Complications associated with the use of central venous access devices

Complications of surgical port-a-cath implantation in paediatric patients: a single institution experience

Background

Implantable vascular access devices (IVADs) provide durable routes for administering long-term treatments in patients. However, their associated complications pose a problem. One technique variation that can influence complication rates is the method of securing the IVADs, which is either by ligation or a purse-string suture.

Objective

To compare the two port-a-cath securing techniques, ligation and purse string, in terms of complication rates and types.

Study design

We prospectively included 67 paediatric patients who had port-a-cath insertions secured either by ligation or a purse-string suture at Salmaniya Medical Complex in Bahrain from January 2018 to June 2021. We recorded demographics, diagnoses, port-a-cath site of insertion and securing technique, operative time, follow-up duration, and complications. Patients who had previous port-a-cath insertions or other chemotherapy lines were excluded.

Results

Port-a-caths were secured by ligation in 35 cases and by a purse-string suture in 32 cases. There were 58.9% males and 41.8% females; sex was not correlated with complications (P = 0.11). Patients’ ages ranged from 2 months to 13 years. The overall complication rate of port-a-cath insertions was 16.42%. Complications occurred in 25.7% of ligation-secured port-a-caths and 6.3% of purse-string-secured port-a-caths. In the ligation-secured IVADs, complications included malfunction, infections, removal difficulty and blockage, malposition, and haematoma. Meanwhile, only leakage occurred in the purse-string-secured IVADs.

Conclusion

The port-a-cath securing technique was significantly correlated with complication rates. The complication types and rates in purse-string-secured catheters were lower than those reported in the literature. Leakage was the only complication that occurred in purse-string-secured port-a-caths.

A longitudinal observational retrospective study on risk factors and predictive model of PICC associated thrombosis in cancer patients

To analyze the incidence of PICC associated venous thrombosis. To predict the risk factors of thrombosis. To validate the best predictive model in predicting PICC associated thrombosis. Consecutive oncology cases in 341 who initially naive intended to be inserted central catheter for chemotherapy, were recruited to our dedicated intravenous lab. All patients used the same gauge catheter, Primary endpoint was thrombosis formation, the secondary endpoint was infusion termination without thrombosis. Two patients were excluded. 339 patients were divided into thrombosis group in 59 (17.4%) and non-thrombosis Group in 280 (82.6%), retrospectively. Tumor, Sex, Age, Weight, Height, BMI, BSA, PS, WBC, BPC, PT, D-dimer, APTT, FIB, Smoking history, Location, Catheter length, Ratio and Number as independent variables were analyzed by Fisher's scoring, then Logistic risk regression, ROC analysis and nomogram was introduced. Total incidence was 17.4%. Venous mural thrombosis in 2 (3.4%), "fibrin sleeves" in 55 (93.2%), mixed thrombus in 2 (3.4%), symptomatic thrombosis in 2 (3.4%), asymptomatic thrombosis in 57 (96.6%), respectively. Height (χ² = 4.48, P = 0.03), D-dimer (χ² = 37.81, P < 0.001), Location (χ² = 7.56, P = 0.006), Number (χ² = 43.64, P < 0.001), Ratio (χ² = 4.38, P = 0.04), and PS (χ² = 58.78, P < 0.001), were statistical differences between the two groups analyzed by Fisher's scoring. Logistic risk regression revealed that Height (β = -0.05, HR = 0.95, 95%CI: 0.911-0.997, P = 0.038), PS (β = 1.07, HR = 2.91, 95%CI: 1.98-4.27, P < 0.001), D-dimer (β0.11, HR = 1.12, 95%CI: 1.045-1.200, P < 0.001), Number (β = 0.87, HR = 2.38, 95% CI: 1.619-3.512, P < 0.001) was independently associated with PICC associated thrombosis. The best prediction model, D-dimer + Number as a novel co-variable was validated in diagnosing PICC associated thrombosis before PICC. Our research revealed that variables PS, Number, D-dimer and Height were risk factors for PICC associated thrombosis, which were slightly associated with PICC related thrombosis, in which, PS was the relatively strongest independent risk factor of PICC related thrombosis.

