Safety and feasibility of using a central venous catheter for rapid contrast injection rates

OBJECTIVE: Our aim was to determine the safety and feasibility of using a central venous catheter for rapid contrast injections during CT. MATERIALS AND METHODS: An in vitro experiment was performed using a 7-French Arrow-Howes multilumen central venous catheter. Each catheter port was tested by varying contrast agent flow rates delivered by a power injector. Contrast media specifications were kept similar to routine clinical practice. The in vivo experiment included 104 cases in which rapid contrast injections, 3.0-5.0 mL/sec, were delivered through a central venous catheter for dynamic CT examinations. Patient monitoring for early complications of contrast extravasation, cardiac arrhythmia, and allergic reactions was performed. Contrast injections were monitored for pressure limitation, automatic flow-rate adjustment, and catheter injury. Chart review was performed for delayed complications of mediastinal hematoma, infection, or catheter malfunction. RESULTS: During the in vitro experiment, all desired flow rates, 3.0-9.9 mL/sec, could be delivered through the central venous catheter with no catheter injury. No immediate or early patient or catheter complications were observed during the in vivo experiment. Follow-up evaluation revealed that 18 blood cultures and one catheter culture were positive for bacterial growth. In a subgroup of 43 patients, five contrast injections were pressure-limited by the power injector, and only one had the flow rate automatically adjusted to 3.6 mL/sec from 4.0 mL/sec. CONCLUSION: Rapid contrast injection rates, at 3.0-5.0 mL/sec, through the Arrow-Howes multilumen central venous catheter are feasible and safe in the clinical setting. However, a strict protocol should be followed to avoid possible serious complications.     

Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy

OBJECTIVE: This study evaluates the feasibility, safety, and efficacy of power-injecting IV contrast media through central venous catheters for CT examinations. SUBJECTS AND METHODS: Two hundred ninety-five CT examinations were performed during an 18-month period in 225 patients with indwelling central venous catheters. Patients were randomized to power injection either through peripheral IV catheter or through central venous catheter. Feasibility was defined as the percentage of patients with contrast material injected successfully through the randomized access route. Safety was evaluated by comparing patients with complications. Efficacy was evaluated by comparing contrast enhancement of the thoracic aorta, pulmonary artery, abdominal aorta, and liver. RESULTS: Two hundred nine patients had randomization data recorded. One hundred three (94%) of 109 patients were successfully injected through their indwelling catheter compared with 42 (42%) of 100 through a peripherally placed IV catheter (p < 0.001). After reassignment for unsuccessful access, 174 patients underwent central venous catheter injection, and 51, peripheral IV catheter injection. No statistically significant difference was noted in the complications between the central venous catheter and peripheral IV catheter groups. Enhancement was greater in the thoracic aorta, pulmonary artery, and liver for the peripheral IV catheter group (p < 0.03). CONCLUSION: Power injection of contrast media through central venous catheters for CT examinations is feasible and safe when set hospital guidelines and injection protocols are followed. This technique provides an acceptable alternative in patients without adequate peripheral IV access when bolus contrast enhancement is desired.     

Safety considerations in the power injection of contrast media via central venous catheters during computed tomographic examinations.

RATIONALE AND OBJECTIVES. This study addresses the theoretical, experimental, and clinical application of using a central venous catheter system (CVS) for the rapid injection of contrast media during computed tomography (CT). METHODS. Application of Poiseuille's law and the Reynolds equation yielded theoretical data. In-line pressures were measured in experimental models and patients undergoing CT. Diatrizoate meglumine and iohexal contrast media were evaluated. RESULTS. The Reynolds number was consistent with laminar flow, allowing the application of Poiseuille's law. The calculated and experimental catheter tubing-chamber connection pressures were safe for both contrast media, at rates of 1 mL/second for long catheter tubing and 2 mL/second for short tubing. Thirteen patients had measured pressures within safety limits with no complications. CONCLUSIONS. This study establishes that power injection of contrast media via a CVS during CT is a safe procedure. Benefits include no need for peripheral intravenous catheter placement, decreased paramedical staff radiation exposure, and improved CT image quality.     

