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.     

Retrieval of an embolization coil from the internal carotid artery using the Amplatz Microsnare Retrieval System

An unusual case of unintentional release of an embolization coil into the proximal internal carotid artery is reported. The coil migrated and lodged distally in the petrous portion of the internal carotid artery during initial removal attempts using a regular nitinol loop snare. The coil was retrieved with the Amplatz Nitinol Microsnare system.     

Transvascular retrieval of an accidentally ejected tip occluder and wire

Accidental ejection of a tip occluder and wire and subsequent damage of the angiographic catheter tip is described as well as retrieval of the wire. A complication of the final removal was intimal tear and thrombus formation close to the puncture site. Successful thrombectomy and vascular repair was performed. No other complication was encountered.     

Percutaneous retrieval of a retained Jackson-Pratt drain fragment

A retained intraabdominal Jackson-Pratt drain fragment was percutaneously retrieved using an inflated angioplasty balloon that had been maneuvered inside of the drain lumen over a hydrophilic-coated steerable guidewire.     

经皮左锁骨下动脉导管药盒系统植入术的并发症及其处理

目的：探讨经皮左锁骨下动脉行导管药盒系统（ＰＣＳ）植入术的安全性。材料与方法：对１１５例胸、腹部及盆腔恶性实质性肿瘤患者（其中肝癌１０１例），经皮左锁骨下动脉穿刺行ＰＣＳ植入术。术后经ＰＣＳ行规律性化疗或碘油化疗乳剂栓塞。统计与该术有关的并发症。结果：并发症有气胸５例（４．３％），血胸１例（０．９％），植入药盒部位感染３例（２．６％），切口延迟愈合或开裂５例（４．３％），留置管移位６例（５．２％）。所有并发症经处理均痊愈，无严重后遗症及死亡病例。其中大量气、血胸３例，采用８Ｆ胸腔穿刺系统行胸腔闭式引流治疗痊愈；留置管移位者４例进行ＰＣＳ重植入术成功，３例拔除ＰＣＳ，均未见并发症。结论：经皮左锁骨下动脉行ＰＣＳ植入术的并发症少而轻，经适当处理多可痊愈，为动脉内化疗灌注和碘油化疗乳剂栓塞提供了一种安全可靠的途径。     

Combined percutaneous antegrade and cystoscopic retrograde approach in the treatment of distal ureteric fistulae

Purpose To determine the efficacy of a cystoscopic approach, as definitive treatment of ureteral fistulae, after failure of antegrade ureteral stent insertion.Methods Of 43 ureter fistulae encountered over 4 years, 10 postoperative and/or postradiotherapy fistulae could not be stented via an antegrade approach alone. A cystoscopic approach was used, with the antegrade approach available as back-up, if necessary.Results In two patients the ureteral orifice could not be visualized cystoscopically, thus precluding the retrograde approach. In the eight remaining patients, the retrograde approach alone never allowed successful stenting. In six patients, combined antegrade and retrograde approaches permitted stent insertions. In three of those six patients, a complex catheterization procedure was necessary. In two patients the combined approach failed altogether. Therefore, 6 of 10 patients underwent a successful stenting procedure with the combined approach; all ultimately closed the fistula.Conclusion Antegrade stent insertion remains the treatment of choice for ureteral leaks. If the antegrade approach fails, the retrograde approach alone is not likely to be successful. Instead, a combination of both approaches often does succeed.     

Percutaneous retrieval of a central venous catheter sutured to the wall of the inferior vena cava

A central venous catheter was sutured to the wall of the inferior vena cava in a 20-year-old male undergoing retroperitoneal lymphadenectomy for malignant testicular germ cell tumor. We succeeded in retrieving the catheter percutaneously, using a combination of loopsnare wire and myocardial biopsy forceps.     

Formation of an undesirable guide wire loop with the cope introduction set

An undersirable loop of guide wire may occur with use of the Cope loop nephrostomy set. This complication, along with its recognition and prevention, is presented.     

Percutaneous retrieval of a misplaced titanium Greenfield filter

Vena caval filters are considered permanent indwelling devices. Occasionally, malposition of a filter prompts a desire for its removal. We report a method of percutaneous retrieval of a titanium Greenfield filter by snare.     