Evaluation of complications of totally implantable central venous port system insertion

The aim of the present study was to describe the procedure of totally implantable central venous port system (TICVPS) insertion performed at our center and investigate associated complications. The study retrospectively evaluated 827 patients who underwent a single-type TICVPS insertion from January 2013 to July 2015. The length of the procedure, long-term device function, angle (chamber-to-tip) and complications of TICVPS, including infection, skin erosion, occlusion, malposition and thrombosis, were analyzed from the patients' medical records. A total of 843 TICVPS insertions were performed in 827 patients. The TICVPS implantation was successful in all cases (100%). A total of 34 cases (4.0%) with complications were recorded. Complications at the chamber insertion site occurred in 11 patients (1.3%), including 5 infection (0.6%) and 6 erosion cases (0.7%). All patients with chamber insertion site infection were treated by administration of antibiotics and dressing. Of the patients in which chamber insertion site erosion occurred, 2 were subjected to TICVPS removal and reinsertion and 4 were treated with debridement, irrigation and resuture. The most common type of complication was catheter-associated (2.3%; n=19). Among these cases, 7 had catheter-associated infection (0.8%), 8 had catheter migration (1.0%) confirmed by chest radiography, 4 had catheter-associated thrombosis (0.5%) and 2 had chamber malposition (0.3%). The present retrospective study on TICVPS, which used a relatively large cohort, demonstrated a low complication rate (4.0%) compared with that reported in previous studies (5-20%). A well-designed procedure, experienced vascular surgeons, an aseptic operating room environment, ultrasound-guided puncture, a wide angle (chamber-to-tip) and the use of fluoroscopy with contrast agent may reduce the complication rate of TICVPS insertion.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Treatment of Pneumothorax as a Complication of Long-Term Central Venous Port Placement in Oncology Patients. An Observational Study

Background and Purpose

In percutaneous placement of central venous catheters an inadvertent, direct lesion of the lung parenchyma can occur. This is a cause of iatrogenic pneumothorax, whose incidence is approximately 1 to 4%, largely dependent on the experience of the operator, the site of venipuncture and probably the technique employed. Initial treatment currently ranges from observation alone to formal tube-thoracostomy. In an attempt to define the best initial treatment, if any, we reviewed our personal series and contributions from the literature. As a result we have produced a flow-chart proposing a rational treatment of this frequent complication.

Patients and Methods

One thousand four hundred twenty-one ports were placed in patients at the Department of Surgery of the European Institute of Oncology in Milan through an infraclavicular standardized percutaneous subclavian approach. They were placed during the 60-month period from January 1, 1996 to December 31, 2000 for long-term chemotherapy treatment of solid tumours. Chest upright X-rays were obtained post-operatively in all cases to check the correct position of the catheter tip and the presence of pneumothorax.

Results

Twenty-two patients out of 1421 (1.54%) experienced a radiologically-proven pneumothorax, ranging from 5 to 70% of the affected pleural space. Sixteen patients out of 22 (72.7%) with minor portions of affected pleural space received simple observation. In these patients the most common finding was an uncomplicated tachycardia (more than 100 beats/min); 8 of them did not complain of any symptoms. Six patients (27.2%) underwent an additional procedure (3 tube-thoracostomies and 3 aspirations of the pleural space), claiming symptoms of chest pain and various degrees of dyspnea. Tube thoracostomy was mainly adopted at the beginning of our experience, and in patients with a severe degree of pleural involvement (55 to 70% of the pleural space). Aspiration, instead, was used more recently and in patients with varying degrees of pleural space involved, ranging from 40 to 60%.

Conclusions

Looking at our own series and literature data, patients with iatrogenic pneumothorax following central venous cannulation who do not have a severe underlying pulmonary disease can be reassured, at the time of diagnosis, that surgery is usually unnecessary and tube thoracostomy is rarely needed. Simple aspiration of the pleural air by means of a central venous catheter inserted percutaneously into the pleural space under local anesthesia should be considered, even if the amount of affected pleural space is more than 50%, before opting for a formal tube-thoracostomy using small-bore tubes.

Percutaneous Intravascular Retrieval of Embolised Fragments of Long-Term Central Venous Catheters

Embolisation of a catheter fragment is a rare mechanical complication of long-term central venous access devices. From 1995 to 1999 we observed 10 cases: the cause of embolisation was the ‘pinch-off syndrome’ in half of the cases, and in 8 cases out of 10 the fragment had embolised in the pulmonary arterial vessels. Percutaneous transvenous retrieval was successful in all cases; it was performed mainly (8 cases out of ten) through the left transfemoral route, using a single-snare-loop device sometimes associated with a pig-tail catheter. We had no mortality and no major complications. On the basis of our experience, we believe that catheter embolisation of long-term central venous devices can be effectively prevented by adequate insertion technique, proper management of the device during its clinical use, and accurate removal technique. Nonetheless, should catheter embolistion occur, the patient should be referred to a Centre with adequate experience in the field of interventional radiological techniques. Should the radiological retrieval procedure fail, evidence from the literature suggests that leaving the fragment in embolisation site might be safer than open extraction by surgical thoracotomy, particularly in oncological patients with reduced life expectancy.

