techniques, the TIAP implantation via fluoroscopy-guided subclavian vein puncture and via ultrasound-guided jugular vein puncture, are feasible and safe. Regarding intrainterventional pain perception, radiation dose, postinterventional catheter tip position and port function the jugular vein puncture under ultrasound guidance seems to be advantageous.

Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy

INTRODUCTION

Intravenous (i.v.) therapy may be associated with important catheter-related morbidity and discomfort. The safety, efficacy, comfort, and cost-effectiveness of peripherally inserted central catheters (PICCs) were compared to peripheral catheters (PCs) in a randomized controlled trial.

METHODS

Hospitalized patients requiring i.v. therapy >or= five days were randomized 1:1 to PICC or PC. Outcomes were incidence of major complications, minor complications, efficacy of catheters, patient satisfaction, and cost-effectiveness.

RESULTS

60 patients were included. Major complications were observed in 22.6% of patients in the PICC group [six deep venous thrombosis (DVT), one insertion-site infection] and 3.4% of patients in the PC group [one DVT; risk ratio (RR) 6.6; P = 0.03]. Superficial venous thrombosis (SVT) occurred in 29.0% of patients in the PICC group and 37.9% of patients in the PC group (RR 0.60; P = 0.20). Patients in the PICC group required 1.16 catheters on average during the study period, compared with 1.97 in the PC group (P < 0.04). The mean number of venipunctures (catheter insertion and blood sampling) was 1.36 in the PICC group vs. 8.25 in the PC group (P < 0.001). Intravenous drug administration was considered very or quite satisfying by 96.8% of the patients in the PICC group, and 79.3% in the PC group. Insertion and maintenance mean cost was 690 US$ for PICC and 237 US$ for PC.

DISCUSSION

PICC is efficient and satisfying for hospitalized patients requiring i.v. therapy >or= five days. However, the risk of DVT, mostly asymptomatic, appears higher than previously reported, and should be considered before using a PICC.

Peripherally inserted central catheters: guidance with use of US versus venography in 2,650 patients

PURPOSE

To compare technical success and initial complication rates of peripherally inserted central catheters (PICCs) by interventional radiologists using ultrasound (US) or venographic guidance.

MATERIALS AND METHODS

With use of a computer database, the authors retrospectively reviewed 2,650 procedures, 2,126 of which were performed with US and 524 with venography. Technical success was defined as placement of a PICC. Initial complications were defined as development of a hematoma, inadvertent arterial puncture, or neuropathy. Statistical significance was assessed using the chi2 test.

RESULTS

During 33 consecutive months, 2,650 procedures were performed with a complication rate of 1.0%. The technical success rate was 95.8% for venography and 99.6% for US. The initial complication rate was 0.75% for venography and 1.08% for US. There was no statistically significant difference in immediate complication rates (P = .50); however, there is statistical significance in regard to technical success (P < .001).

CONCLUSION

There is no difference in initial complication rates when comparing US and venographic guidance for PICC insertion. The decision to use either method can be based on clinical grounds and/or physician preference, although US has a higher initial success rate.

Peripheral insertion of a central venous access device under fluoroscopic guidance using a peripherally accessed system (PAS) port in the forearm

PURPOSE

We describe the technique, efficacy, and complications of fluoroscopy-guided implantation of a central venous access device using a peripherally accessed system (PAS) port via the forearm.

METHODS

Beginning in July 1994, 105 central venous access devices were implanted in 104 patients for the long-term infusion of antibiotics or antineoplasmic agents, blood products, or parenteral nutrition. The devices was inserted under fluoroscopic guidance with real-time venography from a peripheral route.

RESULTS

All ports were successfully implanted. There were no procedure-related complications. No thrombosis or local infection was observed; however, in six patients catheter-related phlebitis occurred.

CONCLUSION

Fluoroscopy-guided implantation of a central venous access device using a PAS port via the forearm is safe and efficacious, and injection of contrast medium through a peripheral IV catheter before introduction of the catheter helps to avoid catheter-related phlebitis.

Placement of peripherally inserted central catheters in the cardiac catheterization laboratory

This report describes our experiences with three patients requiring several weeks of central venous access for various intravenous therapies. These particular patients posed a considerable challenge for bedside placement of a peripherally inserted central catheter, so the catheters were placed in the cardiac catheterization laboratory by the cardiology team involved using a different technique for each patient.

Radiologic placement of long-term central venous peripheral access system ports (PAS Port): results in 150 patients

PURPOSE

The author reports experience with 150 peripheral access system ports (PAS Ports) placed in an interventional radiology suite. Complication rates from this series are compared with those of surgically placed tunneled catheters. The average cost of placement is compared with that of a surgically placed chest port.

PATIENTS AND METHODS

Findings were retrospectively reviewed in 150 patients in whom the PAS Port catheter was implanted. The age range was 26-84 years (mean, 46 years). The diagnoses in these patients included cancer (n = 68), acquired immunodeficiency syndrome (n = 52), osteomyelitis (n = 21), and abscess (n = 9). Implantation with use of fluoroscopic guidance and "Cath-finder" technology is described.

RESULTS

One hundred fifty ports have been indwelling for a total of 24,151 patient days (range, 40-220 days; mean duration, 161 days). Sepsis occurred in 3.3%, local infection in 5% (early infection 1%, late infection 4%), temporary catheter occlusion in 3.3%, postinsertion phlebitis in 7.3%, and venous thrombosis in 2%. The cost of radiologic PAS Port insertion averaged $1,488 versus $3,720 for surgical chest port insertion.

CONCLUSION

PAS Port central venous catheter placement by an interventional radiologist in this series is safe and cost effective and compares very favorably with surgery. Radiologists will likely see increasing requests by referring physicians for radiologically placed catheters and ports in this era of cost containment.