Venous thrombosis associated with the placement of peripherally inserted central catheters

PURPOSE: Peripherally inserted central catheters (PICCs) have become an essential component of the management of an increasing number of patients, including patients who may require hemodialysis. Reported symptomatic venous thrombosis rates associated with PICC lines are based on clinical signs and symptoms and range from 1% to 4%. The purpose of this study is to evaluate the true rate of thrombosis of upper extremity veins after the placement of PICCs and the potential impact on future access in hemodialysis patients. MATERIALS AND METHODS: A retrospective analysis was performed. Patients who had (i) normal findings during initial venography, (ii) PICC placement, and (iii) who underwent subsequent repeated venography were included. Age, sex, vein cannulated, catheter size, location, and incidence of thrombosis were analyzed. RESULTS: Three hundred fifty-four PICCs were placed in 119 patients. Of the 144 extremities, 137 had normal findings during initial venography. Of the 137 extremities, 32 developed thrombosis of the cannulated vein (or central veins) after initial PICC placement (23.3%). When all extremities with multiple PICC lines placed were considered, 52 developed thrombosis, for an overall thrombosis rate of 38%. The incidence of thrombosis by site was cephalic 57%, basilic 14%, and brachial 10%. No significant differences were noted in the rates of thrombosis by age, sex, or catheter size. CONCLUSIONS: There is a relatively high rate of venous thrombosis associated with PICCs, particularly cephalic thrombus. Because of the high rate of thrombosis associated with these catheters, an alternative mode of access should be considered in current or potential hemodialysis patients. All patients with a history of PICC line placement requiring dialysis access should undergo upper extremity venography prior to the placement of permanent access.     

介入法在难置型外周中心静脉置管中的应用分析

目的回顾分析介入法在难置型外周中心静脉置管(PICC)中的应用价值及安全性。资料与方法 2008年1月至2010年11月经PICC专科护士会诊或操作后在床边直视下直接穿刺置入PICC管困难或失败的52例患者,在DSA下运用改良塞丁格技术置入三向瓣膜PICC管。对静脉显影不佳者采用顺行浅静脉造影穿刺靶静脉,对静脉迂曲或变异者采用微导丝导引法置管。结果 52例患者中50例成功置入PICC管,置管成功率96.1%。其中46例一次成功置管,4例第一次置入失败,第二次置入成功;全部病例均采用改良塞丁格穿刺技术,21例采用顺行浅静脉造影穿刺法,4例因头静脉注入深静脉角度过锐或腋静脉-锁骨下静脉段狭窄,走行迂曲而使用微导丝导引克服血管迂曲后置管成功,2例因双侧肘正中静脉缺如,头静脉及贵要静脉狭窄、闭塞置管失败。50例置管患者中,平均留管时间73天,2例(4.0%)发生深静脉血栓,其中1例(2.0%)发生致命性肺栓塞;1例(2.0%)发生无菌性静脉炎。结论 DSA导引下运用介入方法提高了PICC的置管成功率,减少了床边置管的盲目性。     

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.     

Incidence of upper limb venous thrombosis associated with peripherally inserted central catheters (PICC)

The objective of this study was to prospectively determine the incidence of venous thrombosis (VT) in the upper limbs in patients with peripherally inserted central catheters (PICC). We prospectively investigated the incidence of VT in the upper limbs of 26 patients who had PICC inserted. The inclusion criteria were all patients who had a PICC inserted, whilst the exclusion criterion was the inability to perform a venogram (allergies, previous contrast medium reaction and inability of gaining venous access). Both valved and non-valved catheters were evaluated. Prior to removal of the PICC, an upper limb venogram was performed. The number of segments involved with VT were determined. The duration of central venous catheterization was classified as; less than 6 days, between 6 days and 14 days and more than 14 days. VT was confirmed in 38.5% (10/26) of the patients. The majority 85.7% (12/14) were complete occlusive thrombi and the majority of VT only involved one segment. There was no statistical correlation between the site of insertion of the PICC and the location of VT. Neither was there any observed correlation between the occurrence of VT with the patient's history of hypertension, hypercholesterolaemia, coronary artery disease, diabetes mellitus, cardiac insufficiency, smoking or cancer. There was also no statistical correlation with the size of the catheter. In conclusion, PICCs are associated with a significant risk of upper extremity deep vein thrombosis (UEVT).     

