A comparison of placement techniques and complications of externalized catheters and implantable port use in children with cancer

The complications associated with the placement and use of Hickman catheters (n = 120), Broviac catheters (n = 146), and implantable ports (n = 93) in children with cancer were analyzed. Percutaneously placed central venous access devices (CVADs) tended to fail less often (P = .86) and to develop infections less often (P = .056) than surgically placed CVADs. The difference in complications with percutaneous versus surgically placed CVADs requires confirmation in a randomized trial to assure they are not a result of differences in patient characteristics. When all catheter failures (removal due to infection, obstruction, or dislodgement) were considered, ports had a significantly longer failure-free duration of use than externalized Hickman and Broviac catheters (P = .0009). Ports also remained infection-free longer than externalized catheters (P = .0014). The greatest risk of infection occurs in the first 100 days of use, particularly for ports. This study demonstrates that for long-term use (greater than 100 days) ports are superior to externalized catheters in children with cancer.     

Double-lumen, silicone rubber, indwelling venous catheters. A new modality for angioaccess

This report presents our experience using double-lumen, silicone rubber, indwelling central venous catheters with a subcutaneous Dacron cuff as access for hemodialysis. Twenty-seven catheters were placed in 27 patients through venous cutdowns. A 10-cm subcutaneous tunnel was created leaving the Dacron cuff 2 cm from the external exit. Sixteen Raaf catheters (lumen diameter [LD], 1 mm), three double-lumen Hickman catheters (LD, 1.6 mm) and eight HemoCath catheters (LD, 2 mm) were used. The tip of the catheter was positioned fluoroscopically in either the superior vena cava or the right atrium. One hundred fifty-nine treatments were done with the Raaf catheters (mean blood flow [MBF], 188.1 +/- 26.4 mL/min); two of these catheters became obstructed and could not be used further. Three double-lumen Hickman catheters were used in 12 hemodialysis treatments (MBF, 216.3 +/- 27.1 mL/min). One hundred fifty-five treatments were done using the HemoCath catheters (MBF, 236.7 +/- 5.5 mL/min). The degree of recirculation of these catheters was 8.56% +/- 4.34%. The major advantages of this modality include simplicity of introduction, lack of serious complications, no sacrifice of major arteries, no need for venipuncture, and potential use in either short- or long-term hemodialysis.     

A Prospective Analysis of the Cephalic Vein Cutdown Approach for Chronic Indwelling Central Venous Access in 100 Consecutive Cancer Patients

Background: Chronic indwelling central venous access devices (CICVAD) generally are placed by the percutaneous subclavian vein approach. The cephalic vein cutdown approach is used only infrequently. Although the technique has been well described, few prospective data are available on the cephalic vein cutdown approach.Methods: From September 9, 1998, to July 20, 1999, the cephalic vein cutdown approach was attempted in 100 consecutive cancer patients taken to the operating room with the intention of placing CICVAD. Median patient age was 54.5 years (range 18–88), with 46 men and 54 women. Twenty-five patients had gastrointestinal malignancies, 17 had breast cancer, 15 had lymphoma, 13 had lung cancer, 12 had leukemia, 5 had multiple myeloma, and 13 had other malignancies. Patients were followed prospectively for immediate and long-term outcome.Results: CICVAD placement via the cephalic vein cutdown approach was successful in 82 patients; the remaining 18 patients required conversion to a percutaneous subclavian vein approach. The reasons for inability to place CICVAD via cephalic vein cutdown approach were a cephalic vein that was too small (10 patients), an absent cephalic vein (7 patients), and inability to traverse the angle of insertion of the cephalic vein into the subclavian vein (1 patient). There were 56 subcutaneous ports and 26 tunneled catheters. Median operating time was 44 minutes (range, 26–79 minutes). No postoperative pneumothorax occurred. Median catheter duration was 198 days (range, 0–513 days). Long-term complications included catheter-related bacteremia (6%), site infection (2%), deep venous thrombosis (5%), port pocket hematoma (1%), and superior vena cava stricture (1%). Thirty-seven percent of patients have died since CICVAD placement. Twenty-nine percent of the CICVADs have been removed.Conclusions: The cephalic vein cutdown approach was successful in 82% of patients. This approach is a safe and useful alternative to the percutaneous subclavian vein approach.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, March 16–19, 2000, New Orleans, Louisiana     

Hickman catheter placement simplified

A simplified technique to place the Hickman indwelling right atrial catheter has been devised. This involves securing the catheter to a trocar, which is easily advanced to the cutdown site of the selected vein. Experience in more than 75 patients shows this technique to be associated with less discomfort and fewer complications than seen with standard techniques.     