Catheter-Malposition-Induced Cardiac Tamponade via Contrast Media Leakage During Computed Tomography Study

We present a rare case of a central venous catheter-malposition-induced life-threatening cardiac tamponade as a result of computed tomography (CT) with contrast enhancement in an infant with a ventricular septal defect and pulmonary atresia after a modified Blalock–Taussig shunt. The diagnosis was confirmed by chest radiographs and CT study with catheter perforation through the right atrial wall and extravasation of the contrast medium into the pericardium, leading to cardiac tamponade and subsequent circulatory collapse. Two hours after successful cardiopulmonary resuscitation, the patient gradually resumed normal hemodynamic status.     

Extravasation from venous catheter: a serious complication potentially missed by lung imaging

Three patients were referred for lung ventilation and perfusion (V/Q) imaging with symptoms strongly suggestive of pulmonary embolus (PE). Chest roentgenograms and xenon ventilation studies on all three were normal, save for prominent mediastinal silhouettes and effusions. Technetium-99m macroaggregated albumin (Tc-99m MAA), when injected through the central venous catheter (CVP), revealed mediastinal localization, whereas antecubital injections showed normal pulmonary perfusion. Contrast fluoroscopy introduced through the venous catheter in the first patient defined the extravasation. For patients under strong suspicion of PE, with a venous catheter whose distal tip is seen about the level of the heart on chest radiograph, we recommend administering the perfusion agent slowly through the central catheter to exclude catheter-induced complications. When extravasation is detected, injection of Tc-99m MAA by peripheral vein should be used to exclude PE.     

Perfusion patterns in CT transit studies

Summary Transit studies consist of a rapid sequence of single cross-section CT scans performed during and following the bolus injection of contrast medium into the venous system. The low vascular volume of the brain leads to small changes in attenuation thereby reflecting the perfusion of vasculature. Studies were carried out following 45 examinations on 24 stroke patients and 15 tumor patients. Hypo-, normo- and hyperperfusion were observed in different tissue categories and related to specific tissue elements. The comparison of perfusion patterns with pre-contrast CT values and enhancement after 5 min elucidates cerebral hemodynamics in hypodense to hyperdense lesions with or without damage of the blood-brain barrier (BBB)Cystic lesions and edema were found to have slight damage of the BBB and markedly reduced perfusion. Infarcts demonstrated, depending on their state of evolution to cystic defects or recovery to normal, hypoperfusion and extravasation of contrast medium or hyperperfusion with or without damage of the BBB. A diagnostically valuable difference between edema and infarcts was seen in the phase of stable distribution after 5 min. In most tumors hypervascularity and pathological extravasation were seen, whereby the cause of enhancement could be differentiated.Owing to the properties of the contrast medium used, and to the fact that transit times can not yet be measured, quantification of CBV and CBF was not possible. Definition of large cerebral vessels, especially in the neighborhood of brain tumors, and the improvement in detectability of small lesions by low dose contrast injection, will be demonstrated as a spin-off of CT transit studies.     

Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters

Introduction

CT perfusion studies play an important role in the early detection as well as in therapy monitoring of vasospasm after subarachnoid hemorrhage. High-flow injections via central venous catheters are not recommended but may sometimes be the only possibility to obtain high-quality images.

Materials and methods

We retrospectively analyzed our data for CT perfusions performed with power injection of contrast material with an iodine concentration of 400 mg/ml via the distal 16G lumen of the Arrow three and five lumen central venous catheter with preset flow rates of 5 ml/s.

Results

104 examinations with central venous catheters were evaluated (67 with five lumen and 37 with three lumen). No complications were observed. Mean flow rates were 4.4 ± 0.5 ml/s using the three lumen catheter and 4.6 ± 0.6 ml/s using the five lumen catheter respectively. The mean injection pressure measured by the power injector was 200.7 ± 17.5 psi for the three lumen central venous catheter and 194.5 ± 6.5 psi for the five lumen catheter, respectively.

Conclusion

Following a strict safety protocol there were no complications associated with power injections of contrast material containing 400 mg iodine/ml with preset flow rates up to 5 ml/s via the distal 16G lumen of the Arrow multi-lumen central venous catheter. However, since power-injections are off-label use with Arrow central venous catheters, this procedure cannot be recommended until potential safety hazards have been ruled out by the manufacturer.     

Thoracic and abdominal extravasation: a complication of hyperalimentation in infants.