Which is the Easiest and Safest Technique for Central venous Access? A Retrospective Survey of more than 5,400 Cases

There is an ongoing debate on the technique for central venous catheterization associated with the lowest complication rate and the highest success rate. In an attempt to better define the easiest and safest venous approach, we have reviewed our 7-year experience with 5479 central venous percutaneous punctures (by Seldinger's technique) for the insertion of short-term (n=2109), medium/long-term (n=2627) catheters, as well as double-lumen, large-bore catheters for hemodialysis and/or hemapheresis (n=743). We have analyzed the incidence of the most frequent insertion-related complications by comparing seven different venous approaches: jugular vein, low lateral approach; jugular vein, high lateral approach; jugular vein, low axial approach; subclavian vein, infraclavicular approach; subclavian vein, supraclavicular approach; external jugular vein; femoral vein.

The results of our retrospective study suggest that the ‘low lateral’ approach to the internal jugular vein, as described by Jernigan and modified according to our protocol, appears to be the easiest and safest technique for percutaneous insertion of central venous access, being characterized by the lowest incidence of accidental arterial puncture (1.2%) and malposition (0.8%), no pneumothorax, and an extremely low rate of repeated attempts (i.e. more than two punctures before successful cannulation) (3.3%). We advocate the ‘low lateral’ approach to the internal jugular vein as first-choice technique for venipuncture in both adults and children, for both short-term and long-term central venous percutaneous cannulation.

Protein resistance efficacy of PEO-silane amphiphiles: Dependence on PEO-segment length and concentration

In contrast to modification with conventional PEO-silanes (i.e. no siloxane tether), silicones with dramatically enhanced protein resistance have been previously achieved via bulk-modification with poly(ethylene oxide) (PEO)-silane amphiphiles α-(EtO)3Si(CH2)2-oligodimethylsiloxane13-block-PEOn-OCH3 when n=8 and 16 but not when n=3. In this work, their efficacy was evaluated in terms of optimal PEO-segment length and minimum concentration required in silicone. For each PEO-silane amphiphile (n=3, 8, and 16), five concentrations (5, 10, 25, 50, and 100μmol per 1g silicone) were evaluated. Efficacy was quantified in terms of the modified silicones' abilities to undergo rapid, water-driven surface restructuring to form hydrophilic surfaces as well as resistance to fibrinogen adsorption. Only n=8 and 16 were effective, with a lower minimum concentration in silicone required for n=8 (10μmol per 1g silicone) versus n=16 (25μmol per 1g silicone).

STATEMENT OF SIGNIFICANCE

Silicone is commonly used for implantable medical devices, but its hydrophobic surface promotes protein adsorption which leads to thrombosis and infection. Typical methods to incorporate poly(ethylene oxide) (PEO) into silicones have not been effective due to the poor migration of PEO to the surface-biological interface. In this work, PEO-silane amphiphiles - comprised of a siloxane tether (m=13) and variable PEO segment lengths (n=3, 8, 16) - were blended into silicone to improve its protein resistance. The efficacy of the amphiphiles was determined to be dependent on PEO length. With the intermediate PEO length (n=8), water-driven surface restructuring and resulting protein resistance was achieved with a concentration of only 1.7wt%.

New Technology: Heparin and Antimicrobial-Coated Catheters

Although tunneled hemodialysis catheter must be considered the last option for vascular access, it is necessary in some circumstances in the dialysis patient. Thrombosis and infections are the main causes of catheter-related comorbidity. Fibrin sheath, intimately related with the biofilm, is the precipitating factor of this environment, determining catheter patency and patient morbidity. Its association with bacterial overgrowth and thrombosis has led to the search of multiple preventive measures. Among them is the development of catheter coatings to prevent thrombosis and infections. There are two kinds of treatments to cover the catheter surface: antithrombotic and antimicrobial coatings. In nondialysis-related settings, mainly in intensive care units, both have been shown to be efficient in the prevention of catheter-related infection. This includes heparin, silver, chlorhexidine, rifampicine and minocycline. In hemodialysis population, however, few studies on surface-treated catheters have been made and they do not provide evidence that shows complication reduction. The higher effectiveness of coatings in nontunneled catheters may depend on the short average life of these devices. Hemodialysis catheters need to be used over long periods of time and require clinical trials to show effectiveness of coatings over long periods. This also means greater knowledge of biofilm etiopathogeny and fibrin sheath development.