Peripherally inserted central catheters and upper extremity deep vein thrombosis

The purpose of the study was to determine the incidence and risk factors for venous thrombosis in patients with a peripherally inserted central catheter (PICC). A retrospective study of all upper extremity venous duplex scans was carried out in the Vascular Medicine department from year 2000 to 2002 inclusive. A chart review of positive scans was undertaken to identify possible thrombotic risk factors. Of 317 upper extremity venous duplex scans carried out, 115, or 32%, were positive for upper extremity deep vein thrombosis. Three main risk factors were identified - presence of a central line, malignancy and administration of chemotherapy. PICC were the most common central line present. Symptomatic thrombosis occurred in 7% of PICC inserted for chemotherapy compared with 1% of PICC inserted for other reasons. Ten per cent of the patients receiving chemotherapy through a PICC developed a thrombosis. The post-thrombotic syndrome was infrequent following upper extremity deep vein thrombosis. Patients receiving chemotherapy through a PICC are at increased risk of thrombosis. There may be a role for prophylactic low-dose anticoagulation in these high-risk patients.     

Prospective evaluation of PICC line related complications

PURPOSE: To report the occurrence of complications following placement of peripherally inserted central catheters (PICC). Materials and methods. A total of 127 PICC lines were placed in 115 patients for TPN (n=54), long-term antibiotics (n=29), chemotherapy (n=14) or miscellaneous intravenous therapy (n=18). RESULTS: All PICC lines were successfully inserted. PICC lines were used for a mean duration of 16 days (1-166 days). The following complications were recorded: occlusion (7%), rupture (1.6%), accidental withdrawal (2.4%), infection (3.1%) and venous thrombosis (2.4%). CONCLUSION: PICC lines are a simple, safe and effective alternative to conventional central venous catheters. The occurrence of complications, typically "mechanical", must be reduced and prevented by strict management of this type of central line by the treating team.     

Long-Term Central Venous Access in Pediatric Patients at High Risk: Conventional versus Antibiotic–Impregnated Catheters

PurposeTo study selective use of antibiotic–impregnated catheters in children at increased risk of venous catheter–related infections (CRIs).Materials and MethodsFrom December 2008 to June 2009, 428 peripherally inserted central catheters (PICCs) were placed by the interventional radiology service of a large metropolitan children’s hospital. This retrospective study analyzed demographic and outcome data for the 125 patients in this group at high risk for venous CRI. Patients at high risk were those with active systemic infection, previous complicated central venous access, intensive care unit (ICU) admission, intestinal failure, transplantation, complex congenital heart disease, or renal failure. Patients (age, 7.6 y ± 7.0; 73 male and 52 female) received a conventional or antibiotic-impregnated PICC, with 17 receiving more than one catheter.ResultsOf the 146 of 428 qualifying patient encounters (34%), 53 patients received an antibiotic-impregnated PICC and 93 received a conventional PICC, representing 5,080 total catheter-days (CDs). The rates of CRIs per 1,000 CDs, including catheter exit site infections and catheter-related bloodstream infections, were 0.86 for antibiotic-impregnated PICCs and 5.5 for conventional PICCs (P = .036). A propensity-based model predicts 15-fold greater infection-free survival over the lifetime of the catheter in patients who receive an antibiotic-impregnated PICC (P < .001). Antibiotic-impregnated PICC recipients with active infection or ICU admission at the time of insertion had no catheter-associated infections, compared with 3.42 and 9.46 infections per 1,000 CDs, respectively, for patients who received conventional PICCs. Patients with intestinal failure had 1.49 and 10 infections per 1,000 CDs with antibiotic-impregnated versus conventional PICCs, respectively.ConclusionsAntibiotic-impregnated long-term PICCs significantly improve infection-free catheter survival in pediatric patients at high risk.     

Peripherally inserted central catheter placement in infants and children

The most common venous access procedure performed in children and infants is the peripherally inserted central catheter, or "PICC." Placement of a PICC affords patients stable long-term venous access for medication administration and blood draws. The Interventional Radiology team faces particular challenges in the placement and management of these catheters in a pediatric population. This article discusses our institution's step-by-step approach to operating a hospital-wide PICC service.     

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.     

Placement of peripherally inserted central catheters without fluoroscopy in children: initial catheter tip position

PURPOSE: To determine how often placement of peripherally inserted central catheters (PICCs) without imaging guidance results in an initially correct central venous catheter tip location. MATERIALS AND METHODS: This study was approved by the hospital's institutional review board, which waived the requirement for informed consent. In a children's hospital, 843 PICCs were placed in 698 patients (age range, 0 days to 26 years; mean, 6.9 years) during a 14-month study period. All PICCs were placed by a specialized team of PICC nurses and interventional radiology technologists in an angiography suite with the supervision of pediatric interventional radiologists. All catheters were threaded blindly to a previously estimated length by either a PICC nurse or a pediatric interventional radiologist, according to National Association of Vascular Access Networks guidelines, and the initial PICC tip location was then determined by means of spot fluoroscopy. PICC tips were regarded as central if they resided anywhere within the superior vena cava (SVC). All catheters were then manipulated with intermittent fluoroscopic guidance to achieve a final central position in the distal third of the SVC. A chi2 test was used to compare initial and final PICC tip locations according to patient age, catheter size, accessed vein, and need for radiologist assistance. A t test was used to compare procedure time with and without radiologist assistance. RESULTS: Analysis included 843 consecutively placed pediatric PICCs, of which 723 (85.8%) had a noncentral initial PICC tip position and required additional manipulation. After catheter repositioning performed with intermittent fluoroscopic guidance, a final central PICC tip location was achieved in 760 PICCs (90.2%). CONCLUSION: Pediatric PICC placement without fluoroscopic guidance required catheter manipulation of initial PICC tip position in 723 cases (85.8%). PICC placement with fluoroscopic guidance is highly successful, and the authors believe it is best performed in an angiography suite.     

