Radiologic placement of central venous catheters: rates of success and immediate complications in 3412 cases.

OBJECTIVE: To determine the success and immediate complication rates associated with 3412 central venous catheter placements performed in an interventional radiology suite. METHODS: Success and immediate complication rates were prospectively recorded for 3412 consecutive patients who had central venous catheters radiologically placed at a tertiary care centre between July 1993 and October 2000. The indication for placement and the insertion site were also recorded. RESULTS: The most common indication for both short- and long-term venous access was hemodialysis, and the right internal jugular vein was the most common site for catheter insertion. Placement was successful for 98.8% of tunnelled lines and 99.3% of temporary catheters. The rate for immediate complications (including pneumothorax, air emboli, bleeding and arterial puncture) for tunnelled catheter placements was 3.8% and for temporary catheter placements was 1.6%; no major complications were documented. CONCLUSION: Our results lend further evidence to the claim that the success and immediate complication rates of radiologically placed central venous catheters compare favourably with blind placement and surgical placement of central venous catheters.     

Radiologic placement of tunneled central catheters: rates of success and of immediate complications in a large series.

OBJECTIVE: The objective was to examine the success and immediate complication rates in a large series of radiologically placed tunneled central venous catheters. SUBJECTS AND METHODS: We prospectively recorded the success and immediate complication rates in 880 consecutive radiologically placed tunneled central venous catheters. We also recorded the indication for placement, the success of placement, the number of passes required, and whether a double- or single-wall puncture occurred. RESULTS: Hemodialysis was the most common indication for long-term venous access. Venous access was successful in all patients, and catheter placement was successful in 99.4% of patients, with only five failed placements. All patients in whom placement was initially unsuccessful underwent successful placement the same day. All catheters were placed using real-time sonographic guidance. Most were placed in an internal jugular vein, with 87.4% requiring only a single needle pass. The immediate complication rate was only 4.0%, and no major complications occurred. CONCLUSION: To our knowledge, this series is the largest for which the immediate complication and success rates for radiologically placed central venous catheters have been reported. Our results suggest that radiologic placement of tunneled central venous catheters is a safe and effective alternative to surgery.     

Cost comparison of radiologic versus surgical placement of long-term hemodialysis catheters

OBJECTIVE: The purpose of this study was to compare the cost of radiologic versus surgical placement of long-term hemodialysis catheters. MATERIALS AND METHODS: Our cost analysis was based on 47 long-term hemodialysis catheters radiologically placed in 45 patients and 25 catheters surgically placed in 25 patients from October 1996 through March 1997. Variable and total costs were calculated using data from the hospital administrative computer system that records the actual costs incurred by the hospital in caring for patients. RESULTS: The average total hospital cost was $926 for each radiologic placement and $1849 for each surgical placement of long-term hemodialysis catheters. The total cost saving for radiologic placement was $923 for each catheter. CONCLUSION: Radiologic placement of long-term hemodialysis catheters resulted in substantial savings over surgical placement.     

Conversion of indwelling chest port catheters to tunneled central venous catheters

PURPOSE: To determine the safety and efficacy of the conversion of subcutaneous chest wall infusion ports to tunneled central venous catheters. MATERIALS AND METHODS: During a period of 34 months, 67 patients were referred for conversion of indwelling subcutaneous chest wall ports to tunneled central venous catheters as part of a bone marrow transplant protocol. Six patients were deemed unacceptable for conversion and the remaining 61 underwent successful conversion. All patients had functioning surgically placed single-lumen (n = 50) or double-lumen (n = 11) chest ports, which were removed to maintain the original venous access sites for placement of a tunneled central venous catheter, incorporating the chest wall pocket for tunneling, in 46 patients (75%). A new tunnel was created in the other 15 patients. There were no immediate complications and all patients were followed until catheter removal or patient demise with the catheter in place. RESULTS: 57 of 61 (93%) catheters were used without evidence of infection for 23-164 days (mean, 57 d) after placement. Two (3%) were removed (both at 26 days) because of persistent neutropenic fever without physical signs or laboratory evidence of catheter infection, and two (3%) were removed (at 11 and 77 days) because of proven catheter infection, yielding an overall infection rate of 1.2 per 1,000 catheter days. Two catheters required exchange and two required stripping because of decreased function, resulting in an overall catheter-related complication rate of 2.4 per 1,000 catheter days. CONCLUSIONS: Indwelling subcutaneous chest wall infusion ports can be safely converted to tunneled central venous catheters, even in an immunocompromised patient population, with a low risk of complications such as infection.     