Chemoport-skin erosion: our experience

Chemoports are totally implantable venous access devices, which are retained over long periods of time to facilitate chemotherapy administration. Skin erosion is a rare complication wherein there is breach in the skin overlying the septum. This study reports the author's experience of skin erosion in three cases. Ports were explanted in all cases. Skin incision for port placement should be placed away from the access site and repeated access at the same point must be avoided to lessen the incidence of skin erosions.

Central venous access devices in patients with hemophilia

Hemophilia is a hereditary disorder in which the major clinical manifestation is bleeding into the joints, muscles, internal organs and the CNS, often without any obvious trauma. Bleeding can be fatal as in the case of CNS hemorrhage, or severely debilitating following repeated bleeding into joints that results in crippling arthritis. Treatment for hemophilia includes the intravenous administration of clotting factor concentrates to replace the missing or defective protein. Venous access is therefore critical to the treatment of hemophilia and the prevention of complications due to bleeding. According to the US Centers for Disease Control and Prevention, approximately half of patients less than 16 years of age and one-third of all patients with hemophilia receive regular prophylactic injections of clotting factor concentrates. Prophylaxis, or the regular scheduled administration of antihemophilic factor concentrate, is effective in preventing bleeding. Among those patients with severe disease, in the absence of prophylaxis, approximately 13 bleeds, including nine joint hemorrhages, occur annually. In contrast, when prophylaxis is administered, the annual number of total and joint bleeds decreases to five and three, respectively. One of the major barriers to the more wide-spread use of prophylaxis is venous access. While peripheral venipuncture remains the first choice for venous access, central venous access devices are frequently used to facilitate repeated and/or urgent administration of clotting factor concentrates. The advantages of central venous access devices are well recognized in certain treatment regimens such as prophylaxis and immune tolerance therapy, as well as certain patient groups such as young children in whom venipuncture is often difficult and traumatic, and adults with scarred veins. Central venous access devices also allow earlier commencement of both home treatment and prophylaxis. The goal of this review is to discuss the different types of central venous access devices and their role in the management of hemophilia to provide practitioners that care for patients with hemophilia with the necessary information to make sound therapeutic recommendations to their patients.

Inadvertent port: catheter placement in azygos vein

Totally implantable ports are safe and effective means of venous access for administration of chemotherapy. One of the usual vessels accessed, through which the port is placed, is the subclavian. Herein, we report a case where the central access was obtained through the left subclavian vein. But the catheter when it was placed was found to be in the azygos vein. This was confirmed with dye study. This is the first report of such an occurrence with subclavian access. The catheter was later withdrawn and repositioned in the superior vena cava. We recommend that the entire procedure of catheter placement must be done under fluoroscopy guidance to ensure safe and error-free positioning.

Catheter rupture and distal embolisation: a rare complication of central venous ports

Central venous access devices placed through a percutaneous subclavian approach may be compressed by neighbouring bony structures, leading to biomaterial fatigue, catheter fracture at the compression site, and possible embolisation of distal fragment into the central veins. The aim of this paper is to review the experience of the authors, including more than 1300 subclavian port placements, carried out during a five-year period, discussing possible causes and therapeutic options of this rare complication. Nine patients out of 1320 (0.68%) experienced this complication during the five-year period of this study. Two patients only showed a retrospective radiologic evidence of the 'pinch-off sign' (e.g. initial compression of the catheter at the costo-clavicular junction). No patients had symptoms from the embolised catheter fragment; the most frequent symptom (8 out of 9 cases) was a painful swelling around the port area during infusion, related to the extravasation of medications or fluids into the subcutaneous tissue. The site of embolised segment varied from azygos vein to right pulmonary artery; however, these findings did not affect the outcome, and all the embolised fragments were successfully retrieved through a transfemoral approach using a radiologic interventional technique. No fatality occurred. The catheter fracture and embolisation of the distal fragment are a well-known complication of subclavian central venous long-term cannulation, whose estimated overall incidence is 0.5-1%. Diagnosis is usually based on the radiologic appearance of the catheter compression (so called 'pinch-off sign'), which is far from being constant; a clinical suspicion can derive from intermittent malfunction, which claims differential diagnosis with the pres-ence of a fibrin sleeve around the tip of the catheter. Once diagnosed, the treatment is always an interventional radiologic approach, which has a very high success rate. When it fails, the possibility to leave the fragment embolised in the central veins, heart or pulmonary arteries, should be considered, being the thoracotomy and open catheter retraction questionable, at present time, in patients who have no symptoms and limited life-expectancy.