Air embolism during insertion of central venous catheters.

PURPOSE: To determine the clinical consequences of air embolism occurring during insertion of central venous catheters. MATERIALS AND METHODS: A computer search of our interventional radiology database revealed that 11,583 central venous catheters were inserted between January 1, 1995 and August 1, 2000: 7,178 were nontunneled and 4,404 were tunneled. Air embolism was reported to have occurred in 15 patients. Air embolization was recognized by audible air aspiration during catheter insertion or by fluoroscopic visualization of air within the right atrium or pulmonary artery. The radiology reports and medical records of these 15 patients were reviewed. RESULTS: All 15 patients had an air embolism occur during insertion of a tunneled central venous catheter. These included eight Ash catheters, five chest wall ports, one Tesio catheter, and one Pheres-Flow catheter. Four patients remained asymptomatic. Six patients had mild symptoms that quickly resolved with supplemental oxygen. Four had moderate symptoms that also resolved with supplemental oxygen. One patient died acutely as a result of the air embolism. CONCLUSION: Air embolism is a rare but potentially fatal complication of central venous catheter procedures. In our series, all occurred during insertion of a tunneled catheter through a peel-away sheath. The administration of supplemental oxygen was an effective treatment in the majority of patients.     

Peripherally Inserted Central Catheter Thrombosis—Reverse Tapered versus Nontapered Catheters: A Randomized Controlled Study

PurposeTo compare the thrombosis rate, ease of insertion, bleeding rate, and complications of a nontapered peripherally inserted central catheter (PICC) versus a reverse tapered PICC.MethodsThis was a prospective randomized, controlled trial conducted in single center. All patients 18–90 years old requiring PICC insertion were considered for the study. All patients were followed until PICC removal. Ultrasound examination of the arm was performed at PICC removal or at 28 days. There were 332 patients randomly assigned—164 to the nontapered PICC group and 168 to the reverse tapered PICC group.ResultsThe overall thrombosis rate was 71.9%. The thrombosis rate was 70.4% in the nontapered PICC group and 73.4% in the reverse tapered PICC group (P = .58). The symptomatic thrombosis rate was 4.3% in the nontapered PICC group and 3.6% in the reverse tapered PICC group (P = .75). The complete thrombosis rate was 15.6% in the nontapered PICC group compared with 20.8% in the reverse tapered PICC group (P = .44). There was a statistically significantly higher thrombosis rate in patients with cancer (71.9% vs 66.7%, P = .002).ConclusionsThis study showed a high incidence of thrombosis of peripheral veins used for PICC insertion. The implication of this thrombosis is significant in light of the morbidity and potential mortality associated with this condition. A difference in thrombosis rate between devices could not be detected in this study.     

Exchanging dual-lumen central venous catheters: how I do it

The management of a blocked long-term central venous catheter has traditionally been removal and re-siting, even when device failure is not associated with venous thrombosis or sepsis. It is not possible to 'railroad' a split dual-lumen central venous catheter down a long tortuous s.c. tunnel. Our exchange technique was designed to salvage the tunnel and venous access site in a long-term catheter that has had uncomplicated primary device failure. In this technique we divide the dual-lumen catheter and secure the venous access site and the s.c. tunnel with separate peel-away sheaths. The new catheter is then introduced in the conventional manner through the two peel-away sheaths, which are then removed. The key advantage of the technique is that it preserves one of the few central venous access sites available. This article describes exchange of an internal jugular catheter, but the same technique is applicable to subclavian catheters.     

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.     

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.     

