(Mis)placed central venous catheter in the left superior intercostal vein

BACKGROUND: Chest X-ray is routinely performed to check the position of the central venous catheter (CVC) inserted through the internal jugular or subclavian vein, while the further evaluation of CVC malfunction is usually performed by contrast venography. In patients with superior vena cava obstruction, the tip of the catheter is often seen in collateral mediastinal venous pathways, rather than in the superior vena cava. In such cases detailed knowledge of thoracic vessel anatomy is necessary to identify the exact location of the catheter. CASE REPORT.: We report a case of 32-year-old female patient with relapsing mediastinal lymphoma and previous superior vena cava obstruction with collateral azygos-hemiazygos venous pathways. The patient had CVC inserted through the left subclavian vein and its position was detected by CT to be in the dilated left superior intercostal vein and accessory hemiazygos vein. Considering that dilated accessory hemiazygos vein can tolerate infusion, the CVC was left in place and the patient had no complaints related to CVC (mal)position. Furthermore, we present anatomical and radiological observations on the azygos-hemiazygos venous system with the special emphasis on the left superior intercostal vein. CONCLUSIONS: Non-contrast CT scans can be a valuable imaging tool in the detection of the CVC position, especially in patients with renal insufficiency and contrast media hypersensitivity.     

Persistent Left Superior Vena Cava in Hematological Malignancy Requiring Central Venous Catheter Insertion for Intensive Chemotherapy

Persistent left superior vena cava is a congenital vascular anomaly, which is possibly arrhythmogenic and thrombogenic, rarely complicated with coronary sinus atresia. We treated a 42-year-old male with Hodgkin''s lymphoma requiring central venous catheter placement for intensive chemotherapy. Persistent left superior vena cava was revealed after the insertion of the central venous catheter by the radiological finding of the catheter tip cannulated into the vena cava cavity. The relationship between coronary sinus atresia and persistent left superior vena cava induced by central venous catheterization remains unclear; however, the hematologist should pay attention to the malpositioning of the central venous catheter.Key Words: Persistent left superior vena cava, Coronary sinus atresia, Central venous catheter, Chemotherapy, Hematological malignancy     

正中开胸上腔静脉人工血管置换的程序化处理在胸部肿瘤外科治疗中的应用

背景与目的 上腔静脉系统受累是局部晚期胸部肿瘤较常见的一种情况,手术可能获益,但风险极高.本研究针对正中开胸入路,提出一种程序化的手术方案,旨在优化流程,使得这一类以往认为风险极高的手术能够更加安全地实施.方法 35例胸部疾患累及上腔静脉系统,经正中开胸进行人工血管置换的患者资料,分期检查明确为局部晚期.包括肺部肿瘤16例,纵隔肿瘤19例.手术方法采用从左至右的单向推进,先游离左无名静脉起始部,阻断后切断,掀起瘤体,打开心包,用人工血管桥接左无名静脉和右心耳.游离上腔静脉近心端未受侵部分后,向尾侧牵拉肿瘤,剪开右侧纵隔胸膜,结扎切断右侧乳内血管,可以充分显露右无名静脉.向左上方牵拉瘤体,于肺门上方结扎切断奇静脉,此时可以阻断右无名静脉和上腔静脉,切除中间受侵的血管,以人工血管行右无名静脉-上腔静脉桥接,完成受侵的上腔静脉系统全部替换.结果 全组病例均顺利完成手术.术后并发症包括:心律失常6例,低氧血症5例,肌无力危象1例,心脏疝1例,真菌感染2例.2例患者死亡,死亡率5.12%,分别死于心梗和肺部感染.其余33例顺利出院.平均术后住院日15 d.在10例术前出现上腔静脉综合征的患者中,除2例术中即出现人工血管内血栓形成的患者,其余8例症状均明显改善.结论 上腔静脉人工血管置换手术经程序化的处理,规范治疗的细节,在手术操作过程中可降低手术风险,本组病例手术能够安全实施的实践也支持这一点.     

