Saphenous vein peripherally inserted central catheters: Technique, indications and safety issues

Technical success and safety of peripherally inserted central catheters in the great saphenous and anterior accessory great saphenous veins

BACKGROUND

Peripherally inserted central catheters (PICC) are occasionally placed in the great saphenous vein (GSV) and anterior accessory great saphenous vein (AAGSV) in patients with inadequate upper extremity veins or contraindications to upper extremity placement. Outcomes on the placement of PICCs in these veins are limited.

OBJECTIVES

This study aimed to determine technical success and safety of GSV/AAGSV PICCs.

MATERIALS AND METHODS

This is a retrospective study that reviewed all GSV/AAGSV PICC placements between January 2011 and December 2019. A total of 29 PICC placements procedures were identified. The electronic medical record was queried for demographic, procedural, and complication data. Technical success was defined by whether the vein could be accessed and a PICC could be placed. Catheter-associated infections, dislodgement or migration, malfunction, and PICC-associated thrombosis were recorded.

RESULTS

Technical success of placement was 100%. Twenty-one (72%) catheters were placed in the GSV in the mid to upper thigh and eight (28%) were placed in the AAGSV. The median PICC dwell time was 13 days with a range of 3-155 days. PICC-associated complications occurred after 11 (37.9%) placements. Line associated infection was the most common complication (17.2%).

CONCLUSION

Due to a high complication rate, GSV/AAGSV PICC placement should be considered only when upper extremity or cervical PICC placement is not feasible or contraindicated.

A retrospective analysis of the clinical effectiveness of subcutaneously tunneled femoral vein cannulations at the bedside: A low risk central venous access approach in the neonatal intensive care unit

OBJECTIVE

The purpose of this retrospective analysis was to evaluate the clinical efficacy and safety of ultrasound (US)-guided, subcutaneously tunneled, femoral inserted central catheters (ST-FICCs) in the neonatal intensive care unit (NICU).

METHODS

Following clinical success with ST-FICCs in adults, we expanded this practice to the neonatal population. In an 18-month retrospective cohort analysis (2018-2020) of 82 neonates, we evaluated the clinical outcome for procedural success, completion of therapy, and incidence of early and late complications for insertion of US-guided ST-FICCs in the NICU.

RESULTS

Placement of ST-FICCs were successful in 100% of neonates (n = 82/82) with 94% to the right (n = 77/82) and 6% to the left common femoral veins (n = 5/82). Gestational age ranged 23-39 weeks with median age of 29 weeks. Birthweight ranged from 450 g to >2000 g. Weight at insertion ranged 570 to 3345 g and day of life 1 to 137, with median at day 5. Ultrasound guided femoral vein puncture was recorded on 74 patients, first attempt 63/74 (85%), second attempt 8/74 (11%) and third attempt 3/74 (4%). Catheter french used: 1.9Fr (n = 80/82), 2.6Fr (n = 1/82), and 3-Fr (n = 1/82). Catheter lengths were 8 to 20 cm, average 12cm. Catheter termination confirmed with posterior/anterior and lateral abdominal radiographs with inferior vena cava (IVC) (n = 33/82), IVC/right atrial junction (n = 31/82), or right atrium (n = 18/82). Atrial placements were retracted; no cases of malposition to the lumbar/renal/hepatic veins (n = 0/82). 1528 catheter days ranging 5 to 72 days (average 18). No insertion-related or post-insertion complications. All patients completed prescribed therapy with one catheter.

CONCLUSION

Bedside placement of an ST-FICC is a safe route for central venous access in the NICU, preserving upper extremity vasculature, eliminates risks associated with sedation, fluoroscopy, tunneled and non-tunneled supra-diaphragmatic central venous insertion.

Review and Case Studies of Midthigh Femoral Central Venous Catheter Placement

Background: Bedside vascular access options have been limited to the short peripheral intravenous, midline catheter, peripherally inserted central catheter, and central venous catheter (CVC) insertion sites such as the jugular, subclavian, and femoral vein. Many patients with limited options for upper extremity, subclavicular, supraclavicular, and cervical limitations have traditionally received a femoral CVC in the inguinal region. This insertion site is considered a high risk for infection because of its location in the inguinal region and associated difficulties with maintaining the dressing integrity. An alternative location was selected for the insertion of a femoral vein central venous catheter in the midthigh to reduce the risk of infection.