Two infants with five separate episodes of extravasation from hyperalimentation catheters are described. Three were intrathoracic and two were retroperitoneal, one of the latter producing clinical ascites. Clinical respiratory distress or ascites developing in an infant undergoing hyperalimentation may indicate vein wall perforation with extravasation into the pleural or abdominal cavities or the retroperitoneum. Questionable situations may be readily resolved by contrast injection through the catheter. Suboptimal position of the catheter tip and venous thrombosis seem to be major contributors to this problem. Prompt recognition and removal of the catheter are generally sufficient to correct the situation.     

Is hand injection of central venous catheters for contrast-enhanced CT safe in children?

OBJECTIVE: Our objective is to review our safety experience with hand injection of central venous catheters for administration of i.v. contrast material for CT in children. CONCLUSION: Administration of i.v. contrast material by means of hand injection led to damage of four central venous catheters during a 6-year period at our institution (0.3% of central venous catheters hand injected during that time). In addition to the growing evidence of the safety of power injection of i.v. contrast material in central venous catheters, the potential danger of hand injection of central venous catheters should be considered when policies are made concerning the delivery of i.v. contrast material via central venous catheters.     

Clinical application of DSA and evaluation of its methods: analysis of 160 cases and review of literature

A total of 160 patients of two hospitals received 192 DSA examinations with different contrast administrations, and techniques of performing DSA were analyzed, compared, and evaluated with reference to the literature. It was concluded that (1) the peripheral injection of contrast material for IVDSA via cannula is simpler than that via a short catheter, but the incidences of contrast extravasation in both cases are higher than with central injection. (2) Both the lower part of the superior vena cava and the right atrial cavity are safe sites for central injection. With central injection for IVDSA, the arterial iodine concentration is approximately double that of peripheral injection, and consistent high quality examinations of the intracranial vessels may be obtained. However, neither peripheral nor central injections can visualize the small vessels clearly. (3) IVDSA may be substituted for conventional angiography only in examinations of the aorta and its main branches. (4) IADSA is becoming a superior angiographic technique and its clinical application is increasing. In addition, means of avoiding contrast extravasation during IVDSA and the main points of selecting the optimal technique for DSA are described in this paper.     

Impact of Different Vein Catheter Sizes for Mechanical Power Injection in CT: In Vitro Evaluation with Use of a Circulation Phantom

The purpose of this study was to evaluate the influence of different peripheral vein catheter sizes on the injection pressure, flow rate, injection duration, and intravascular contrast enhancement. A flow phantom with a low-pressure venous compartment and a high-pressure arterial compartment simulating physiological circulation parameters was used. High-iodine-concentration contrast medium (370 mg iodine/ml; Ultravist 370) was administered in the venous compartment through peripheral vein catheters of different sizes (14, 16, 18, 20, 22, and 24 G) using a double-head power injector with a pressure limit of 325 psi. The flow rate was set to 5 ml/s, with a total iodine load of 36 g for all protocols. Serial CT scans at the level of the pulmonary artery and the ascending and the descending aorta replica were obtained. The true injection flow rate, injection pressure, injection duration, true contrast material volume, and pressure in the phantom during and after injection were continuously monitored. Time enhancement curves were computed and both pulmonary and aortic peak time and peak enhancement were determined. Using peripheral vein catheters with sizes of 14–20 G, flow rates of approximately 5 ml/s were obtained. During injection through a 22-G catheter the pressure limit was reached and the flow rate was decreased, with a consecutive decreased pulmonary and aortic contrast enhancement compared to the 14- to 20-G catheters. Injection through a 24-G peripheral vein catheter was not possible because of disconnection of the canula due to the high flow rate and pressure. In summary, intravenous catheters with sizes of 14–20 G are suitable for CT angiography using an injection protocol with a high flow rate and a high-iodine-concentration contrast medium.     