Long-term vascular access via the inferior vena cava

A prospective evaluation of long-term venous access catheters placed via the inferior vena cava was performed to determine their efficacy as well as short- and long-term morbidity. From June 1987 to May 1989, 31 catheters were placed in 26 patients, for a total of 3,503 catheter use days. All catheters were placed via an infraumbilical approach when the more conventional supraumbilical route was technically difficult, dangerous, or impossible to be used. There were a total of 14 complications in 12 episodes (one in every 701 catheter use days), six episodes of catheter occlusion or vessel thrombosis (one in every 583 catheter use days), one catheter malfunction, one episode of cuff erosion through the skin, and one catheter that migrated through the inferior vena cava into the retroperitoneum. These results compared favorably with our experience with long-term catheters of a similar type placed via a supraumbilical approach into the superior vena cava. We conclude that the infraumbilical route for long-term central venous access is safe and technically easy and should be strongly considered in patients in whom venous access via the supraumbilical approach will be technically difficult or have a high likelihood of failure.     

多层螺旋CT在肺癌致上腔静脉综合征中的应用价值

目的探讨多层螺旋CT在肺癌致上腔静脉综合征中的应用价值。方法回顾性分析12例临床确诊的肺癌致上腔静脉综合征的多层CT扫描等临床影像资料。结果 12例患者中,肺癌位于上肺叶8例(右侧6例,左侧2例)、右中肺叶1例、右全肺3例;中央型6例、右上纵隔型4例、周围型2例。上腔静脉梗阻征表现为环状包埋及夹心状包埋(6例)、推移(5例)、完全闭塞(1例)。增强CT还显示了3例侧枝循环形成情况。结论多层螺旋CT增强扫描可明确诊断肺癌致上腔静脉综合征。     

An 11-year retrospective study of totally implanted central venous access ports: Complications and patient satisfaction

Aims

We wanted to assess the factors that predict complications and patient satisfaction of totally implanted central venous access ports (TIAP).

Methods

We reviewed 550 patients with breast or gynaecological malignancies who had initial port placement for chemotherapy between 1995 and 2006. We retrospectively assessed all TIAP complications, port duration and follow-up care until the TIAPs were removed (or the last known recorded documentation) or until the death of the patient. TIAP-related patient satisfaction was also assessed via a questionnaire-based survey of 356 patients.

Results

561 TIAPs were placed in 550 cancer patients (11 patients received 2 TIAPs during the study period); the median time of port duration was 22.5 months. There were 104 complications in this group. Of these, 81 occurred during chemotherapy treatment that lasted a median time of 182 days. Removal secondary to complication was observed in 48 cases. TIAPs placed on the left chest side, through the subclavian vein or with the catheter tip localized in the peripheral part of superior vena cava demonstrated the highest incidence of complications. Patients with a BMI >28.75 had an increased risk for developing complications. Our follow-up questionnaire revealed a 93% patient satisfaction rate with the TIAP.

Conclusions

Patients with left-sided ports, catheter tips lying in the upper part of the superior vena cava and implantation via the subclavian vein are at a higher risk for TIAP-associated complications. Being excessively overweight was assessed as another risk factor for developing complications. TIAPs are highly accepted and further recommended by patients.     

Case report of a long-term home parenteral nutrition patient

We experienced a patient who received long-term home parenteral nutrition. A 55-year-old woman underwent left adrenalectomy in June, 1992. The histopathological diagnosis was aldosteronism. Abdominal pain and ileus appeared in July, 1993, and an adhesiotomy was conducted. Due to poor appetite and weight loss, fluid was sometimes injected peripherally. After abdominal pain in November, 1996 and April, 1997, the ileus reappeared in July, 1997. A Groshong catheter with a port was then inserted through the subclavian vein to the superior vena cava/right atrial junction. Using this catheter, home parenteral nutrition started. Some time later oral nutrition became possible, but now high calorie parenteral nutrition is continued. The only complications were pain and red skin at the port. A Groshong catheter with port is thus useful for home parenteral nutrition.     

Iatrogenic superior vena cava syndrome. A new entity

Four patients with cancer developed superior vena cava syndrome following placement of a central venous catheter (Broviac or Hickman catheter) without evidence of mediastinal tumoral involvement. Diagnostic and therapeutic considerations are discussed.     

Guidewire assisted cephalic vein cutdown for insertion of totally implantable access ports

BACKGROUND: Totally implantable access ports (TIAP) placed by the cephalic vein cutdown technique have high failure rates. METHODS: We describe a guidewire assisted technique of the cephalic vein cutdown for TIAP placement that can be easily introduced catheter when difficulties in insertion of the catheter. The key point of the presented technique is the use of J guidewire to go beyond the stenosis and advancement of catheter through the guidewire into the superior vena cava. RESULTS: We used this technique for introducing the catheter in six patients without failure or complication. CONCLUSION: The presented technique is easy and simple. It can be used where there are difficulties in insertion of the catheter by cephalic vein cutdown method.     

