Approach to Fragmented Central Venous Catheters

Prolonged venous access devices are needed in cancer patients for central venous access. Catheter fragmentation leading to catheter malfunction represents a rare problem. Herein we present our experience in the management of fragmented catheters.

Between 2001 and 2003, 183 catheters were placed via the subclavian vein, and five cases of fragmented catheters were observed. Fragments were removed by an Amplatz gooseneck snare (Microvena, St. Paul, MN) with angiographic intervention.

The diagnosis of the breakage was made by chest radiography. The incidence of catheter rupture was 2.7%. All fragments were removed by the snare, without any complications. Catheter narrowing and breakage owing to its medial positioning in the subclavian vein were the main causes of catheter malfunction.

In any case of catheter malfunction, radiologic evaluation of the catheter must be done to rule out its rupture. Removal of the fragments using the Amplatz snare is a safe and easily applied procedure.

[An athletic man with a swollen arm]

A 28-year-old male was referred to our emergency department with a swollen left arm after intensive exercise. Physical examination revealed distension of the superficial veins of his left arm and chest. Duplex ultrasound confirmed the diagnosis of Paget-Schroetter syndrome. He was successfully treated with thrombolysis and first rib resection.

[Ultrasound-guided infraclavicular venipuncture at the junction of the axillary and subclavian veins]

BACKGROUND

Compared to other access routes a central venous catheter inserted via the subclavian vein (VS) is advantageous in terms of patient comfort, care of the puncture site and the infection rate. Puncture of the VS admittedly has a higher risk of mechanical complications but ultrasound guidance can reduce this risk; however, it is technically demanding due to anatomical peculiarities and this access route is therefore used comparatively less frequently.

AIM

The aim of the study was to clarify to what extent a modified puncture technique guided by sonography can reduce the risk potential.

MATERIAL UND METHODS

A technique is presented in which the infraclavicular insertion site is laterally shifted in the direction of the axillary vein (VA).

RESULTS

When the vein is visualized by sonography in the long axis the accompanying artery and the pleura remain outside the ultrasound plane. By doing so, a needle that is strictly guided in the imaging plane can barely damage these structures even if accidentally inserted too deep as they lie outside of the needle trajectory.

CONCLUSION

This presented technique can provide benefits for operators experienced in in-plane puncture.

Paget-von Schroetter Syndrome: Upper Extremity Deep Vein Thrombosis after Continuous Lifting of Heavy Weight

Effort-induced axillary and/or subclavian vein thrombosis occurring in otherwise normal individuals is referred to as Paget-von Schroetter Syndrome (PVSS) or primary, effort-induced, upper extremity deep vein thrombosis (UEDVT). A 42-year old right-handed male presented with complaints of swelling over the left shoulder and arm and dull aching pain in the left arm for two days following regular lifting of heavy LPG gas cylinders. Left upper limb venous Doppler study revealed partial thrombus in the distal axillary vein and near total thrombus in the subclavian and basilic vein. He was managed with anticoagulation therapy.

The Ultrasound-Only Central Venous Catheter Placement and Confirmation Procedure

The placement of a central venous catheter remains an important intervention in the care of critically ill patients in the emergency department. We propose an ultrasound-first protocol for 3 aspects of central venous catheter placement above the diaphragm: dynamic procedural guidance, evaluation for pneumothorax, and confirmation of the catheter tip location.

[Aspiration of blood does not verify intravenous location of central venous catheters]

This case which involves a misplaced central venous catheter demonstrates the importance of certain recognition of intravenous placement before the administration of fluids and medicine.

Dynamic multiplanar real time ultrasound guided infraclavicular subclavian vein catheterization

Ultrasound guided vascular access has been well-characterized as a safe and effective technique for internal jugular and femoral vein catheterization. However, there is limited experience with the use of ultrasound to access the infraclavicular subclavian vein. Multiple ultrasound techniques do exist to identify the subclavian vein, but real time access is limited by vessel identification in a single planar view. To overcome this limitation, a novel technique of ultrasound guided infraclavicular subclavian vein catheterization using a real time multiplanar approach has been developed. The initial experience with this approach is described. A single surgeon used combined oblique, transverse, and longitudinal views along with Doppler color flow images to both define the infraclavicular anatomy and to obtain subclavian vein access in 42 adult patients (20 M/22 F and 22 L/20 R) with a mean body mass index of 29.2 (range = 18.9-55.4). Chest x-ray was obtained to confirm position and to rule out pneumothorax. Subclavian vein cannulation was achieved in 100 per cent of patients; subsequent catheterization was successful in 92.9 per cent. The number of attempts required for cannulation averaged 1.3 (range = 1-5), and decreased after a five patient learning curve. No patient developed a pneumothorax, hematoma, or cannula malposition. Ultrasound guided multiplanar infraclavicular subclavian vein access appears to be a safe and effective adjunct for central line placement.

