Peroperative Electrocardiographic Control of Catheter Tip Position during Implantation of Femoral Venous Ports

Totally implanted central venous access devices inserted by the femoral route: A narrative review and the proposal of a novel approach, the FICC-port

BACKGROUND

Femoral ports are used in patients with indication to a totally implanted venous access device but with contraindication to chest-ports and brachial ports because of obstruction of the superior vena cava. In the last three decades, femoral ports have been implanted almost exclusively by cannulation of the common femoral vein at the groin, while the position of the tip has been assessed by X-ray.

METHODS

We report our experience with a new approach to femoral ports, which includes recent methods and techniques developed in the last few years. These novel femoral ports, which we call "FICC-ports," are characterized by (a) long femoral 5 Fr polyurethane catheter inserted by ultrasound-guided puncture of the superficial femoral vein at mid-thigh; (b) intraprocedural location of the tip in the sub-diaphragmatic inferior vena cava, using ultrasound visualization by the transhepatic and/or the subcostal view; (c) low-profile or very low-profile reservoir implanted above the quadriceps muscle, at mid-thigh.

RESULTS

In the last 3 years, we have implanted 47 FICC-ports in young adults with mediastinal lymphoma compressing the superior vena cava. We had no immediate/early complication, and only three late complications (one kinking of the catheter in the subcutaneous tissue; one tip migration with secondary venous thrombosis; one persistent withdrawal occlusion due to fibroblastic sleeve).

CONCLUSION

If there is indication to a femoral port, the implantation of a "FICC-port"-as described above-is to be strongly considered in terms of safety, effectiveness, and cost-effectiveness: no immediate-early complications, minimal late complications, no X-ray exposure, low invasiveness, low cost.

Effect of intracavitary electrocardiographic localization on the success rate and complications of PICC in infants

BACKGROUND

Peripherally inserted central catheter (PICC) is widely used in chemotherapy of children with malignant tumors because of its safe operation and long indwelling time.

OBJECTIVE

To investigate the effect of intracavitary electroencephalogram (CEEG) localization technique on the success rate and complications of PICC in infants.

METHODS

A total of 180 children with PICC catheterization and maintenance at Shijiazhuang People's Hospital First Hospital from January 2017 to January 2020 were selected and divided into control group (n= 90 cases) and observation group (n= 90 cases). The control group observed the tip position of the fixed catheter through X-ray film and adjusted the catheter until its tip was located in the superior vena cava. The observation group used intracavitary electrocardiogram positioning technology. Comparison of the effects of two groups on the success rate and complications of PICC puncture in infants and young children.

RESULTS

The success rate of one puncture in the observation group was significantly higher than that in the control group (P< 0.05). Within one month of catheterization, 13 cases had complications, with an incidence rate of 16.00% lower than the control group's 34.00% (27/80) (P< 0.05). The screening test results showed that the specificity, sensitivity, Youden index, accuracy, kappa coefficient, positive and negative predictive value were 88.89%, 97.56%, 0.86, 96.00%, 0.86, 0.86, respectively. The measured values were 97.56% and 88.89% respectively, and the cost and time of localization were lower than those of X-ray.

CONCLUSION

The technique of intracavitary electrogram can be more accurate for infants to place the tip of central venous catheter through peripheral vein, which can effectively improve the success rate of one puncture with low cost, and has high reliability, accuracy and practicability, which is safe and effective.

The SIF protocol: A seven-step strategy to minimize complications potentially related to the insertion of femorally inserted central catheters

The insertion of central venous catheters through the femoral veins is not uncommon and is potentially associated with the risk of immediate puncture-related complications and severe late complications as infection and thrombosis. As for other central venous access devices, the use of a standardized protocol of insertion and the correct application of evidence-based strategies are beneficial in reducing the risk of complications. We proposed a standardized protocol (S.I.F.: Safe Insertion of Femorally Inserted Central Catheters) consisting of seven strategies that should be part of vascular cannulation and should be adopted during the insertion of femoral venous catheters, aiming to minimize immediate, early and late insertion-related complications. These strategies include: preprocedural evaluation of the patient history and of the veins, appropriate aseptic technique, ultrasound guided puncture and cannulation of the vein, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and appropriate coverage of the exit site.

Ultrasound-guided cannulation of the superficial femoral vein for central venous access

BACKGROUND

In some clinical conditions, central venous access is preferably or necessarily achieved by threading the catheter into the inferior vena cava. This can be obtained not only by puncture of the common femoral vein at the groin, but also-as suggested by few recent studies-by puncture of the superficial femoral vein at mid-thigh.

METHODS

We have retrospectively reviewed our experience with central catheters inserted by ultrasound-guided puncture and cannulation of the superficial femoral vein, focusing mainly on indications, technique of venipuncture, and incidence of immediate/early complications.