Systemic to portal shunting following vena cava obstruction: Computed tomography and venographic appearances

Obstruction of the inferior or superior vena cava normally leads to the formation of a well‐described and consistent pattern of collateral venous pathways. We present the angiographic and CT features of the unusual development of systemic to portal venous shunting in two cases with central vein obstruction.     

Necrotizing pneumonitis caused by 5-fluorouracil infusion. A complication of a Hickman catheter.

The authors report the case of a patient with a Hickman catheter that migrated into the lung parenchyma. The resultant inadvertent infusion of 5-fluorouracil caused necrotizing chemical pneumonitis. Possible mechanisms of catheter migration include the lateral orientation of the catheter tip and the partial thrombosis of the innominate vein and superior vena cava. The patient recovered but had residual contraction fibrosis of the right upper lobe of the lung.     

局部晚期非小细胞肺癌的扩大手术治疗

目的探讨局部晚期非小细胞肺癌的外科手术治疗方法及其疗效.方法对4例局部晚期非小细胞肺癌分别施行肺叶袖状切除、肺叶袖状切除 肺动脉袖状切除(部分心包切除)、肺叶袖状切除 肺动脉袖状切除 上腔静脉部分切除、人造血管置换术.结果 4例局部晚期非小细胞肺癌均施行完全性手术切除(R0),无一例发生围手术期并发症及死亡,手术后随访期间未发现肿瘤局部复发和(或)转移.讨论非小细胞肺癌患者确诊时多数已属局部晚期病变,对该类患者施行袖状肺叶切除术、袖状肺叶切除 肺动脉袖状切除术[包括心包和(或)心房部分切除术]是较全肺切除术更为安全的手术治疗方式.对于合并上腔静脉综合征的患者,亦有可能手术治疗.诱导治疗及肺外科手术技巧的发展,使完整切除肺病变及受累的邻近结构(上腔静脉,肺动脉等)已成为可能.     

Superior vena cava syndrome with central venous catheter for chemotherapy treated successfully with fibrinolysis

Abstract Recently, there has been an increase in the number of cases of superior vena cava (SVC) syndrome associated with chronic indwelling central venous catheters. Fibrinolytic therapy and endovascular treatment are currently achieving good results. We present a case history of a patient with SVC with a catheter used for chemotherapy, which was successfully treated with catheter-directed (intraclot) infusion thrombolytic therapy with urokinase.     

内支架联合局部定向溶栓治疗上腔静脉综合征

目的　探讨内支架联合导管定向溶栓治疗肿瘤性上腔静脉阻塞综合征的方法及意义。方法　 2 6例肿瘤性上腔静脉阻塞综合征患者中 ,肺癌伴纵隔淋巴结转移 17例 ,纵隔恶性肿瘤 5例 ,食管癌纵隔淋巴结转移 2例 ,非霍奇金淋巴瘤 2例。采取股静脉入路 ,将多侧孔导管送至上腔静脉阻塞段血栓内 ,经导管滴注尿激酶 ,时间为 2 0～ 40min。然后球囊扩张 ,植入自张式支架。结果　 2 4例开通成功 ,2例因闭塞导丝无法通过而失败。 2 4例中有 3例患者狭窄段长 10cm ,置入 2个支架 ;余 2 1例均置入一个支架。 2 4例在扩张前均行溶栓治疗。开通前后梗阻远侧测静脉压 ,从术前的 2 1.2 3± 1.80mmHg降到术后的 5 .33± 0 .98mmHg(患者均为卧位测压 )。经统计学处理 ,开通前后梗阻远侧静脉压力变化差异有显著性 (P <0 .0 1)。开通后造影示侧支静脉均不再显影 ,上腔静脉管径接近正常 ,轮廓光整。上腔静脉阻塞症状于术后 2～ 3d消退。结论　经股静脉入路 ,上腔静脉支架置入术联合导管定向溶栓是肿瘤性上腔静脉阻塞综合征有效的微创治疗方法     

Treatment of deep vein thrombosis using temporary vena caval filters after allogeneic bone marrow transplantation

Bone marrow transplant (BMT) recipients have risk factors for deep vein thrombosis (DVT) including venous stasis caused by immobilization in the sterile unit, vessel wall damage caused by preparative regimen or indwelling catheters, and hypercoagulability caused by decreased natural anticoagulants. We successfully treated a patient who developed massive DVT in the superior vena cava after BMT with anticoagulation and the use of temporary vena caval filters. Considering the delayed complications, permanent filter is not appropriate for BMT recipients, because the risk factors for DVT associated with BMT are transient. We considered that temporary vena caval filter is a safe and useful device to prevent pulmonary embolism after DVT in BMT recipients.     

