Endovascular electrocardiography to guide placement of totally implantable central venous catheters in oncologic patients

Aetiology and management of persistent withdrawal occlusion in venous ports in oncology patients

INTRODUCTION

Persistent withdrawal occlusion (PWO) is a specific catheter malfunction characterized by the inability to withdraw blood through the device. The most common cause of PWO in ports is the presence of a fibroblastic sleeve (FS). If malfunction occurs, medication can be applied incorrectly with the increased risk of complications.

METHODS

One hundred seventy-seven cases of PWO in venous ports were managed. We focused on evaluating the cause of PWO, the frequency of occurrence of FS, and the options to address the malfunction. The patients underwent fluoroscopy with a contrast agent administration. Mechanical disruption (MD) with a syringe of saline using the flush method was used; in case of its failure, subsequent administration of a lock solution with taurolidine and urokinase, or low-dose thrombolysis with alteplase was indicated. Demographic data were compared with a control group.

RESULTS

A significantly higher proportion of female patients was found in the cohort of patients with PWO (80.3% vs 66.3%, p = 0.004), dominantly patients with ovarian cancer (12.8% vs 4.8%, p = 0.022). No effect of the cannulated vein or the type of treatment on the incidence of PWO was demonstrated. The presence of FS was verified in 70% of cases. MD with a syringe was successful in 53.5% of cases. A significantly shorter time to referral (3 weeks) was demonstrated with successful management. The overall success rate of achieving desobliteration by MD alone or in combination with a thrombolytic (urokinase or alteplase) administration was 97.4%.

CONCLUSION

We created a method for resolving PWO using MD +/- application of thrombolytics with 97.4% success rate. Current evidence showed that FS is not likely to be affected by thrombolytic drugs; however, we have ascertained an effect of these drugs, proposing a hypothesis of microthrombotic events at the tip of the catheter if fibroblastic sleeve is present.

An ultrasound-based technique in the management of totally implantable venous access devices with persistent withdrawal occlusion

Persistent withdrawal occlusion is a specific catheter malfunction characterized by inability to withdraw blood through the device while infusion is maintained. The main causes are fibroblastic sleeve and tip malposition (associated or not to venous thrombosis around the tip). All current guidelines recommend infusing vesicant/antiblastic drugs through a central venous port only after assessment of blood return. In PWO, blood return is impossible. We have recently started to assess the intravascular position of the tip and the delivery of the infusion in the proximity of the cavo-atrial junction utilizing transthoracic/subxiphoid ultrasound with the 'bubble test'. We found that this is an easy, real-time, accurate and safe method for verifying the possibility of using a port for chemotherapy even in the absence of blood return, as it occurs with persistent withdrawal occlusion.

Intracavitary electrocardiography for tip location during central venous catheterization: A narrative review of 70 years of clinical studies

Intracavitary electrocardiography is an accurate and non-invasive method for central venous access tip location. Using the catheter as a traveling intracavitary electrode, intracavitary electrocardiography is based on the increase in the detected amplitude of the P wave while approaching the cavoatrial junction. Despite having been adopted diffusely in clinical practice only in the last years, this method is not novel. In fact, it has first been described in the late 40s, during electrophysiological studies. After a long period of quiescence, it is in the last two decades of the XX century that intracavitary electrocardiography became popular as an effective mean of central venous catheters tip location. But the golden age of this technique began with the new millennium, as documented by high-quality studies in this period. In fact, in those years, intracavitary electrocardiography has been studied broadly, and important achievements in terms of comprehension of the technique, accuracy, and feasibility of the method in different populations and conditions (i.e. pediatrics, renal patients, atrial fibrillation) have been gained. In this review, we describe the technique, its history, and its current perspectives.

Use of real-time ultrasound for locating tip position in neonates undergoing peripherally inserted central catheter insertion: A pilot study

Background & objectives:

Securing long-term venous access is an essential part of sick newborn care. The malposition of central line tip leads to several complications. There is a need for an easily available bedside investigating tool to diagnose these malpositions. This study was done to compare the effectiveness of real-time ultrasound (RTUS) with X-ray in identifying the peripherally inserted central catheter (PICC) line tip.