Percutaneous placement of permanent central venous catheters: experience with 200 catheters

The prospective registration of 200 percutaneous placements of permanent central venous catheters (Hickman catheters and subcutaneous infusion ports) was conducted in 172 patients aged 3 months-95 years. The insertions were reviewed to assess whether certain groups of patients or physicians were associated with more complications than others. Complications occurred in 16 patients (8.0%), of which 12 were arterial punctures. Two attempts (1%) at catheter placement failed. None of the complications required treatment. Of the catheter placements, 70% were performed by one of the three authors, and the rest by seven other experienced anesthesiologists. The complication rates were not different between the two groups. Nor was the complication rate significantly higher in small children. Percutaneous placement of permanent central venous catheters thus proved to be a safe and reliable technique, even in small children. The method is easily learnt by physicians experienced in central venous catheterization. Using this method, permanent venous access may be offered to a large number of patients.     

Clinical performance of Hickman and Portacath atrial catheters

A recent advance in semipermanent vascular access has been the development of the totally implanted Portacath atrial catheter. The outcome of 100 sequential insertions of atrial catheters, 61 of which were Hickman catheters and 39 Portacaths, has been retrospectively reviewed in order to determine differences in clinical performance between these two types. The majority (90%) of the patients were from haematology or oncology wards. The incidence of complications was 66% for Hickman catheters and 46% for Portacaths. Local sepsis developed in 34% of the Hickman catheters and line-related septicaemia in 21%. The frequency of local sepsis and septicaemia following Portacath insertion was 31% and 3% respectively. Complications necessitated the removal of 33% of the Hickman catheters and 15% of Portacaths. The mean duration of insertion was 10 weeks for Hickman catheters and 24 weeks for Portacaths. It is concluded that the Portacath is less frequently complicated by sepsis and offers significant advantages for those patients in whom it is used.     

PERCUTANEOUS INSERTION OF LONG-TERM VENOUS ACCESS CATHETERS VIA THE EXTERNAL ILIAC VEIN

Long-term venous access using Hickman catheters and implantable subcutaneous ports is a well established technique. These devices have customarily been inserted via the internal jugular, subclavian or cephalic veins. On occasions, these routes may be unavailable. This article reviews the outcome of 53 prolonged venous access catheters (39 Hickmans and 14 catheters attached to implantable ports) inserted percutaneously via the external iliac vein into 37 patients over a period of 5.7 years. The indications for insertion were chemotherapy (40%), total parenteral nutrition (36%), intravenous antibiotics (13%), poor venous access (7%) and bone marrow transplantation (4%). The main reasons for use of the external iliac vein were thrombosis of the subclavian veins or superior vena cava and subclavian central line sepsis. The only complication of insertion was one inadvertent puncture of the external iliac artery. Twenty-seven catheters (51%) remained complication free and functioning for the time for which they were required. Four catheters (7%) are still functioning in situ having been present for 1–5 years. Sixteen catheters (30%) became infected, with a 17% incidence of septicaemia. Venous thrombosis was associated with three catheters (6%). Catheters remained in situ for a median period of 30 days (range 5–569 days). The authors conclude that long-term venous access using percutaneous external iliac vein insertion is a useful technique when other routes are unavailable, but there is a relatively high incidence of catheter-related sepsis.     

Central venous access for haemodialysis using the Hickman catheter

One hundred and seven Hickman catheters for haemodialysis were inserted in 90 end-stage chronic renal failure patients, and were used for 1-448 days (median 45 days). Sixty-nine per cent of the patients were treated without any problem for 1-165 days (median 34 days). Clinically evident complications occurred in 44 catheters inserted in 28 patients, and included outflow obstruction (16.8% of the catheters) and thrombosis (13.1% of the catheters). However, many episodes of clotting or insufficient flow could be corrected by simple manoeuvres. Other less frequent complications were recorded: sepsis, mainly in patients with increased risk factors (4.1% of the catheters), laceration of the catheter (3.7%) and occasional cases of jugular-vein phlebitis, transient palsy of a vocal cord, haematoma of the wound, and bleeding of the cutaneous orifice. No clinical sign of subclavian or innominate-vein thrombosis was observed. Nevertheless, a prospective study conducted in 50 asymptomatic patients demonstrated a 12% rate of anomalies of the venous system, although two-thirds of these alterations were mild and had no consequence. When the present series is compared to the results obtained with currently available percutaneous haemodialysis catheters, it is concluded that the Hickman catheter is a safe, comfortable and efficient vascular access device.     