A nurse led peripherally inserted central catheter line insertion service is effective with radiological support

AIM: Peripherally inserted central catheters (PICC) are increasingly used as a route of chemotherapy administration. Our aims were to assess a collaborative approach to PICC placement, with radiological support for a nurse led line insertion service in a minority of cases, and to determine whether PICC provided a safe and reliable method of chemotherapy administration. MATERIALS AND METHODS: Prospective data on 100 consecutive patients undergoing PICC placement for chemotherapy were collected. Lines were inserted by ward based nurses or under ultrasound guidance by radiologists. End points were successful completion of treatment or patient death. RESULTS: One hundred and forty-four lines were placed for 118 courses of chemotherapy. 107 (74%) were placed by nurses and 37 (26%) by radiologists. Ninety-five percent of patients completed therapy with either one or two lines. Seventy percent of lines were removed on achieving the primary end points. In two additional patients PICC could not be placed radiologically. Twelve patients were unable to complete treatment with PICC alone, nine of these required an alternative administration route. The catheter related sepsis rate was 4.9%. CONCLUSION: The majority of PICC can be successfully placed by trained nurses, reserving image guidance only for more difficult cases. PICC have an acceptable complication profile, and decrease the need for tunnelled central lines.     

Routine chest radiographs after central line insertion: Mandatory postprocedural evaluation or unnecessary waste of resources?

Purpose: To study the cost and impact on patient management of the routine performance of chest radiographs in patients undergoing imaged-guided central venous catheter insertion. Methods: Six hundred and twenty-one catheters placed in 489 patients over a 42-month period formed the study group. Catheters were placed in the right internal jugular vein (425), left internal jugular vein (133), and subclavian veins (63). At the end of the procedure fluoroscopy was used to assess catheter position and check for complications. A postprocedural chest radiograph was obtained in all patients. Results: Postprocedural chest fluoroscopy showed no evidence of pneumothorax, hemothorax, or mediastinal hematoma. Inappropriate catheter tip position or catheter kinks were noted with 90 catheters. These problems were all corrected while the patient was on the interventional table. Postprocedural chest radiographs showed no complications but proximal catheter tip migration was noted in six of 621 catheters (1%). These latter six catheters required further manipulation. The total technical and related charges for the postprocedural chest radiographs in this series were estimated at ￡15,525. Conclusion: Postprocedural chest radiographs after image-guided central venous catheter insertion are not routinely required. A postprocedural chest radiograph can be performed on a case-by-case basis at the discretion of the interventional radiologist.     

Previous PICC Placement May Be Associated With Catheter-Related Infections in Hemodialysis Patients

Background  

Catheter-related infections (CRIs) are a significant source of morbidity and mortality in hemodialysis patients. The identification of novel, modifiable risk factors for CRIs may lead to improved outcomes in this population. Peripherally inserted central catheters (PICCs) have been hypothesized to compromise vascular access due to vascular damage and venous thrombosis, whereas venous thrombosis has been linked to the development of CRIs. Here we examine the association between PICC placement and CRIs.     

Central venous catheters in home infusion care: outcomes analysis in 50,470 patients

PURPOSE: Outpatient home infusion therapy is increasing; however, little data exist on the outcomes of patients receiving care. The purpose of this study was to document the natural history of central venous catheters (CVCs) used in home infusion care to determine the rate and type of catheter complications. MATERIALS AND METHODS: Data from the Strategic HealthCare Programs National Database from April 1999 to September 2000 were analyzed. Primary study objectives were to identify (i) types of CVCs and principal diagnoses, (ii) type and rate of catheter complications, and (iii) outcomes in managing thrombotic catheter complications. Event rates were calculated per 1,000 catheter days; 50,470 patients representing 2.83 million catheter days met study criteria. RESULTS: The rates of complications (per 1,000 catheter days) for the most common events were: catheter dysfunction (0.83 total; 0.6 nonthrombotic, 0.23 thrombotic), catheter site infections (0.26), and bloodstream infections (BSIs; 0.19). A total of 4,138 complication events were identified (event rate per 1,000 days: 1.5). The total rates of complications with each catheter type were: midline catheters (4.5), PICCs (2.0), nontunneled central catheters (1.1), tunneled catheters (1.0), and chest ports (0.52). Catheter dysfunction with loss of patency was the most common group of complications. Thrombotic occlusion was the principal cause of catheter dysfunction, occurring in 28% of patients in this group, typically within 7 days of catheter insertion. BSI was reported in 541 patients, generally more than 30 days after catheter insertion. Catheter thrombosis outcomes resulted in therapy interruption (43%), catheter replacement (29%), premature CVC removal (14%), unscheduled emergency room visits (9%), and/or hospitalizations (6%). CONCLUSION: Catheter dysfunction is the most frequent complication of all CVCs in this population, almost twice that of infections. Outpatient home infusion catheter dysfunction results in delays to therapy, unscheduled hospitalizations, and need for device replacement.     

A new curved peel-away sheath for central venous catheter placement

A new 10F peel-away sheath with a preformed curve is now available. The procedure for insertion of central venous cathetes remains the same, with the new curved sheath replacing the straight version. In our experience, this modification facilitates the placement of central venous catheters and decreases the incidence of catheter tip malposition and kinking.