Methods:

This pilot observational study was conducted in a level III Neonatal Intensive Care Unit of a tertiary care hospital in India, from June 2012 to June 2013. A total of 33 PICC lines in 31 infants were included in the study. After insertion of PICC line, X-ray and RTUS were done to locate the tip of the PICC line.

Results:

In this study, PICC line tip could be identified by bedside RTUS in 94 per cent of line insertions. Standard X-ray identified the tip in all cases. RTUS has been shown to have good diagnostic utility in comparison with X-ray with sensitivity and specificity being 96.55 and 100 per cent, respectively. In our study, majority of malpositions were identified and manipulated by RTUS, thus second X-rays were avoided.

Interpretation & conclusions:

The result of this pilot study shows that RTUS may be a reliable and safe bedside tool for determining the tip of PICC lines. However, studies with large sample size need to be done to confirm these findings.

Clinical evaluation of the use of an intracardiac electrocardiogram to guide the tip positioning of peripherally inserted central catheters

The use of peripherally inserted central catheters (PICCs) provides important central venous accesses for clinical treatments, tests and monitoring. Compared with the traditional methods, intracardiac electrocardiogram (ECG)-guided method has the potential to guide more accurate tip positioning of PICCs. This study aimed to clinically evaluate the effectiveness of an intracardiac ECG to guide the tip positioning by monitoring characteristic P-wave changes. In this study, eligible patients enrolled September 2011 to May 2012 according to the inclusion and exclusion criteria received the catheterization monitored by intracardiac ECG. Then chest radiography was performed to check the catheter position. The results revealed that, with 117 eligible patients, all bar one patient who died (n = 116) completed the study, including 60 males and 56 females aged 51.2 ± 15.1 years. Most (n = 113, > 97%) had characteristic P-wave changes. The intracardiac ECG-guided positioning procedure achieved correct placement for 112 patients (96.56%), demonstrating 99.12% sensitivity and 100% specificity. In conclusion, the intracardiac ECG can be a promising technique to guide tip positioning of PICCs. However, since the sample size in this study is limited, more experience and further study during clinical practice are needed to demonstrate achievement of optimal catheterization outcomes.

Evaluation of the Correct Position of Peripherally Inserted Central Catheters: Anatomical Landmark vs. Electrocardiographic Technique

Purpose

The purpose of this study is to verify as early as possible the correct positioning of the peripherally inserted central catheter (PICC) tip in order to reduce complications due to possible malpositioning. The ECG-guided technique proved to be reliable, easy to carry out, straightforward, low-cost and allows us to recognize an incorrect or a suboptimal positioning throughout the procedure. The purpose of this study is to compare two methods used during the PICC insertion so as to prevent catheter malpositioning; the first study estimates the catheter length by the landmark method (based on cutaneous anatomical landmarks, CALs) with the addition of the postprocedural verification of tip location by chest X-Ray (CxR), whereas the second method of intraprocedural tip location is based on the observation of the morphological variations of the P wave (ECG-guided technique) with the addition of the postprocedural verification by CxR.

Methods

From 2010 to 2012, 90 PICCs were positioned, 48 using the anatomical landmarks and 42 using the ECG technique.

Results

Twenty-five percent of the catheters positioned with the anatomical landmark technique did not reach the correct position of the tip in SVC; of these, 6.25% were placed in an aberrant position and others in a suboptimal position. Of the 42 PICCs positioned with the ECG technique, only in three cases (equal to 7.14%), a suboptimal position of the tip was observed, whereas there was no case of aberrant positioning.

Conclusions

The ECG technique represents an accurate, low-cost and safe technique to verify the correct positioning of the tip. The use of the ECG allowed a more correct positioning in terms of catheter tip-carina distance and catheter tip-tracheobronchial angle, and in no patient was it necessary to place a catheter again.