Recanalization of obstructed tenckhoff peritoneal dialysis catheter: Wire/stylet manipulation combined with endoluminal electrocauterization

We report the results of fluoroscopically guided wire/stylet manipulation combined with endoluminal electrocauterization in seven patients with obstructed Tenckhoff peritoneal dialysis catheters. In preparation for clinical application, electrocauterization was performed using a stone basket to recanalize surgically removed Tenckhoff catheters obstructed with omental fat ingrowing through the side holes. All ingrowing omental fat was removed easily by electrocauterization with the rotating movement of a stone basket. The technique was then applied in vivo in seven cases with ingrowing omental fat and malpositioned catheter; six (86%) were successfully recanalized. Among those six cases with initial success, four maintained good catheter function with durable patency (mean 261.3 days). No significant complication was noted.     

New “mesh basket” for percutaneous removal of wall-adherent thrombi in dialysis shunts

A new basket, developed for percutaneous removal of wall-adherent thrombi, was tested in model thrombosed hemodialysis shunts, and clinically in two polytetrafluoroethylene grafts and one Brescia-Cimino shunt after recanalization by aspiration thrombectomy. The residual wall-adherent thrombus was removed by one or two passes with the mesh basket. The occlusion material was firmly captured within the mesh and was removed through an 8F sheath without hardly any material being sheared off from the basket. The device adapts well even to tortuous vessel segments and exerts a gentle brush effect. It may prove to be a valuable adjunct to aspiration thrombectomy or to balloon catheter embolectomy.     

Percutaneous transluminal coronary angioplasty: Analysis of unsuccessful procedures as a guide toward improved results

Technical success in percutaneous transluminal coronary angioplasty (PTCA) is a function of patient selection, operator experience, and the capabilities of the angioplasty equipment employed. When unsuccessful PTCA occurs, it is the result of one several factors: (1) a failure to cross the stenosis: (2) a failure to dilate the stenosis; (3) an ischemic complication; or (4) a late recurrence of the anginal syndrome. In this paper, we discuss the relative frequency of these types of failure, and the ways in which improvements in technique and/or equipment may be employed to improve the chance of a successful procedure.     

Percutaneous retrieval of a right atrioventricular embolus

Percutaneous retrieval of a 12-cm-long serpiginous clot lodged in the right atrium and ventricle is reported. Following bilateral common femoral vein puncture, a Bird’s Nest cava filter was first positioned ready to deploy immediately below the renal veins via the right femoral vein. From the left femoral vein, a Cook intravascular retrieval basket was advanced to the right atrium. Under transthoracic echocardiographic visualization, the basket was used to engage, trap, and gently withdraw the clot in a single long strand below the prepositioned inferior vena cava filter. The filter was immediately deployed, leaving the clot trapped inferior to the renal veins, in the cava and left iliac vein. The patient remained well and asymptomatic at discharge.     

Percutaneous cholecystostomy for patients with acute cholecystitis and an increased surgical risk

Purpose To evaluated percutaneous cholecystostomy in patients with acute cholecystitis and an increased surgical risk. Methods Thirty-three patients with acute cholecystitis (calculous,n=22; acalculous,n=11) underwent percutaneous cholecystostomy by means of a transhepatic (n=21) or transperitoneal (n=12) access route. Clinical and laboratory parameters were retrospectively studied to determine the benefit from cholecystostomy. Results All procedures were technically successful. Twenty-two (67%) patients improved clinically within 48 hr; showing a significant decreased in body temperature (n=13), normalization of the white blood cell count (n=3), or both (n=6). There were 6 (18%) minor/moderate complications (transhepatic access,n=3; transperitoneal access,n=3). Further treatment for patients with calculous cholecystitis was cholecystectomy (n=9) and percutaneous and endoscopic stone removal (n=8). Further treatment for patients with acalculous cholecystitis was cholecystectomy (n=2) and gallbladder ablation (n=2). There were 4 deaths (12%) either in hospital or within 30 days of drainage; none of the deaths was procedure-related. Conclusion Percutaneous cholecystostomy is a safe and effective procedure for patients with acute cholecystitis. For most patients with acalculous cholecystitis percutaneous cholecystostomy may be considered a definitive therapy. In calculous disease this treatment is often only temporizing and a definitive surgical, endoscopic, or radiologic treatment becomes necessary.     