The Groshong catheter: initial experience and early results of imaging-guided placement.

Fifty Groshong catheters were placed in 50 patients with use of ultrasound (US) and fluoroscopic guidance in the radiology suite: 49 were placed via the subclavian vein and one was placed via the left internal jugular vein. All (100%) attempts at catheter placement were successful. Imaging guidance affected the placement of catheters in 12 cases (24%), including four patients (8%) in whom vascular access would not have been possible with blinded percutaneous venipuncture or surgical cutdown. After a four-case learning curve period, during which one pneumothorax (2%) and two arterial punctures (4%) occurred, there were no further venipuncture-related complications. One catheter was removed because of infection (2%) and one because of allergic reaction (2%) to the antimicrobial cuff. Four patients with cutaneous infections and one with catheter-related sepsis were successfully treated with antibiotics. Results demonstrate the initial promise of imaging-guided placement of central venous access catheters when performed in the radiology suite.     

The implantation of Hickman catheters. A new function of interventional radiology

Hickman catheters are used mainly in patients with hematologic diseases, especially lymphatic and myelotic leukemias, and malignant lymphomas. They facilitate the administration of chemotherapeutics, hyperosmolar solutions and other substances with local toxicity as well as frequent taking of blood samples. Usually Hickman catheters are placed by surgical cut-down on a jugular vein. In lieu of this surgical placement, we recommend the implantation of Hickman catheters by means of interventional radiology techniques. In a period of 13 months 78 Hickman catheters were placed in 67 patients, 37 catheters (= 47%) stayed more than one month, 8 catheters (= 10%) stayed 5 to 8 months in the central venous system, 26, respectively 6, of these catheters are until now in situ. Lethal or life threatening complications did not occur. There were no infections at the introduction site of the catheter. The main complications were: pneumothorax without drainage: 3.2%, pneumothorax with drainage: 3.2%, slipping back of the tip of the catheter: 4.8%, thrombosis of the subclavian vein: 3.2%, fluid in the pleural cavity: 1.6%. In correspondence to the literature the complications of Hickman catheter placement by means of interventional radiology are less serious than by means of surgical cutdown. Further advantages are: general anesthesia can be avoided (less strain on severely ill patients, no problems to wean from assisted ventilation in patients with respiratory insufficiency), the smooth curve of the implanted catheter avoids sharp kinking and occlusion of the lumen, very small skin incisions are sufficient (lesser risk of hematomas in patients with thrombopenia), time and cost are reduced in comparison to surgical placement.     

The role of the interventional radiologist in enteral alimentation

The provision of enteral nutrition through the placement of gastrostomy/gastrojejunostomy tubes is a well-established procedure. Traditionally, these catheters have been placed either surgically or endoscopically; however, over the past two decades interventional radiologists have increasingly performed these procedures successfully. The perceived advantages of this route lie in the reported lower morbidity and mortality rates. In addition, percutaneous radiologically guided (PRG) catheters may be placed in certain subgroups of patients in whom it would be technically difficult or impossible by other routes, e.g., patients with head and neck or oesophageal tumours. The aim of this review is to describe the techniques of radiologically placed gastrostomy/gastrojejunostomy, discuss its indications and contraindications, describe any associated potential complications and compare PRG results with the more established techniques of open surgical and endoscopic placement. We also describe some recent procedural and catheter modifications.     