The MTHFR C677T and ΔDNMT3B C‐149T polymorphisms confer different risks for right‐ and left‐sided colorectal cancer

Etiological risk factors for proximal (right‐sided) colon cancers may be different to those of distal colon and rectal (left‐sided) cancers if these tumors develop along distinct pathways. The CpG Island Methylator Phenotype (CIMP+) occurs in approximately 15% of colorectal cancers (CRC) and predominantly in the proximal colon. CIMP+ tumors have frequent methylation of gene promoter regions and increased tissue folate levels. The aim here was to determine whether polymorphisms in 2 genes involved in cellular methyl group metabolism were associated with different risks for right‐ and left‐sided CRC. This population‐based case–control study involved 859 incident cases of CRC and 973 sex and age‐matched controls. Information on dietary folate and alcohol intake was obtained from food frequency questionnaires and information on the anatomical site of tumors from pathology reports. DNA was collected using FTA cards and genotyping performed for the MTHFR C677T and ΔDNMT3B C‐149T polymorphisms. The MTHFR 677 T allele was associated with increased risk for proximal colon cancer (adjusted odds ratio, AOR = 1.29) but decreased risk for distal cancers (AOR = 0.87). The increased risk for proximal cancers was especially pronounced in older individuals (AOR = 1.49) and those with a low folate diet (AOR = 1.67) or high alcohol consumption (AOR = 1.90). The ΔDNMT3B‐149 TT genotype was protective against proximal colon cancers (AOR = 0.65), but showed no association with the risk of distal colon and rectal cancers (AOR = 1.02). Epidemiological studies on dietary and genetic risk factors for CRC should take into account these may confer different risks for right‐ and left‐sided tumors. © 2009 UICC     

应用大隐静脉转流治疗术后复发性上腔静脉综合征

目的：为解除上腔静脉阻塞、改善患者生活质量、为综合治疗创造条件。方法;１９９３年１１月至９９７年１２月,对３例恶性上腔静脉综合征开胸手术后复发患者中大隐静脉－颈外静脉转流术。结果;术后患者症状即改善,体征分别在７天至２０天消失。２例患者存活３个月和７个月,例至今已存活１１个月。结论：大隐静脉－颈外静脉充手术简单、安全,有效地改善了ＳＶＳＣ太,是ＳＶＳＣ较好的一下手术方法。     

肺切除合并上腔静脉切除人造血管置换术治疗上腔静脉综合征的麻醉处理

目的 介绍对肺癌合并上腔静脉综合征患者，施行肺切除合并上腔静脉切除人造血管置换手术的麻醉经验。方法 18例肺癌伴上腔静脉综合征的患者，在静吸复合气管插管全身麻醉下施行肺癌根治性切除合并上腔静脉切除人造血管置换术。结果 全部患者麻醉平稳，手术经过顺利，术毕安返监护室，术后清醒，未发现神经系统损害的症状及体征，如期出院。结论 肺切除合并上腔静脉切除人造血管置换手术者手术难度大，麻醉危险性高。降低上腔静脉阻断期间的压力，减轻中枢神经系统缺血性损害是麻醉管理的关键。     

Superior vena cava syndrome caused by chemotherapy-induced fibrosis

We report a case of a 51-year old man with small cell lung cancer who developed superior vena cava syndrome due to obstruction of the superior vena cava at the junction of the brachiocephalic vein by a fibrotic band, 2 months after completing six cycles of chemotherapy with cisplatin and etoposid. Superior vena cava syndrome caused by chemotherapy-induced pulmonary fibrosis should be kept in mind during follow-up.     

Intrapericardial infusion of 5-fluorouracil. An unusual complication of a Hickman catheter

Venous access devices (VAD) have become an important tool in the management of patients with cancer. Multiple complications can occur as a consequence of insertion of a VAD. The authors report a case of a Hickman catheter perforating the wall of the superior vena cava into the pericardium, resulting in accidental intrapericardial infusion of 5-fluorouracil (5-FU). Pericarditis and cardiac arrhythmias developed, but the patient did not have cardiac tamponade. She recovered from the event without apparent chronic cardiac dysfunction.