Experimental impeller fragmentation of iliocaval thrombosis under tulip filter protection: Preliminary results

Purpose To assess the efficacy of catheter fragmentation of massive caval thrombosis and of filter protection against procedure-related pulmonary embolism. Methods In 10 sheep, a self-expanding tulip-shaped filter made from Wallstent mesh (diameter 25 mm) was introduced from the right jugular approach into the proximal inferior vena cava. Experimentally induced massive iliocaval thrombosis was fragmented by an impeller catheter (expanded diameter 14 mm), which was advanced coaxially through the sheath of the expanded filter. Post-procedural cavography and pulmonary angiography were performed to document the extent of caval recanalization and pulmonary embolism. Results In all cases, impeller fragmentation cleared the inferior vena cava and the iliac veins of thrombi completely. Fragments washed downstream were trapped in the filter. In two of the first cases, parts of the clots caused pulmonary embolism before the filter was in place. Further events were avoided by a modification of the experimental setup. Except for some small peripheral perfusion defects in two cases, pulmonary angiograms did not show any incidence of pulmonary embolism. Conclusion Our preliminary results suggest that impeller fragmentation of iliocaval thrombi under tulip filter protection is effective and does not cause significant pulmonary embolism.     

Percutaneous treatment of hepatic cysts by aspiration and sclerotherapy

We treated 35 patients who had hepatic cysts (30 congenital cysts, 5 hydatid cysts) with percutaneous puncture and sclerotherapy. After puncture and drainage of the cyst, a 95% alcohol solution was instilled as sclerosing agent into the cystic cavity. In all the patients, cyst puncture and drainage was successful. Follow-up in all cases was at least 12 months. In three uncooperative patients, cysts recurred due to incomplete sclerosis of the lining epithelium of the cyst wall. No major complications were encountered in all cases. All congenital cysts were treated on an outpatient basis. Patients with hydatid cyst were hospitalized for 48 h after puncture and aspiration. In our opinion, percutaneous drainage and sclerosis of congenital hepatic cysts can be considered an effective alternative to surgical treatment.     

A comparative analysis of radiological and surgical placement of central venous catheters

Purpose To compare the differences in practice and outcome of all radiologically and surgically placed central venous catheters retrospectively over a 2-year period simultaneously, at a single institution. Methods A total of 253 Hickman catheters were inserted in 209 patients; 120 were placed radiologically in 102 patients and 133 were placed surgically in 107 patients. The indication was chemotherapy in 76% of radiological and in 47% of surgical cases; the remainder were for total parenteral nutrition and venous access. Results There were 6 (4.5%) primary surgical failures and a further 17 (13%) surgical cases requiring multiple placement attempts. Pneumothorax occurred once (0.8%) surgically and four times (3.3%) radiologically. There were no radiological primary misplacements but there were five (3.7%) surgical ones. Catheter or central vein thrombosis occurred in four (3.3%) radiological and five (3.7%) surgical cases. The rate of infection per 1000 catheter-days was 1.9 in radiologically placed catheters and 4.0 in surgically placed ones (p<0.001). Average catheter life-span was similar for the two placement methods (100±23 days). Conclusion Radiological placement is consistently more reliable than surgical placement. There are fewer placement complications and fewer catheter infections overall.     

Transfemoral repositioning of malpositioned central venous catheters

Purpose To determine the efficacy of the transfemoral vein approach to repositioning malpositioned central venous catheters. Methods During a 41/2-year period, malpositioned central venous catheters were repositioned 91 times in 83 patients via the transfemoral vein approach. All repositioning was initially attempted with a Grollman catheter or other pigtail catheter and a tip-deflecting wire. If these techniques failed or the venous anatomy was unfavorable, gooseneck or long loop snares were used. Results During 48 repositionings, rotating a pigtailtype catheter alone was used successfully in 39 (81%). In 6 of 9 failures, the addition of a tip-deflecting wire also failed. A Grollman catheter and tip-deflecting wire were used initially in 39 repositionings (6 failures; 85% success). Successful repositioning required a snare in 8 (4 as the primary repositioning technique) and a longloop technique in 5. All repositionings were ultimately successful and there were no complications. Conclusion Central venous catheters can be repositioned consistently by the transfemoral route. Pigtail catheters or tip-deflecting wires alone are successful in over 80% of cases.     

Pulmonary Artery Perforation Repair During Thrombectomy Using Microcoil Embolization

A distal pulmonary artery perforation was successfully occluded by percutaneous microcoil embolization via a microcatheter. Microcoil embolization is a reasonable alternative therapeutic approach for this rare complication of pulmonary interventional procedures.