Accidental migration of ASH-split catheter during central venous catheter replacement: retrieval using an interventional radiology approach

Catheter fracture and embolization of the distal fragment are well-known complications of subclavian central venous long-term cannulation. In hemodialysis it is an exceptional event. We report a case of accidental rupture of a cuffed hemodialysis catheter with distal migration of a fragment during a procedure of catheter exchange via guide-wire. According to most reported cases, intravascular catheter separation usually occurs completely asymptomatically; our report confirms that catheter embolization itself is usually asymptomatic. Less than one third of the literature-reported cases have associated symptoms, such as palpitations or chest discomfort. Once diagnosed, treatment is an interventional radiological approach, which has a very high success rate. The replacement of permanent cuffed hemodialysis catheters via guide-wire is a delicate procedure and if catheter embolization is diagnosed, the patient must be referred to a center with specific experience in the retrieval of intravascular objects.

Percutaneous retrieval of an embolized central venous chemoport in a patient with colon cancer

The central access device is commonly used as a route of chemotherapuetic agents in patients with malignant diseases for its convenient and safety for insertion. This report describes a case of 66-year-old man with colon cancer who suffered a rare complication in which a chemoport embolized into the inferior vena cava and it was successfully retrieved by a percutaneous approach using a goose neck snare.

Skin erosion over totally implanted vascular access devices in children

Erosion of the skin over a totally implanted vascular access device (TIVAD) is a rare event that may lead to life-threatening sequelae. From 1994 to 2007, we reviewed the medical records and central line database of 960 central line insertions for the complication of skin erosion over the TIVAD. Outcome measures included age, gender, and nutritional status, number of days until complication, insertion site, and attending surgeon. A total of 540 of the 960 central lines were TIVAD. Skin erosion occurred in 9 patients for an incidence of 1.67%. Average age at insertion was 51 months (range 25-116.5 months). The average catheter duration use in days was 335 with a range of 39-1575 days. Malnutrition defined as BMI <5% or a decrease in BMI percentiles occurred in 2 and 4 patients, respectively, and contributed to the thinning of the subcutaneous fat. Skin erosion over TIVAD is a rare complication. Most cases can be prevented by inserting the device in a subfacial location in the very young child or in the child with expected weight loss. Furthermore, the device should be placed at a fair distance from the skin incision to prevent early skin erosion through the wound.

Guidelines on the insertion and management of central venous access devices in adults

Central venous access devices are used in many branched of medicine where venous access is required for either long-term or a short-term care. These guidelines review the types of access devices available and make a number of major recommendations. Their respective advantages and disadvantages in various clinical settings are outlined. Patient care prior to, and immediately following insertion is discussed in the context of possible complications and how these are best avoided. There is a section addressing long-term care of in-dwelling devices. Techniques of insertion and removal are reviewed and management of the problems which are most likely to occur following insertion including infection, misplacement and thrombosis are discussed. Care of patients with coagulopathies is addressed and there is a section addressing catheter-related problems.

Consensus recommendations for use of central venous access devices in haemophilia

Venous access is essential for delivery of haemophilia factor concentrate. Wherever possible, peripheral veins remain the route of choice, and the use of central venous access devices (CVADs) should be limited to cases of clear need in patients with caregivers able to exercise diligence in CVAD care and should continue no longer than necessary. CVADs are of recognized value for repeated administration of coagulation factors in haemophilia, particularly for prophylaxis and immune tolerance therapy and in young children. Evidence to guide best practices has been fragmentary, and standardized methods for CVAD usage have yet to be established. We have developed management recommendations based upon available published evidence as well as extensive clinical experience. These recommendations address patient and CVAD selection; CVAD placement, care and removal; caregiver/patient guidance; and complications, including infection and thrombosis. In the absence of inhibitors, ports are recommended, primarily because of fewer associated infections than with external catheters. For patients with inhibitors, ports also appear to be associated with fewer infections. Infection is the most frequent complication, and recommendations to prevent and treat infections are supported by extensive clinical data and experience. Strict adherence to handwashing and aseptic technique are essential elements of catheter care. Evidence-based data regarding the detection and treatment of CVAD-related thrombotic complications are limited. Caregiver education is an integral part of CVAD use and the procedural practices of users should be regularly re-assessed. These recommendations provide a basis for sound current CVAD practice and are expected to undergo further refinements as new evidence is compiled and clinical experience is gained.

Central venous catheters: choosing the most appropriate access route

Intravenous therapy and care is a complex and intricate area of practice, which is being subsumed into the core role of registered nurses. As more patients become recipients of a vascular access device (VAD), particularly those requiring intermediate to long-term central venous access, it is important to ensure that not only the device but also the most appropriate vein meets their clinical physiological and psychological needs. There is much research and literature on the insertion and care of central venous catheters (CVCs) as well as the detection and treatment of complications. However, apart from a few small studies comparing the performance of devices placed either in the subclavian or jugular veins, there is little to guide doctors or nurses as to which vein is preferable, if secondary complications are to be avoided. This article will describe a number of primary and secondary complications associated with both the subclavian and internal jugular veins and how these can be minimized by selecting the most appropriate vessel. The article concludes with the author's suggestions for correct patient assessment in order that the correct vein is utilized.