Incidence of intravenous contrast extravasation: increased risk for patients with deep brachial catheter placement from the emergency department

Deep brachial intravenous catheter (IV) placement can be performed in emergency department patients with difficult vascular access, but the safety of deep brachial IV for iodinated contrast administration has not been assessed. This study compares the relative risk for extravasation of deep brachial IV compared with antecubital IV during power injected computed tomography (CT) examinations. A departmental practice quality improvement was performed to assess the rate of IV extravasation for all CT examinations during a 1 year period. De-identified data was analyzed with a waiver of informed consent to identify the rate and relative risk of iodinated contrast extravasation by catheter type. A total of 10,750 injections were performed, with 82 extravasation events (0.8 %). There were 51 extravasations of antecubital IV from approximately 8,599 placed (0.6 %). For 123 deep brachial IV placed, there were eight extravasations (6.5 %). The relative risk of a deep brachial IV extravasation was 9.4 compared to 0.4 for antecubital placement. Deep brachial IV demonstrated a markedly higher rate of contrast extravasation than antecubital IV. For power injected iodinated contrast administration, it is recommended to avoid the use of deep brachial IV whenever possible.     

Squeeze maneuver: an easy way to manage radiological contrast-medium extravasation

BACKGROUND: Contrast-medium extravasation injuries may be self-limited to catastrophic. Adequate prophylactic measures are enforced when risk factors for extravasation are present, and prompt treatment can avoid serious complications. PURPOSE: To describe the squeeze maneuver, an effective method for the treatment of symptomatic contrast-medium extravasation. MATERIAL AND METHODS: Over a 3-month period, eight patients with >50 ml contrast-medium extravasation resulting in vascular compromise of the fingers were managed with the squeeze maneuver as follows. The intravenous catheter used for contrast-medium injection was removed, and the skin around the insertion site was cleaned with povidone-iodine. An 18-gauge needle was then used to puncture five to eight openings near the catheter insertion site as deeply as possible. We then began squeezing from the periphery of the swelling toward the needle holes. As the contrast medium drained, it was swabbed away with iodine-soaked cotton swabs. RESULTS: In all eight patients, the maneuver was successful with immediate resolution of the vascular compromise. CONCLUSION: The squeeze maneuver provides an easy way to manage radiological contrast-medium extravasation and can be performed immediately in the CT suite.     

The use of central venous catheters for intravenous contrast injection for CT examinations

The use of intravenous (i.v.) contrast media in CT examinations is often of great value in improving diagnostic accuracy. The preferable route of administration is via a peripheral i.v. cannula, with powered injectors allowing reliable delivery of rapid flow rates. However, many patients with a pre-existing central venous access device may have difficult peripheral access and there is a temptation to use the central device for delivery of contrast media. This review summarises the available evidence for the safe and effective use of these devices to assist the radiologist in balancing the relative risks and benefits of their use for contrast medium injection.     

Power injection of contrast media via peripherally inserted central catheters for CT

PURPOSE: To evaluate patient safety, catheter rupture rates, and computed tomography (CT) image quality when using peripherally inserted central catheters (PICCs) in vivo for the power injection of CT contrast media at standard injection rates. MATERIALS AND METHODS: A prospective study to evaluate the safety and effectiveness of power injection of contrast media via indwelling PICCs was performed. Single-lumen and double-lumen polyurethane PICCs (5 F) were injected in vivo with contrast media for clinical CT examinations at injection rates ranging from 1 mL/sec to 4 mL/sec. Data collected included PICC rupture rate, patient complications, injection rate, peak injection pressure, PICC length, PICC age, and quality of contrast enhancement on the CT images. RESULTS: One hundred ten power injections of PICCs for CT examinations were performed. There were 12 injections of single-lumen PICCs and 98 injections of double-lumen PICCs. The most common injection rate was 2 mL/sec, accounting for 89 of the 110 injections (81%). Two PICCs ruptured during power injection, both as a result of operator error. One of the PICCs that ruptured was clamped at the time of injection and the other one was kinked at its venous entry site. One additional PICC showed evidence of dysfunction; it ballooned without actually rupturing. No significant patient complications occurred. Contrast enhancement of the CT images was subjectively rated as average or above average in 95% of cases. CONCLUSIONS: Contrast media can be power-injected via PICCs for routine CT examinations at a rate of 2 mL/sec, yielding satisfactory image quality without exposing patients to significant additional risk. Power injection rates greater than 2 mL/sec, as are typically used in CT angiography applications, were not fully evaluated by this study.     