Interventional Radiology Techniques for Provision of Enteral Feeding

Gastrostomy placement in patients who are unable to maintain their nutrition orally has been attempted using a variety of techniques over the past century. This includes surgical, endoscopic, and, more recently, percutaneous radiologically guided methods. Surgical gastrostomy placement was the method of choice for almost a century, but has since been superseded by both endoscopic and radiological placement. There are a number of indications for gastrostomy placement in clinical practice today, with fewer contraindications due to the recent innovations in technique placement and gastrostomy catheter type. We describe the technique of gastrostomy placement, which we use in our institution, along with appropriate indications and contraindications. In addition, we will discuss the wide variety of catheter types available and their perceived advantages. There remains some debate with regard to gastropexy performance and the use of primary gastrojejunal catheters, which we will address. In addition, we will discuss the advantages and disadvantages of the three major types of gastrostomy placement currently available (i.e., surgical, endoscopic, and radiological) and their associated complications.     

Venous thrombosis related to peripherally inserted central catheters

PURPOSE: To determine factors that may lead to venous thrombosis in patients with peripherally inserted central catheters (PICC). MATERIALS AND METHODS: The medical records of 678 patients with 813 PICCs during 1997 were cross-referenced with all patients receiving venous duplex examinations (1,631) during the same time period. Multiple factors were examined in the patients with catheter-related thrombosis, including diagnosis, solution infused, catheter tip position, vein accessed, and catheter diameter. RESULTS: Nurses placed 269 PICCs with 12 venous thromboses, for a rate of 4.5%. Radiologists placed 544 PICCs with 20 venous thromboses, for a rate of 3.7%. There was no significant difference in these rates. The overall thrombosis rate was 3.9%. After multivariate analysis, only catheter diameter remained significant. There were no thromboses in catheters 3 F or smaller. The thrombosis rate was 1% for 4-F catheters, 6.6% for 5-F catheters, and 9.8% for 6-F catheters. CONCLUSIONS: Thrombosis rate associated with PICCs was low (3.9%). The smallest acceptable catheter diameter should be used to decrease the incidence of venous thrombosis.     

Radiologic placement of tunneled hemodialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion

PURPOSE: To evaluate interventional radiologic placement of tunneled hemodialysis catheters in small thyrocervical collateral veins or in occluded veins in the neck or chest in patients with limited venous access. MATERIALS AND METHODS: A femoral venous approach was used to recanalize occluded veins or catheterize small collateral veins in 24 patients in whom all major central veins were occluded. A loop snare or catheter was used as a target for antegrade puncture. Metallic stents were deployed if necessary. Once antegrade access was secured, catheters were placed in a conventional fashion. RESULTS: Technical success was achieved in 22 (88%) of 25 procedures (one patient underwent two procedures). All catheters functioned immediately after placement. There were two procedural complications: a vasovagal episode requiring intravenously administered atropine sulfate and an episode of respiratory distress requiring intubation. There were no instances of pneumothorax, nerve injury, or bleeding complications. Catheter malfunction requiring exchange occurred at a rate of 0.67 per 100 catheter days. Infection requiring catheter removal occurred at a rate of 0.06 per 100 catheter days. Primary patency was 90% at 1 month, 71% at 6 months, and 25% at 12 months. Secondary patency was 100% at 6 months and 70% at 12 months. CONCLUSION: In patients undergoing hemodialysis in whom conventional venous access sites have been exhausted, interventional radiologic venous recanalization for the placement of permanent catheters is safe and effective. Catheters placed in recanalized veins or small collateral veins have shorter primary patency rates compared with those of conventionally placed catheters, but the former can be maintained for relatively long periods.     