Central venous access devices in haemophilia

Central venous access devices (CVADs) can facilitate repeated and/or urgent administration of coagulation factors in haemophilic patients. We conducted a systematic review and meta-analysis of complication rates and risk factors for poor outcome. Forty-eight studies with a total of 2704 patients and 2973 CVADs were included. The primary indications for CVADs were immune tolerance therapy (34.9% of patients), difficult venous access (31.8%) and prophylaxis (29.1%). Fully implanted CVADs were employed in 77.4% of cases and external CVADs in 22.6%. A total of 1190 infections were reported, and the pooled incidence of infection was 0.66 per 1000 CVAD days [confidence interval (CI), 0.44-0.97 per 1000 CVAD days]. Among patients developing infection, the pooled time to first infection was 295 days (CI, 181-479 days). Presence of inhibitors was an independent risk factor for infection with an incidence rate ratio (IRR) of 1.67 (CI, 1.15-2.43). Infection was less likely in patients >6 years of age (IRR, 0.46; CI, 0.27-0.79) and recipients of fully implanted CVADs (IRR, 0.31; CI, 0.12-0.86). Available information on thrombosis was limited, with only 55 cases being reported. Eventually, 31.3% of CVADs were removed, and infection was the reason for removal in 69.9% of cases and thrombosis in 4.1%. The pooled time period CVADs remained indwelling prior to removal or the expiration of the study observation period was 578 days per CVAD (CI, 456-733 days per CVAD). CVADs can confer major benefits in patients with haemophilia requiring long-term venous access, and serious complications are rare.

Radiologic diagnosis and management of complications related to central venous access

Central venous access is an important aspect of medical treatment. There are different designs of access devices for different purposes. In essence, they can be classified as short- and long-term devices. Insertion procedures vary for different devices. There is a risk for both acute and delayed complications. Radiology plays a central role both in placement and in device management. Image-guided insertion increases technical success and reduces the rate of acute complications. The diagnostic approach to long-term complications includes radiography, fluoroscopy, CT, and ultrasound. Treatment by interventional procedures is possible for a number of these conditions. These interventions increase device lifespan and reduce the number of necessary reinsertions.

Case report: the malfunctioning implanted venous access device

Totally implanted venous access devices (VADs) are an alternative to central line placement for those patients requiring frequent intravenous access. Venous thrombosis, infection, extrusion, extravasation and occlusion are commonly encountered complications of central VADS. Fracture with embolization of implantable venous access catheter is a rare complication of this commonly used device, but it may have serious consequences. Clinical manifestation may include infraclavicular or chest pain, paraesthesias in the arm, cardiac arrhythmias, palpitation or an extra heart sound, in addition to withdrawal occlusion, swelling, and resistance to infusion. Nursing staff should be aware of these signs and symptoms and they should immediately stop any infusion if these signs and symptoms emerge. Whenever problems with a VAD occur a chest radiograph or a contrast enhanced angiographic control of the VAD is advised. This article provides two cases relating to malfunction of a VAD. Despite typical symptoms in both cases a catheter fracture with embolization was not taken into consideration, and a radiological control of the VAD was not performed. It was only by chance that the patients did not sustain any harmful sequels from the broken VAD.

Therapeutic embolization of an internal mammary artery damaged by placement of a central venous catheter

We describe the embolization of a left internal mammary artery damaged by left internal jugular venous catheterization. Because potentially serious complications can occur with a blind approach for central venous catheterization, portable ultrasound machines should be used more often to ensure correct placement of the catheter.

A prospective analysis of the cephalic vein cutdown approach for chronic indwelling central venous access in 100 consecutive cancer patients

BACKGROUND

Chronic indwelling central venous access devices (CICVAD) generally are placed by the percutaneous subclavian vein approach. The cephalic vein cutdown approach is used only infrequently. Although the technique has been well described, few prospective data are available on the cephalic vein cutdown approach.

METHODS

From September 9, 1998, to July 20, 1999, the cephalic vein cutdown approach was attempted in 100 consecutive cancer patients taken to the operating room with the intention of placing CICVAD. Median patient age was 54.5 years (range 18-88), with 46 men and 54 women. Twenty-five patients had gastrointestinal malignancies, 17 had breast cancer, 15 had lymphoma, 13 had lung cancer, 12 had leukemia, 5 had multiple myeloma, and 13 had other malignancies. Patients were followed prospectively for immediate and long-term outcome.