1000 Port-A-Cath ® placements by subclavian vein approach: single surgeon experience

INTRODUCTION

Totally implantable venous access ports are widely used for the administration of chemotherapy in patients with cancer. Although there are several approaches to implantation, here we describe Port-A-Cath(®) (PAC) placement by percutaneous puncture of the subclavian vein with ultrasonographic guidance.

PATIENTS AND METHODS

Data on our vascular access service were collected prospectively from June 2004. This service included port-a-caths and Hickman lines. Once 1000 consecutive port-a-caths(®) had been reached the study was closed and data analysed for the port-a-caths(®) alone. The left subclavian vein was the preferred site for venous access, with the right subclavian and jugular veins being the alternative choices if the initial approach failed. Patients were followed up in the short-term, and all the procedures were carried out by a single surgeon at each one of two institutions.

RESULTS

Venous access by PAC was established in 100 % of the 1,000 cases. Of the 952 patients where the left subclavian vein was chosen for the first attempt of puncture, the success rate of PAC placement was 95 % (n = 904). Pneumothorax occurred in 12 patients (1.2 %), and a wound haematoma occurred in 4 (0.4 %) out of the total 1,000 patients. No infections were recorded during the immediate post-operative period but only in the long-term post-operative use with 8 patients requiring removal of the PAC due to infection following administration of chemotherapy.

CONCLUSION

This is a very large series of PAC placement with an ultrasound-guided approach for left subclavian vein and X-ray confirmation, performed by a single surgeon, demonstrating both the safety and effectiveness of the procedure.

Acute Pulmonary Embolism due to Paget-Schroetter Syndrome

A 17-year-old Japanese male athlete presented to the emergency department at our hospital with a chief complaint of exertional dyspnea. Although there were no significant findings in the right and left upper extremities on a physical examination, a chest computed tomography scan showed bilateral multiple thrombosis in the pulmonary arteries, indicating pulmonary thromboembolism, and deep vein thrombosis in the left subclavian vein. Upper limb venography showed interruption of the left subclavian vein (so-called Paget-Schroetter syndrome; PSS). We herein report this rare case of PSS that led to pulmonary thromboembolism in a young, male field athlete.

Computed tomography (CT) venography using a multidetector CT prior to the percutaneous external jugular vein approach for an implantable venous-access port

BACKGROUND AND PURPOSE

The objective of this study was to determine the success rate and complications of using the percutaneous approach of the external jugular vein (EJV) for placement of a totally implantable venous-access port (TIVAP) with a preoperative estimate of the detailed anatomical orientation of the cervical venous plexus using computed tomography venography (CT-V).

METHODS

A prospective cohort study of 45 patients in whom placement of a TIVAP was attempted via the right EJV was conducted. The preoperative anatomical estimation of the cervical venous plexus was performed with CT-V using a Multidetector Helical 16-section CT. The angulation between the right EJV and the right subclavian vein, anterior jugular vein, transverse cervical vein, and suprascapular vein was estimated.

RESULTS

CT-V success was achieved in 45 of 45 patients (100 %). A plexus of veins under the clavicle was most commonly responsible for the insertion of the central venous catheter. The EJV approach resulted in a successful cannulation rate of 93 %. No initial complications of pneumothorax or carotid artery puncture occurred during insertion procedures. Late complications occurred in three patients. These included one port erosion (2 %), one catheter occlusion (2 %), and one wound hematoma (2 %). Catheter-related infections were observed in one patient (2 %).

CONCLUSIONS

The percutaneous EJV approach with CT-V guidance is an optional method for patients with multiple central venous cannulations, those in hemodialysis, or those with long catheter indwelling periods.

[Safety of axillary and subclavian vein cannulation using real-time ultrasound guidance]

BACKGROUND

The safety of real-time ultrasound-guided subclavian and axillary vein cannulation as opposed to ultrasound-guided internal jugular vein cannulation has not received much attention. We retrospectively compared the safety and value of real-time ultrasound-guided cannulation in the subclavian and axillary veins with those of the landmark method.