Methods: After a multiple-year implementation process, midthigh femoral (MTF) insertions were performed on a select group of patients. The case studies that are included in this report outline the indications, procedures, and other pertinent aspects of the MTF placement. Patients at this institution with contraindications to upper extremity and thoracic catheter insertion received a MTF vein CVC in place of a traditional common femoral vein catheter insertion in the inguinal area. All procedural consents include permission for photography of procedure sites.

Results: All but a single patient completed their therapy without complication; 1 intentional dislodgement by a patient was recorded. There were no MTF catheter-related bloodstream infections and 2 confirmed central line associated bloodstream infections (n = 2 of 100) with the second noted as probable contaminated specimen. Outcomes reflected no procedural complications (eg, expanding hematoma or femoral nerve injury or any other femoral artery or vein injuries) and 1 nonocclusive deep vein thrombosis (n = 1 of 100).

Conclusions: The MTF CVC provides an alternative to traditional common femoral vein catheter placement for nonemergent patients with upper extremity and thoracic contraindications to central line placement.

The feasibility and safety of PICCs accessed via the superficial femoral vein in patients with superior vena cava syndrome

Objective:

To investigate the feasibility and safety of the peripherally inserted central catheters (PICCs) accessed via the superficial femoral vein in patients with superior vena cava syndrome (SVCS).

Methods:

From October 2010 to December 2014, 221 cancer patients with SVCS in our center received real-time ultrasound-guidance of the superficial femoral vein inserted central catheters (FICCs) at the mid-thigh. PICC insertion via upper extremity veins had also been investigated in 2604 cancer patients without SVCS as control. The average catheterization time, one-time puncture frequency, catheter duration and complications were compared between two groups.

Results:

In the FICC group, the mean catheterization time was 31.60 ± 0.15 minutes, one-time puncture frequency was 1.05 ± 0.08, and catheter duration was 168.95 ± 20.47 days. There was no significant difference compared with the upper extremity veins PICC group: 31.11 ± 3.86 minutes, 1.03 ± 0.30, and 173.58 ± 39.81 days, respectively. The major complications included skin allergy to chlorhexidine gluconate (CHG) dressings, exudation, catheter-related infection, catheter occlusions, unplanned catheter withdrawal, venous thrombosis, mechanical phlebitis, and catheter malposition. It is interesting that a higher rate of catheter malposition was observed in the upper extremity veins PICC group than in the FICC group (2.15% vs. 0.00%). There were no significant differences in other complications between the two groups.

Conclusions:

Real-time ultrasound-guided PICCs accessed via the superficial femoral vein at the mid-thigh is a new modified technique with low complications, which can be a feasible and safe alternative venous access for patients with SVCS.

Greater saphenous venous access as an alternative in children

BACKGROUND

In the pediatric population, obtaining venous access in high-risk neonates, severely ill children with cardiac anomalies or very young children (<10 kg) can be very challenging. In the literature to date, the greater saphenous vein has not been primarily used by interventional radiologists as an entry site for venous access in children.

OBJECTIVE

To demonstrate the utility and effectiveness of using the greater saphenous vein as a venous access site for the placement of peripherally inserted central catheters in children.

MATERIALS AND METHODS

This is a retrospective study from a large tertiary care children's hospital from November 2010 to August 2012. Peripheral insertion of central venous catheters (PICC) using the greater saphenous vein was attempted in 86 children ranging in age from 3 days to 17 years (mean: 1.8 years). Indications included congenital heart disease, urinary tract infection, intravenous access, pneumonia, meningitis, total parenteral nutrition, sepsis and other infections. All procedures were performed by interventional radiologists. No insertion-related complications were identified. There was no follow-up planning, but no mechanical or infectious complications were brought to our attention.

RESULTS

Of the 86 patients in whom PICC placement was attempted, placement was successful in 67 (78%). Forty-two PICCs were placed in the greater saphenous vein at the thigh level using US guidance and 25 at the ankle level using anatomical landmarks. The mean weight of the 67 patients who underwent successful placement was 9.98 kg, with 51 (76%) weighing <10 kg. The mean vessel diameter in placement failures was 1.35 mm compared to 1.83 mm in successful placement. Inability to obtain venous access was the cause of failure in all thigh access sites while inability to advance the catheter centrally was the cause of failure for all ankle access sites. A total of 1,060 catheter days (with a maximum dwell time of 97 days in one patient) were reviewed without complication.

CONCLUSION

In children, the greater saphenous vein provides a safe, suitable alternative for venous access, particularly in very young children (<10 kg) and in a select group of older children who are not mobile. In the lower extremities, greater saphenous venous puncture and access may be a preferred initial access site in small children to preserve future venous access.