Azygo-Tracheal Fistula in a Complete Implantable Central Venous System

A 4-year tunneled hemodialysis catheter malpositioned into the azygos vein and how to remedy the hemodialysis circuit

Mispositioning in the azygos vein is a rare but hazardous complication of central venous catheterization. A patient was admitted for a dysfunctional hemodialysis tunneled cuffed catheter (TCC) placed in the azygos vein for 4 years. Computed tomography angiography revealed multiple sites of occlusion, including the superior vena cava (SVC), right and left innominate veins (IVs), and right femoral vein. Percutaneous transluminal angioplasty and a TCC replacement based on a segment-by-segment recanalizing strategy were performed. First, an 8-Fr sheath was inserted through the left femoral vein approach to retrogradely traverse the occlusive SVC followed by a guidewire extending to the occlusive left IV. A left transjugular 15-cm snare was inserted to capture the transfemoral guidewire and achieve recanalization from the left IV to the SVC. Second, a transjugular guidewire was advanced through the dysfunctional TCC yet shunted into the left IV due to the inability to cross the SVC. A left transfemoral 15-cm snare was inserted to capture the guidewire and achieve complete recanalization from the right internal jugular vein to the SVC. Balloons were passed over the guidewires to dilate the obstructive lesions sequentially, and a new TCC was inserted successfully with the tip positioned in the right atrium.

Venous-Airway Fistula With Aspergilloma: A Case of an Implanted Catheter Gone Bad

The implanted venous access catheter is commonly used in the treatment of oncology patients. Although common long-term complications of these devices, such as infection and thrombosis, have been widely reported, venous-airway fistula due to port placement is an extremely rare and poorly understood complication. We report a case of a 56-year-old woman with pancreatic adenocarcinoma whose implanted catheter was complicated by the development of an azygo-bronchial fistula with a concomitant aspergilloma. Herein is the first reported case of successful venous-airway fistula closure obtained through silicone stenting.

Recurrent migration of peripherally inserted central catheter into the azygos vein

Peripherally inserted central catheter (PICC) migration into azygos vein (AV) is a rare complication. It is recognised only when catheter malfunction occurs or when patients develop associated complications. PICC migration into AV has been reported to be associated with various complications such as catheter malfunction, perforation, haemorrhage, thrombosis, infection and stenosis of AV. Pleural effusion and trachea-azygos fistulas have also been reported. We present a patient with recurrent migration of PICC into AV after an initial corrective repositioning during the same hospital stay. In this case, PICC migration was possibly related to left-sided approach, use of smaller diameter PICC, severe congestive heart failure and her bedbound status. PICC migration should be considered when PICC found be malfunctioning, especially if associated with the above risk factors.

Ultrasound-Guided Arm Ports: Indications, Techniques, and Management

Purpose: Various venous access devices are available, including peripheral venous lines, peripherally inserted central catheters lines, and subcutaneous port catheters. The latter provides medium-to long-term venous access and includes medical devices that can be inserted either on the chest (chest ports) or in the arm (arm ports). We report the techniques, dedicated indications, and main complications of arm port insertion using the ultrasonography (US) guidance method.

Methods: Tips and tricks of percutaneous real-time US-guided vein access technique in the arm are reviewed, and a brief literature review is reported.

Results: Technical feasibility is almost 99%. US guidance allows depiction of anatomic variants, reduces the number of failed attempts, and increases the technical access rate compared with venography-guided access. Comparison of arm ports to chest ports reveals a higher global complication rate. We also report typical (mechanical) complications and dedicated indications, including contraindications to chest port insertion and selected patients for whom chest ports are not possible (eg, those with breast, head, and neck cancer; obesity; cosmesis; and requiring upright position).

Conclusions: Arm port insertion under US guidance is safe and effective, and has dedicated indications.

The azygos vein pathway: an overview from anatomical variations to pathological changes

The azygos venous system represents an accessory venous pathway supplying an important collateral circulation between the superior and inferior vena cava. The aim of this article is to revise the wide spectrum of changes ranging from normal to pathological conditions involving the azygos system. Teaching points • The azygos vein is a collateral venous pathway, becoming a vital shunt if major pathways of venous return are obstructed. • In azygos continuation, the azygos vein becomes significantly enlarged due to inferior vena cava interruption. • Fibrosing mediastinitis is an underestimated acquired disorder. • Fibrosing mediastinitis induces a variable engorgement of collateral veins. • Fibrosing mediastinitis leads to superior vena cava syndrome.

Upper gastrointestinal tumors: current status and future perspectives

Recent therapeutic developments that have provided new promising and successful approaches to the treatment of solid tumors are in large part due to the increasing understanding of their molecular biology. Despite this progress, these new therapies have provided minimal benefit in the treatment of upper gastrointestinal (GI) malignancies. Hence, the overall survival of patients with upper GI tumors remains dismal. These disappointing results are largely due to the lack of early detection strategies, inadequate medical treatments and the poor understanding of upper GI tumor biology. Clinically, the treatment paradigm has been evolving for these malignancies. Esophageal cancer is now commonly treated with preoperative chemoradiation in the USA, in both academic and community cancer centers, due to its theoretical advantages. Adjuvant chemotherapy and chemoradiation are also frequently used in patients with pancreatic cancer. Exciting prospects remain in the medical and surgical treatment of these malignancies with the inclusion of biologic agents in many protocols, newer chemotherapeutic agents (such as S-1 in the treatment of gastric cancer), and the use of minimally invasive procedures for the treatment of premalignant and, possibly, early malignant lesions of the esophagus and stomach. This review focuses on the current practice in the management of upper GI tumors and summarizes the recent advances in the field.

Epidermal growth factor receptor-directed therapy in esophageal cancer

Esophageal adenocarcinoma (EAC) is one of the fastest growing malignancies in the US. The long-term survival of patients with this cancer remains poor; only 25% of patients undergoing surgical excision are alive after 5 years. Multimodal programs that incorporate radiotherapy, chemotherapy and surgery for localized tumors may result in a modest survival advantage. However, significant strides in this disease can result from the inclusion of targeted therapies. The epidermal growth factor receptor (EGFR) family represents one such target and is receiving increasing attention due to the advent of specific inhibitors. Studies conducted by us and others have shown that the overexpression of EGFR family signaling intermediates is common in Barrett's esophagus and EAC. In the latter case, EGFR expression may have prognostic significance. EGFR inhibitors, including oral tyrosine kinase inhibitors and monoclonal antibodies, result in a synergistic antitumor effect with chemotherapeutic agents or with radiotherapy. Therefore, several ongoing studies include EGFR-directed therapy either alone or in combination with chemoradiotherapy for this disease. Our study of gefitinib, oxaliplatin and radiotherapy suggested that gefitinib can be safely incorporated into an oxaliplatin-based chemoradiation program for esophageal cancer, although the clinical activity of this combination is modest. Herein, we review the current literature on this subject.

Central venous access: techniques and indications in oncology

Long lines can be inserted centrally or peripherally through patent veins into the central venous system down to the atrial caval junction. Traditionally surgeons, anesthetists, cardiologists and more recently interventional radiologists have been placing them using vein cutdown or percutaneous needle puncture techniques. Typical candidates for implanted venous catheters are cancer patients undergoing long-term chemotherapy. The most important issues, in addition to the patency of central veins and the history of previous indwelling catheters, pacewires or venous thrombosis, are the patient's performance status, body mass index, medical history and respiratory status, and the relevant technique. The present article will give an overview of the radiological and surgical implantation techniques and will highlight the impact of imaging means on the technical feasibility, assessment and treatment of device-related complications.