Peripherally inserted central catheters with distal versus proximal valves: prospective randomized trial

PURPOSE: To evaluate whether peripherally inserted central catheters (PICCs) with a proximal valve have any advantage compared to those with a distal valve in regard to the incidence of occlusion, infection, or malfunction. MATERIALS AND METHODS: One hundred patients (mean age, 46 y) were randomized to receive either a distal-valved Bard Groshong catheter (n = 48) or a proximal-valved Catheter Innovations Pressure Activated Safety Valve catheter (n = 52). All catheters were 4-F, single-lumen PICCs. Catheters were placed under fluoroscopic (n = 82) or sonographic (n = 18) guidance. Most (91%) were placed for the administration of antibiotics. The placement procedure, maintenance, and weekly follow-up were the same for both catheters. RESULTS: Percutaneous placement with the catheter tip in the central veins was successful in all patients. Mean dwell time was 36 days. There were 12 (25%) occlusive or infectious complications in the distal valve catheter group and six (11.5%) in the proximal valve group (P = .08). There were 25 fractures in 17 distal valve catheters (35.4%) and three (5.8%) proximal valve catheter fractures (P < .01). CONCLUSION: There was a marked difference in durability between the valved catheters, in favor of the catheter with a proximal valve. There was also a trend for fewer occlusive and infectious complications with the proximal valve catheter.     

Percutaneous placement of central venous catheters: comparing the anatomical landmark method with the radiologically guided technique for central venous catheterization through the internal jugular vein in emergent hemodialysis patients

Purpose: To compare the success and immediate complication rates of the anatomical landmark method (group 1) and the radiologically (combined real-time ultrasound and fluoroscopy) guided technique (group 2) in the placement of central venous catheters in emergent hemodialysis patients.

Material and Methods: The study was performed prospectively in a randomized manner. The success and immediate complication rates of radiologically guided placement of central venous access catheters through the internal jugular vein (n = 40) were compared with those of the anatomical landmark method (n = 40). The success of placement, the complications, the number of passes required, and whether a single or double-wall puncture occurred were also noted and compared.

Results: The groups were comparable in age and sex. The indication for catheter placement was hemodialysis access in all patients. Catheter placement was successful in all patients in group 2 and unsuccessful in 1 (2.5%) patient in group 1. All catheters functioned adequately and immediately after the placement (0% initial failure rate) in group 2, but 3 catheters (7.5% initial failure rate) were non-functional just after placement in group 1. The total number of needle passes, double venous wall puncture, and complication rate were significantly lower in group 2.

Conclusion: Percutaneous central venous catheterization via the internal jugular vein can be performed by interventional radiologists with better technical success rates and lower immediate complications. In conclusion, central venous catheterization for emergent dialysis should be performed under both real-time ultrasound and fluoroscopic guidance.     

Insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations

Introduction

Central venous catheter placement is an effective alternative vascular access for dialysis in patients with chronic renal failure. The purpose of this study was to evaluate the insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations in terms of efficacy of the procedure and early complications.

Materials and methods

Between 2008 and 2010, the vascular access team of our hospital placed 409 central venous catheters in patients with chronic renal failure. The procedure was performed using the Seldinger blind technique. In 18 (4.4%) cases it was impossible to advance the guidewire, and so the patients were transported to the angiography suite.

Results

Using the angiographic technique, the guidewire was advanced in order to position the central venous catheter. The latter was inserted into the subclavian vein in 12 (66.6%) cases, into the internal jugular vein in 4 (22.2%) and into the femoral vein in 2 (11.1%) cases. There was only one complicated case with severe arrhythmia in 1 (5.5%) patient.

Conclusion

Our results suggest that insertion of central venous catheters using angiographic techniques in hemodialysis patients with previous multiple catheterizations is a safe and effective procedure with few complications and high success rates.     

Apheresis: another indication for radiologically placed central venous catheters.

OBJECTIVE: Apheresis is an important technique, used increasingly for a variety of conditions. It is sometimes performed via peripheral access because of concern over major complications associated with central venous catheter (CVC) placement. This study was to determine the safety and success of radiologic placement of CVCs for apheresis. METHODS: Data were collected prospectively for 278 CVCs placed under real-time sonographic or fluoroscopic guidance in the radiology department. Complications were noted in all cases; the number of passes required for venipuncture and whether this was achieved with a single wall puncture were noted in 265 cases; duration of catheterization and reason for removal of the catheter were recorded in all cases. The study group included 83 donors providing peripheral blood stem cells for allogeneic transplant. RESULTS: CVCs were successfully placed in all patients, 269 in the internal jugular and 9 in the femoral vein. In 87% of cases, only a single pass was required, and in 80% of cases venipuncture was achieved with a single anterior wall puncture. There was inadvertent but clinically insignificant arterial puncture in 6 cases (2%). In no case did this prevent CVC placement. Most catheters (211/274, 77%) were removed the same day. Only 3 catheters were removed prematurely (1%), 1 because of infection and 2 because of clotting. There was 1 case of venous bleeding. CONCLUSION: CVCs are safe for apheresis if real-time sonographic guidance is used for the puncture, guide wire and catheter placement are confirmed fluoroscopically, and the duration of catheterization is short.     

Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access

PURPOSE: To compare the incidence of symptomatic venous thrombosis after tunneled infusion catheter placement via the internal jugular vein (IJV) versus the subclavian vein (SCV). MATERIALS AND METHODS: A retrospective analysis was performed of 774 catheters placed. Only patients with complete follow-up were included, which yielded a population of 279 catheters in 238 patients (166 in the SCV, 113 in the IJV; total of 26,242 catheter days). All catheters were placed by interventional radiologists with ultrasonographic (in IJV) or venographic (in SCV) guidance. RESULTS: Initial complications were limited to one pneumothorax in the SCV group and one episode of oversedation in the IJV group. There was no difference in infection rates between the two sites (SVC vs IJV: 0.25 vs 0.32 per 100 catheter days; P >.99). The mean dwell time was slightly longer for SCV catheters (103 days) than for IJV catheters (79 days) (P =.04). Venous thrombosis developed in 13% of patients (0.12 per 100 catheter days) with an SVC catheter placed as compared with in 3% (0.04 per 100 catheter days) with an IJV catheter (P =.018). This difference persisted after adjustment for catheter size and side of placement (P =.025). The mean time to thrombosis was 36 days for SCV catheters and 142 days for IJV catheters. CONCLUSION: The IJV is the preferred site for tunneled infusion catheter placement because of the lower incidence of symptomatic venous thrombosis.     

The insertion of chronic indwelling central venous catheters (Hickman lines) in interventional radiology suites

The insertion of Hickman central venous catheters for chronic venous access is a procedure usually conducted in the operating theatre under local or general anaesthesia. In a prospective study over a one year period we have assessed the feasibility of radiologists inserting central venous catheters for long term access. A subclavicular approach to the subclavian vein with prior digital subtraction angiography or video imaging of the vein was the technique of choice. Thirty-one Hickman catheters were inserted in 21 patients. All but two patients had a haematological malignancy. Ages ranged from 19 to 77 years. The mean time for insertion was 43 min (range 20-80 min). The catheters remained in situ for between 2 days and 242 days with a mean of 86 days. There was one documented line infection; nine patients had episodes of septicaemia with identified organisms, and a further six had pyrexias of unknown origin during the line indwelling period. There were four documented line and or ipsilateral subclavian vein thromboses, and one death occurred within 36 hours of the procedure. We conclude that radiological placement is an excellent alternative to 'blind' surgical placement. Screening during insertion provides immediate facilities for correction of malposition and monitoring of immediate complications. The time taken for catheter insertion did not impede the usual patient throughout in the interventional radiology suite.     

Treatment of loculated pleural effusions with transcatheter intracavitary urokinase

Surgical thoracostomy tube placement and radiologically guided catheter drainage are standard therapy for loculated pleural fluid collections. Treatment may fail if the catheter is not placed optimally within the loculation or if the fluid is hemorrhagic or fibrinous. We studied the value of transcatheter urokinase instillation in facilitating drainage of hemorrhagic or fibrinous nonhemorrhagic loculated pleural collections in 11 patients with 13 loculated pleural collections. Eight of the fluid collections were hemorrhagic, five were nonhemorrhagic. Five patients had had a thoracostomy tube placed surgically and all had had radiologically guided placement of single lumen drainage catheters managed with suction, saline irrigation, and mechanical guidewire manipulation. This therapy had failed to drain the loculations completely over an average of 10 days (range, 1-22 days). Urokinase (1000 units/ml) was instilled into the drainage catheters in 80- to 150-ml aliquots. After 1-2 hr, suction was reinstituted and the procedure was repeated. Twelve (92%) of the 13 collections were drained completely after an average of 4.3 instillations (range, three to eight instillations). Successful urokinase therapy required an average of 28 hr (range, 8-75 hr). In one case, therapy was discontinued after partial resolution for unrelated clinical reasons. There were no complications. These results suggest that transcatheter intracavitary urokinase therapy is a safe and effective method to facilitate drainage of loculated hemorrhagic or fibrinous nonhemorrhagic pleural fluid collections.     