RESULTS

CICVAD placement via the cephalic vein cutdown approach was successful in 82 patients; the remaining 18 patients required conversion to a percutaneous subclavian vein approach. The reasons for inability to place CICVAD via cephalic vein cutdown approach were a cephalic vein that was too small (10 patients), an absent cephalic vein (7 patients), and inability to traverse the angle of insertion of the cephalic vein into the subclavian vein (1 patient). There were 56 subcutaneous ports and 26 tunneled catheters. Median operating time was 44 minutes (range, 26-79 minutes). No postoperative pneumothorax occurred. Median catheter duration was 198 days (range, 0-513 days). Long-term complications included catheter-related bacteremia (6%), site infection (2%), deep venous thrombosis (5%), port pocket hematoma (1%), and superior vena cava stricture (1%). Thirty-seven percent of patients have died since CICVAD placement. Twenty-nine percent of the CICVADs have been removed.

CONCLUSIONS

The cephalic vein cutdown approach was successful in 82% of patients. This approach is a safe and useful alternative to the percutaneous subclavian vein approach.

Pregnancy outcome in patients requiring parenteral nutrition

OBJECTIVE

The purpose of this retrospective study was to evaluate maternal and perinatal outcomes and complications of parenteral nutrition during pregnancy in our institution.

METHODS

This study was a review of medical records of all women who required parenteral nutrition during pregnancy at our institution from 1990-1997. The frequency of maternal and perinatal complications was calculated.

RESULTS

Twenty-six pregnancies required parenteral nutrition for the following indications: hyperemesis gravidarum (n = 16), cholecystitis/pancreatitis (n = 3), small bowel obstruction (n = 2), intracranial bleed (n = 2), ulcerative colitis (n = 1), and other (n = 2). The mean gestational age at initiation of therapy was 16.2 weeks and the mean duration of therapy was 30.6 days. Five pregnancies were terminated prior to fetal viability. Of the remaining pregnancies, obstetric complications occurred in 11, including two cases of idiopathic preterm labor resulting in preterm deliveries. Maternal complications resulting from the central venous catheters included four infections, two thromboses, one occlusion, one pneumothorax, and one catheter dislodgment. The complication rate for centrally inserted central catheters (50%) was significantly greater than the rate for peripherally inserted central catheters (9%).

CONCLUSIONS

Successful outcomes can be achieved in obstetric patients requiring parenteral nutrition. In this group of patients, the frequency of maternal complications secondary to centrally inserted central venous catheters was greater than that reported in nonpregnant patients. Peripherally inserted central catheters may be preferable when parenteral nutrition is required during pregnancy.

The futility of chest roentgenograms following routine central venous line changes

OBJECTIVE

To demonstrate chest roentgenograms after central venous line changes over a guidewire delay the use of the central lines and increases charges with no change of morbidity or the rate of complication.

METHODS

Retrospective study using the Surgical Intensive Care database followed by a nonrandomized, prospective study of central venous line changes. The total time from the catheter change until chest radiograph confirmation and an analysis of charges was done.

RESULTS

The retrospective study of 1,201 central line changes demonstrated no pneumothorax and two central lines malpositioned. The prospective study of 100 patients demonstrated no pneumothorax and one catheter malpositioned. The average time from completion of the central line change until the radiographic confirmation was 60.2 minutes. The charge for the chest x-ray film was $156.

CONCLUSIONS

The combined studies composed of 1,301 patients demonstrated no pneumothorax and three malpositioned catheters. This study demonstrates that radiographic confirmation of central venous line placement after routine line change is of no benefit as the malpositioned catheters caused no morbidity, produces significant delays and increases medical charges to the patient. Extrapolation predicts an annual reduction of $46,800 in the Vanderbilt Surgical Intensive Care Unit.

Central venous catheter failure is induced by injury and can be prevented by stabilizing the catheter tip

PURPOSE

Thrombosis associated with central venous catheters is a significant cause of device failure, morbidity, and loss of access sites. We hypothesized that central vein thrombosis is caused by catheter injury to the vein wall and that it can be reduced by stabilizing the catheter tip. To test these hypotheses, we studied central vein catheters in a porcine model. Test catheters had a silicone-encased stainless steel loop at the indwelling end that contacted the vein wall and stabilized the catheter tip in the center of the vessel.