METHODS

We divided 355 patients who had undergone central venous cannulation of the subclavian and axillary vein under local anesthesia into a group that had undergone real-time ultrasound-guided cannulation (Group U), and another group cannulated using the landmark method (Group L). We compared rates of complications and cannulation success as well as average procedural durations between the two groups.

RESULTS

The complication rate was significantly lower in Group U (P=0.005). Most of the complications were arterial puncture. Five patients who developed pneumothorax and nerve damage were in Group L. The success rates and average procedural duration did not significantly differ.

CONCLUSIONS

Real-time ultrasound-guided subclavian and axillary vein cannulation is associated with a low incidence of complications similar to that of the internal jugular vein when competent individuals with appropriate training apply the technique.

Subclavian vein aneurysm secondary to a benign vessel wall hamartoma

Venous aneurysms are rare clinical entities, particularly in children, and their presentation and natural history often depend on the anatomical location and underlying etiology. We present a single case of a 12-year-old girl who presented with a palpable right supraclavicular mass. Imaging evaluation with CT, conventional venography, MRI and sonography revealed a large fusiform subclavian vein aneurysm with an unusual, mass-like fibrofatty component incorporated into the vessel wall. The girl ultimately required complete resection of the right subclavian vein with placement of a synthetic interposition graft. This case provides a radiology/pathology correlation of an entity that has not previously been described as well as an example of the utility of multiple imaging modalities to aid diagnosis and preoperative planning.

Ultrasound-guided subclavian venous catheterisation - is this the way forward? A narrative review

Central venous catheterisation is a commonly performed procedure in anaesthesia, critical care, acute and emergency medicine. Traditionally, subclavian venous catheterisation has been performed using the landmark technique and because of the complications associated with this technique, it is not commonly performed in the United Kingdom - where the accepted practice is ultrasound-guided internal jugular vein catheterisation. Subclavian vein catheterisation offers particular advantages over the internal jugular and femoral vein sites such as reduced rates of line-related sepsis, improved patient comfort and swifter access in trauma situations where the internal jugular vein may not be easily accessible. There is a growing body of evidence to suggest a potential emerging role for ultrasound-guided subclavian vein catheterisation. Barriers to this approach include many physicians still believing that the clavicle obscures imaging of the vein. In this article, we review the evidence supporting ultrasound-guided subclavian vein catheterisation and ask the question whether, in view of it potential advantages, it could be the way forward?

Sonographic evaluation of intravascular volume status in the surgical intensive care unit: a prospective comparison of subclavian vein and inferior vena cava collapsibility index

BACKGROUND

Traditional methods for intravascular volume status assessment are invasive and are associated significant complications. While focused bedside sonography of the inferior vena cava (IVC) has been shown to be useful in estimating intravascular volume status, it may be technically difficult and limited by patient factors such as obesity, bowel gas, or postoperative surgical dressings. The goal of this investigation is to determine the feasibility of subclavian vein (SCV) collapsibility as an adjunct to IVC collapsibility in intravascular volume status assessment.

METHODS

A prospective study was conducted on a convenience sample of surgical intensive care unit patients to evaluate interchangeability of IVC collapsibility index (IVC-CI) and SCV-CI. After demographic and acuity of illness information was collected, all patients underwent serial, paired assessments of IVC-CI and SCV-CI using portable ultrasound device (M-Turbo; Sonosite, Bothell, WA). Vein collapsibility was calculated using the formula [collapsibility (%) = (max diameter - min diameter)/max diameter × 100%]. Paired measurements from each method were compared using correlation coefficient and Bland-Altman measurement bias analysis.

RESULTS

Thirty-four patients (mean age 56 y, 38% female) underwent a total of 94 paired SCV-CI and IVC-CI sonographic measurements. Mean acute physiology and chronic health evaluation II score was 12. Paired SCV- and IVC-CI showed acceptable correlation (R(2) = 0.61, P < 0.01) with acceptable overall measurement bias [Bland-Altman mean collapsibility difference (IVC-CI minus SCV-CI) of -3.2%]. In addition, time needed to acquire and measure venous diameters was shorter for the SCV-CI (70 s) when compared to IVC-CI (99 s, P < 0.02).

CONCLUSIONS

SCV collapsibility assessment appears to be a reasonable adjunct to IVC-CI in the surgical intensive care unit patient population. The correlation between the two techniques is acceptable and the overall measurement bias is low. In addition, SCV-CI measurements took less time to acquire than IVC-CI measurements, although the clinical relevance of the measured time difference is unclear.