Nonsurgical repositioning of central venous catheters

Long-term central venous catheters are placed for total parenteral nutrition and/or chemotherapy. These catheters are placed surgically and fixed to the subcutaneous tissues. Complications include infection, venous thrombosis, and mechanical problems. The authors developed a method to percutaneously reposition displaced central venous catheters. The procedure is performed with fluoroscopy and modified angiographic techniques. Fifteen patients underwent a total of 17 procedures. The initial success rate was 76%; the final success rate was 88%. Many central venous catheters can be salvaged with this low-morbidity procedure, which negates the need for surgical intervention.     

Peripherally inserted central catheter placement in patients with unsuspected central venous obstruction

PURPOSE: To evaluate the feasibility and clinical usefulness of peripherally inserted central catheter (PICC) placement in patients with unsuspected central venous obstruction. MATERIALS AND METHODS: Of 3,272 PICC procedures performed from January 1999 to July 2006, 57 patients had central venous stenosis or obstruction during placement of the PICC. Sixty PICC placements were performed in 57 patients (30 male and 27 female patients; mean age, 59 years). The PICC placements in 57 patients were evaluated with regard to the location and severity of venous disease, underlying causes of venous stenosis or obstruction, catheter placement technique, technical success rate, catheter dwelling time, and complication rate. RESULTS: There were 48 complete obstructions and 12 stenoses. Ipsilateral lesion passage was attempted in 31 patients and was successful in 26 (84%) and unsuccessful in five (16%). Over-the-wire PICC placement was performed in 16 patients, and PICC placement after angioplasty was performed in 10. Contralateral PICC placement without a trial of traversing the lesion was done in 26 patients. The PICC dwell time ranged from 2 to 150 days (median, 25.5 days). Complications occurred in four of the 57 patients (7%) and included tube tip migration (n = 1), catheter occlusion (n = 1), and catheter infection (n = 2). CONCLUSIONS: PICCs can be safely placed across central venous lesions in patients with asymptomatic central venous stenosis or obstruction. Contralateral placement is favorable in cases of ipsilateral passage failure.     

Transhepatic catheter access for hemodialysis

PURPOSE: To retrospectively review the authors' experience regarding the safety and functionality of transhepatic hemodialysis catheters. MATERIALS AND METHODS: Sixteen patients (seven men and nine women aged 21-77 years; mean age, 51.6 years) underwent placement of 21 transhepatic hemodialysis catheters. Transhepatic catheters were placed in the absence of an available peripheral venous site (11 patients) or for preservation of a single remaining venous site to achieve permanent vascular access. Safety was assessed by means of complications encountered, and catheter functionality was assessed by means of total access site service interval. Catheter patency was described by using a Kaplan-Meier survival curve, and number of catheter days were compared according to patient sex by using a two-sample t test. RESULTS: Technical success was achieved in all patients. The mean total access site service interval was 138 catheter days (range, 0-599 days), and there was no significant difference according to patient sex (P =.869). Of the 16 catheters placed initially, five became dislodged and required an additional access procedure to be performed. These 21 catheters required 30 exchanges in 10 patients (48%) (range, 1-6 exchanges per patient). The most common reason for catheter exchange was device failure. There were six complications among 21 catheters placed (29%), including one death from massive intraperitoneal hemorrhage on the day after catheter placement. CONCLUSION: Transhepatic hemodialysis catheters offer a viable option to patients with limited options; however, there are maintenance issues and complications.