METHODS

Sealed silicon elastic (Silastic) catheters (3.2 mm outer diameter) with and without a stabilizing loop were inserted via the external jugular vein into the superior vena cava just above the right atrium. Animals were killed at 1, 2, 4, and 8 weeks, and the vena cava was inspected for the presence of thrombus and entrapment of the catheter tip.

RESULTS

In control animals mural thrombus developed at the site of the catheter tip. This thrombus organized by invasion of macrophages and smooth muscle cells, eventually forming a lesion similar to intimal hyperplasia. Lesion cross-sectional area was significantly smaller in animals with loop catheters than in control animals at 2 weeks (1.2 +/- 1.3 vs 34.5 +/- 23.9 mm2; p = 0.05) and 4 weeks (2.8 +/- 0.3 vs 13.9 +/- 5.8 mm2; p < 0.05). By 8 weeks the vena cava was nearly occluded in most animals and the catheter tip was entrapped in this lesion in all cases. Test catheters eliminated the injury process for up to 8 weeks (p < 0.01, chi2 control vs loop catheter entrapment). Very little injury response was found where the loop contacted the vein wall, and the catheter tip was free of thrombus in all cases.

CONCLUSIONS

Mural thrombosis at the tip of indwelling central catheters is caused by chronic mechanical venous wall injury. Vessel injury and the resulting thrombosis can be prevented by a catheter modification that stabilizes the tip. Such a catheter may significantly reduce catheter malfunction and morbidity associated with these devices.

Factor V Leiden mutation does not account for central venous catheter-related thrombosis

Indwelling central venous access devices are frequently associated with catheter-related thrombosis. The factor V Leiden gene mutation decreases the sensitivity of factor V to the anticoagulant activity of activated protein C, and has been shown to be the most common inherited defect associated with a hypercoagulable state. In this study, we sought to determine whether an increased prevalence of the factor V gene mutation could be identified in individuals with malignancies who had catheter-related thrombosis. Twenty-seven patients who had catheter-related thrombosis were identified and two (7%) tested positive for the heterozygous presence of the factor V gene mutation. Since the vast majority of patients with venous access devices who developed catheter-related thrombosis did not have the factor V gene mutation, pre-catheter placement testing for this mutation would have limited clinical utility.

[Staphylococcus aureus bacteremia and a mass in the right atrium in a patient carrying a central port]

A male heroin abuser was admitted because of Candida endophthalmitis. A permanent central venous line was inserted. Three months later, he had positive catheter and blood cultures with Staphylococcus aureus. Transthoracic and transesophageal echocardiography and magnetic resonance revealed a right atrial mass. Treatment with antibiotics in addition to clinical and echocardiographic follow up was decided upon. Six weeks later, a transesophageal echocardiography showed a decrease in right atrial mass size and the patient was discharged asymptomatic without treatment. Three months later, he was well and a new transesophageal echocardiography showed a further decrease in atrial mass size with signs of fibrosis. This follow up supports the clinical suspicion of thrombus in the right atrium attributable to a central venous line and Staphylococcus aureus bacteremia.

Principles of chronic venous access: recommendations based on the Roswell Park experience

At Roswell Park Cancer Institute, we have seen a dramatic increase in the need for long-term venous access. Chronic venous catheters are an indispensible part of the treatment provided to oncology patients. Cancer patients are often at higher risk for complications secondary to their underlying disease and treatments. These risks may be minimized by paying close attention to several important aspects of central line placement. These include matching individual patient needs with the access device most suited to those needs, a thorough preoperative assessment, and the safest and most appropriate operative approach for placement. Likewise, the prompt recognition and treatment of complications when they do occur is crucial to the care of these patients. In order to optimize the care of patients with long-term venous access devices, we have reviewed our experience of over 700 vascular access consultations and offer the following recommendations.

Diagnosis and treatment of bacteremia and intravascular catheter infections

The past decade has witnessed an explosive rise in the rate of bacteremia and intravascular catheter infection. Although gram-negative organisms continue to account for up to one third of these infections, gram-positive organisms have become increasingly prevalent pathogens. Virulent antibiotic-resistant bacterial strains have emerged and present a formidable treatment challenge. Simultaneously, management of catheter infection has evolved. Although patients who develop fungemia, gram-negative bacteremia, or sepsis syndrome are best treated by catheter removal in addition to antimicrobial therapy, an increasing body of evidence suggests that many gram-positive bacterial catheter infections can be treated by use of antimicrobial agents without catheter removal. Advances in catheter design and immunotherapy for sepsis syndrome also hold promise. Despite these innovations, determining the initial need for catheter placement, adherence to meticulous sterile surgical technique during insertion, and subsequent fastidious catheter maintenance remain the mainstays of preventing these potentially disastrous infections.