RESULTS

From June 2020 to December 2020, we have inserted 98 non-tunneled central venous catheters (tip in inferior vena cava or right atrium) by ultrasound-guided puncture of the superficial femoral vein at mid-thigh or in the lower third of the thigh, all of them secured by subcutaneous anchorage. The success of the maneuver was 100% and immediate/early complications were negligible. Follow-up of hospitalized patients (72.5% of all cases) showed only one episode of catheter dislodgment, no episode of infection and no episode of catheter related thrombosis.

CONCLUSIONS

The ultrasound approach to the superficial femoral vein is an absolutely safe technique of central venous access. In our experience, it was not associated with any risk of severe insertion-related complications, even in patients with low platelet count or coagulation disorders. Also, the exit site of the catheter at mid-thigh may have advantages if compare to the exit site in the inguinal area.

The application of intracavitary electrocardiogram for tip location of femoral vein catheters in chemotherapy patients with superior vena cava obstruction

BACKGROUND

Most studies focused on the application of intracavitary electrocardiogram (IC-ECG) location in superior vena cava access catheterization, this study aimed to explore the effect of IC-ECG for tip location of femoral vein catheters in chemotherapy patients with superior vena cava obstruction (SVCO).

METHODS

A total of 158 patients placed catheters through superficial femoral vein from July 2016 to May 2019 were enrolled in the randomized controlled study. The patients were divided into two groups by envelope lottery method: X-ray location was used in the control group (n = 79); IC-ECG location was used in the observation group (n = 79). The catheters should be located at or near the inferior vena cava (IVC)-right atrium (RA) junction (above the level of diaphragm within the IVC). The general information of patients, clinical catheterization effects and catheter-related complications were compared between the groups.

RESULTS

No significant differences in general information, catheter obstruction, catheter-related thrombosis, catheter exit-site bleeding and infection were found between the groups. The rate of successful insertion at the first attempt and patient satisfaction in the observation group were significantly higher than that in the control group (p < 0.05). The time and cost of location and the incidence of catheter-related complications in the control group were 32.57 min and 140.51 Yuan and 21.5%, which were significantly higher than 6.94 min and 13.59 Yuan and 7.6% in the observation group (p < 0.05).

CONCLUSION

IC-ECG accurately located the tip of femoral vein catheters, reduced the incidence of catheter-related complications and the time and cost of location, improved patient satisfaction.

Central venous catheters misplaced in paraspinal veins: A systematic literature review based on case reports

BACKGROUND

Paraspinal vein misplacement is an uncommon complication of central venous catheterization via lower extremities, most of which have been reported in case reports.

AIM

To determine the clinical characteristics of paraspinal vein misplacement.

DESIGN

This was a systematic review.

METHODS

A systematic literature search in the PubMed, EMBASE, Scopus, and Web of Science databases was performed from their inception to 18 June 2019. Case reports and small case series describing central venous catheter misplacement in the paraspinal vein were included. Data on the catheterization procedure, catheter tip position, complications, and radiographic features of misplacement were extracted.

RESULTS

Thirty studies with a total of 36 patients were included. The ascending lumbar vein accounted for the majority of misplacements (n = 30), followed by the lumbar vein (n = 4), iliolumbar vein (n = 1), and vertebral venous plexus (n = 1). Six patients had eventful catheterization procedures. Twenty-six patients experienced misplacement-induced complications, of whom seven died. The most common complications included cerebrospinal fluid abnormalities, neurological symptoms, and deteriorated respiration. Among the entire case cohort, the onset of complications was the primary sign that alerted medical staff to misplacement (n = 23). The typical radiographic characteristics were posterior deviation of the catheter course overlapping with the spine on lateral X-rays and a bend, kink, or hump in the catheter course on anteroposterior X-rays at the L4 to L5 levels.

CONCLUSIONS

Nurses should be aware of this particular complication if a patient who has undergone catheterization via a lower extremity presents deterioration of neurological function and respiration.

RELEVANCE TO CLINICAL PRACTICE

Lateral X-ray radiography is an effective method to verify misplacement and is recommended as routine practice during catheterization via lower extremities.

Intraoperative identification of persistent left superior vena cava with intracavitary electrocardiogram during venous port insertion: A report of eight cases

Persistent left superior vena cava is a rare congenital anomaly, occurring in 0.3% to 0.5% of general population and up to 10% in patients with congenital heart disease. This anomaly is usually discovered incidentally during central venous catheterization from left side. Since 2015, we have identified eight cases of persistent left superior vena cava out of a total of 2637 patients who had left sided venous port insertion in our department. The persistent left superior vena cavae were identified with the aid of intracavitary electrocardiogram. The characteristic finding was an initial negative P-wave (in lead II), followed by a biphasic P-wave pattern during catheter insertion. All the ports worked properly, with a total catheter dwelling time of 2586 days (range: 96-756 days, mean: 323.25 days), and no catheter-related complication was observed. However, because of the paucity of clinical evidence, we should still be prudent in the long-term use of venous ports in persistent left superior vena cava.

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.