Percutaneous infraclavicular insertion of long-term central venous Hickman catheters

Percutaneous infraclavicular subclavian vein insertions of single lumen Hickman right atrial catheters (n = 342) were performed on 308 patients at Royal Prince Alfred Hospital. The indications for insertion were administration of total parenteral nutrition (44.8%), intravenous chemotherapy (40.9%), intravenous therapy in patients with inaccessible peripheral veins (11.7%), and intravenous antibiotic administration (2.6%). Three percutaneous catheter insertions were complicated by pneumothorax (0.88%). There were no other complications of insertion. Catheters remained in situ for a median period of 30 days (range: 2-853 days). The majority of catheters (69.6%) remained functioning and complication-free until the completion of therapy or until the patient died of their original disease. Some catheters became infected (9.9%) and there was a 0.6% incidence of septicaemia due to infected catheters; 8.5% of catheters were removed because of a suspicion of infection that was not subsequently proven. The incidence of infection was highest within the first month after catheter insertion, and decreased thereafter. Percutaneous subclavian insertion of Hickman right atrial catheters appears to be the insertion method of choice in patients requiring long-term central venous access.     

Comparison between peripherally implanted ports and externally sited catheters for long-term venous access.

In a comparative study, we examined the use of a peripherally implantable venous access system which does not require either central venous cannulation or radiological screening. We compared the complication rate in 85 patients receiving this system with that in 112 similar patients receiving Hickman lines. In addition, we examined the safety and cost implications of using a ward setting instead of full operating facilities for port insertion. There was a 10.7% incidence of early and 37.6% incidence of late complications in the group receiving Hickman lines compared with only 2.4% early complications and 10.6% late complications in those receiving peripherally implantable ports. There was no difference in complication rates between those patients who had the ports inserted in a ward side room compared with those who had their procedure performed in the operating theatre. We have demonstrated the ease and reliability of port insertion in the absence of screening radiology and we therefore suggest the peripheral port as a safe, cost-effective alternative to existing venous access systems.     

Hickman catheter implantation in the treatment of acute leukemia

Between July 1980 and May 1981, 32 permanent indwelling Hickman catheters were implanted in 29 patients. Most of the catheters were placed for treatment of acute leukemia (25 patients) or lymphoma (two patients). Catheters were used for a total of 3,461 patient-days (mean, 108 days). Two patients had infections at the exit site, one seven and the other 11 days after implantation. Four patients had sepsis, but none of those infections appeared to be catheter related. Hickman catheters appear to provide ease of treatment in acute leukemia and are associated with patient satisfaction and an acceptable complication rate.     

The fate of 100 prolonged venous access devices

The fate of 100 prolonged venous access devices (PVAD) placed for chemotherapy (97) or antibiotics (3) during a three-month period was prospectively evaluated. The PVAD included 52 double lumen Hickman (DLH), 29 Infuse-a-port (IAP), and 19 single lumen Hickman (SLH) catheters using percutaneous puncture in 72 pts and venous cutdown in 28 patients. The Hickman catheter subcutaneous tunnel ranged from 4-20 cm with the cuff placed 0.5 to 10 cm from the exit site. Each patient was contacted at two-week intervals to determine the state of the catheter until removal or death. After a one-year follow-up period, 16 per cent of the PVAD remain in place. There were 37 deaths and 22 PVAD were removed after completion of treatment. Mechanical problems led to removal in 12 patients including venous thrombosis (4), poor placement (3), occlusion (3), and a leaking device (2). There were four catheters that "fell out" and nine (8 DLH, 1 SLH) were removed for infection; all 13 catheters were placed in a subcutaneous tunnel less than or equal to 6 cm with the cuff 0.5 cm from the exit site. This study is unique in its accurate determination of fate; 40 per cent of the patients would have been "lost to follow-up" had a retrospective chart review been used, as many patients died at home or had their PVAD removed elsewhere. Recommendations to increase catheter life/patient satisfaction include 1) IAP as the PVAD of choice, 2) SLH preferable to DLH and 3) placement of long Hickman catheter tunnels (greater than or equal to 10 cm) with cuff greater than or equal to 2 cm from exit site.     