A new device to limit extravasation during contrast-enhanced CT

OBJECTIVE: The extravasation detection accessory (EDA) is designed for use during contrast-enhanced CT studies performed with a power injector. The EDA detects the changes in soft-tissue impedance that occur with enhanced extravasation and halts the further infusion of contrast material via a feedback circuit to the injector. We tested the sensitivity of this device in a model of contrast extravasation. MATERIALS AND METHODS: Study subjects had an extravasation of 5% dextrose in water (nonionic contrast equivalent) in one arm and 0.9% sodium chloride solution (ionic contrast equivalent) in the other. An EDA was placed over the site of infusion and connected to a power injector. Injections were performed at 0.25 ml/sec (n = 40), 2.5 ml/sec (n = 62), or 5 ml/sec (n = 20). RESULTS: At infusion rates of 2.5 and 5 ml/sec, the device halted the injector in every subject after an average volume of 12.5 +/- 1.6 ml was delivered. At 0.25 ml/sec, the device failed to halt the injector in 11 of 20 events. After reprogramming the algorithm, 10 more subjects were tested at the lowest injection rate. The device halted 18 of 20 extravasation events with an average volume of 3.7 +/- 0.5 ml. CONCLUSION: In our model of contrast extravasation, the EDA halted a power injector with reliability and reproducibility before a large volume of contrast material was delivered. The sensitivity of the device approached, but did not reach, 100%. This device may serve to diminish the morbidity of extravasation events.     

Collateral pathways in lumbar epidural venography

Summary Opacification of collateral pathways other than the central channels is very rare in lumbar epidural venography. Two cases of opacification of the inferior mesenteric vein following extravasation of contrast medium at the tip of the lateral sacral vein catheter are reported. One case is presented in which filling of normal parametrial venous plexuses and the left ovarian vein occurred as a consequence of incompetent or absent valves in the internal iliac vein. The literature containing comparable collateral flow patterns in disease is reviewed. The significance of the phlebographic features in our cases is discussed.     

Serendipitous detection of an errant central venous catheter

The inappropriate placement of a patient's central venous catheter in the pleural space by the serendipitous injection of Tc-99m labeled red blood cells through the catheter during a GI bleeding study was discovered. Position and patency of central venous lines can be incidentally evaluated by using existing central venous catheters for administration of radiopharmaceuticals during radionuclide imaging studies.     

Central venous stenosis of left versus right arm: its prevalence and effects on image quality in CT of the neck

Objective

The purpose of this study was (1) to evaluate the prevalence of the left and right central venous stenosis by measuring the narrowest area and (2) to assess the effects of the central venous stenosis on perivenous artifacts and reflux of contrast material, in CT of the neck.

Materials and methods

Images of a total of 443 CT of the neck with an injection of contrast material into the left (n = 249) or right (n = 194) arm were retrospectively reviewed. The maximum stenosis area in the central vein ipsilateral to the injection side was measured in each patient. We also graded the perivenous artifacts and reflux of contrast material with 4-point scale. These results were compared between patients with right arm injection and those with left arm injection.

Results

The maximum stenosis area in the left arm was significantly smaller than that in the right arm. The stenosis was most frequently identified at the medial clavicular region. The mean scores of the perivenous artifacts and the reflux of contrast material were significantly higher in patients with left arm injection than in those with right arm injection. The perivenous artifacts and reflux of contrast material were more prominent in patients with central venous stenosis (maximum stenosis area <50 mm²) than those without stenosis.

Conclusions

The image degradation in CT of the neck, due to perivenous artifacts and venous reflux, can be reduced with the right arm injection of contrast material when compared with the left arm injection.     

Percutaneous translumbar inferior vena cava cannulation under computed tomography guidance

Percutaneous translumbar inferior vena cava (IVC) cannulation is an alternative approach for central venous catheterization, but there have been sporadic reports of puncture-related complications. To avoid complications during IVC puncture, percutaneous translumbar IVC cannulation was performed under computed tomography (CT) guidance in addition to fluoroscopy in two patients. To perform chemotherapy for recurrent breast cancer, we planned subcutaneous port catheter placement for central venous access. Under CT guidance, the direction and insertion distance of a long elastor needle were adjusted, and the IVC was punctured at the level of the third lumbar vertebra while taking care to avoid the right urinary tract. A guidewire was inserted through the long elastor needle, and a catheter was placed over the guidewire. It was possible to perform central venous catheterization by percutaneous translumbar inferior vena cava cannulation under CT guidance.