Teaching a sonographically guided invasive procedure to first-year medical students using a novel finger transducer

OBJECTIVES

The exposure to ultrasound technology in medicine is increasing at multiple training levels. Ultrasound transducers have evolved to provide higher-resolution imaging for more accurate structural identification, with few improvements in ease of use. This study investigated a novel finger ultrasound transducer used by first-year medical students conducting structural identification and practicing an invasive procedure.

METHODS

A literature search was conducted on texts, specialty journals, and websites regarding the anatomy of internal jugular and subclavian vein central line placement with sonographic guidance and the use of a finger transducer. First-year medical students performed timed sonographically guided cannulation on the internal jugular and subclavian veins on a phantom torso and identified the internal jugular and subclavian veins on a healthy volunteer using the finger transducer and a conventional transducer. After exposure to both transducers, a survey was taken regarding transducer preference.

RESULTS

The literature search revealed no studies comparing finger and classic transducers or sonographically guided central line techniques being conducted by first-year medical students. The students identified and cannulated the internal jugular and subclavian veins using both transducers. Survey results revealed that 70% of the students preferred the finger transducer.

CONCLUSIONS

This study showed that first-year medical students could interpret sonographic anatomy while conducting a clinical procedure. The finger transducer proved successful in structure identification and was preferred to the classic transducer because of its combined tactile presence. This pilot study of a novel finger transducer showed the benefits of combining palpatory skills with ultrasound technology in teaching first-year medical students to perform invasive procedures.

Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography

In 210 consecutive patients undergoing emergency central venous catheterization, we studied whether an ultrasonography examination performed at the bedside by an emergency physician can be an alternative method to chest X-ray study to verify the correct central venous catheter placement, and to identify mechanical complications. A prospective, blinded, observational study was performed, from January 2009 to December 2011, in the emergency department of a university-affiliated teaching hospital. Ultrasonography interpretation was completed during image acquisition; ultrasound scan was performed in 5 ± 3 min, whereas the time interval between chest radiograph request and its final interpretation was 65 ± 74 min p < 0.0001. We found a high concordance between the two diagnostic modalities in the identification of catheter position (Kappa = 82 %, p < 0.0001), and their ability to identify a possible wrong position showed a high correlation (Pearson's r = 0.76 %, p < 0.0001) with a sensitivity of 94 %, a specificity of 89 % for ultrasonography. Regarding the mechanical complications, three iatrogenic pneumothoraces occurred, all were correctly identified by ultrasonography and confirmed by chest radiography (sensitivity 100 %). Our study showed a high correlation between these two modalities to identify possible malpositioning of a catheter resulting from cannulation of central veins, and its complications. The less time required to perform ultrasonography allows earlier use of the catheter for the administration of acute therapies that can be life-saving for the critically ill patients.

Coronary sinus draining into the left subclavian vein through a persistent left superior vena cava

A persistent left superior vena cava (PLSVC) is formed by the remains of the oblique vein of the left atrium, which is not completely degenerated during embryonic development. The incidence is approximately 0.3% in the general population. Approximately 80-92% of PLSVCs drain into the right atrium through the coronary sinus. This report describes a rare case of PLSVC in which the coronary sinus (CS) did not open into the right atrium, but rather drained into the left subclavian vein through the PLSVC.

Multiple extrasplanchnic venous thromboses: a rare complication of pancreatitis. A case report

CONTEXT

Venous thrombosis has been described in patients with acute and chronic pancreatitis. This is especially common in portal vein, splenic vein and superior mesenteric vein. To the best of our knowledge, involvement of superior vena cava and subclavian vessel due to pancreatitis has not been reported.

CASE REPORT

We present here a case of an adult male with alcoholic chronic pancreatitis who presented with multiple vessel thromboses involving superior vena cava, inferior vena cava, bilateral subclavian, internal jugular vein, axillary, iliac and renal vein without involvement of portal, splenic and superior mesenteric vein that was effectively treated with i.v. anticoagulation therapy.

CONCLUSION

Venous thromboses can occur outside the splanchnic circulation in pancreatitis.

Recurrent strokes caused by a malpositioned pacemaker lead

This case report illustrates the case of a patient who developed recurrent strokes after a pace maker lead was inserted into his left ventricle. It was removed successfully by the cardiothoracic surgeons but he remained very dependent functionally. This case highlights the importance of always reviewing the electrocardiogram and chest radiograph after the insertion of a pacemaker as late diagnosis of this complication can leave the patient with significant morbidity.