Complications of percutaneous insertion of Hickman catheters in children.

BACKGROUND/PURPOSE: The aim of this study was a retrospective evaluation of insertion and management complications of percutaneous Hickman catheter lines in pediatric patients to investigate whether the complication rate is acceptable in comparison with other insertion methods or other age groups. METHODS: Over a period of 22 months a total of 27 Hickman catheters were inserted in 22 pediatric patients (20 oncological, 2 nononcological; age 6 weeks to 17.5 years). RESULTS: Twenty-three of 36 insertion attempts (63.9%) were successful at first attempt. In another 4 patients, catheters were placed after repeated attempts. In an additional 4 patients, catheters were inserted by surgeons after percutaneous insertion failed. As immediate complications, 1 pneumothorax and 1 malposition were seen. Late complications included 1 to 29 (median, 8) days of fever in 15 patients, corresponding to 53 of 1,000 catheter days. Fourteen patients showed 21 positive blood cultures, including 11 cases of Staphylococcus epidermides, which might be related to the catheter. Antibiotics were given for a total of 1 to 130 (median, 35) days, that is 205 of 1,000 catheter days. No catheter was removed because of infectious complications. The total life span of the Hickman catheters was 1 to 371 (median, 163) days, the patients were in the hospital from 1 to 351 (median, 102) days because of their underlying disease. At the end of the study period, 8 of 27 (29.6%) catheters remained functioning in situ; 9 (33.3%) had been selectively removed. Two patients died with the catheter (7.4%) functioning well. Another 2 patients showed catheter thrombosis. Six catheters (22.2%) in 5 patients showed inadvertent dislodgement. CONCLUSION: Percutaneous Hickman catheter insertion in pediatric patients is effective; however, complication rate is relevant, but not higher than percutaneous insertion of subclavian vein or Hickman catheters in adults.     

A Modified Internal Jugular Vein Access for Long-Term Catheter Placement in Cancer Patients

Background Placement, handling, and maintenance of indwelling central venous access devices may be difficult due to anatomical, clinical, or hematologic conditions in many cancer patients needing chemotherapy. An alternative approach technique is suggested joining surgical dissection to venipuncture, assisted by fluoroscopy, as a secure way to avoid complications of long-term indwelling catheters. Although ultrasound guided puncture is a safe procedure, it is not always available or familiar to most surgeons. Methods At the National Cancer Institute (INCA) in Rio de Janeiro, Brazil, 1750 long-term catheter placements were performed between the years 1997 and 2005. Among those, 160 were done through an alternative technical procedure consisting of an anterior cervical cutdown approach to the internal jugular vein (IJV) followed by percutaneous visual puncture of the vein. This modified internal jugular vein access (MIJVA) was employed when other access techniques were not feasible or if other underlying conditions increase the risk of bleeding complications. Results The MIJVA procedure was successful in all 160 patients. Although it was used only as an exceptional option in difficult venous accesses, further prospective trials must be conducted, however, for comparison with other technical approaches. Conclusion The MIJVA is an option that provides successful IJV dissection and safe percutaneous visual puncture overcoming anatomical pitfalls in placement of long-term venous access for chemotherapy in cancer patients.     

A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter-related deaths.     

Prolonged access to the venous system using the Hickman right atrial catheter

Seventy-one Hickman catheters were inserted into 63 patients for prolonged access to the venous system. The mean catheter life was 98 days, but despite the long life in situ provided by these catheters only 5 (7%) had to be removed for septic complications. The technique of insertion is described and the subsequent management of these catheters discussed. The management of patients receiving parental nutrition, those undergoing bone marrow transplantation for acute leukaemia, and those having cytotoxic chemotherapy was greatly facilitated by the use of the catheter.     

Direct cephalic vein cannulation for safe subclavian access

Over a 2-year period we have successfully inserted 70 subclavian catheters in 68 patients from 76 attempts by cephalic vein cutdown. There were no complications of catheter insertion although 40% were inserted by junior surgeons (mean survival of catheters was 16.5 days) and in 30% of patients the catheter was removed before the completion of treatment for both infective and other complications. From our results, we recommend that direct cephalic vein cutdown is the route of choice for elective subclavian access because of its safety.     

Percutaneous placement of Hickman catheters for prolonged venous access

The Hickman catheter is well established as a safe, reliable means of venous access in a variety of clinical situations. Although the technique for placement by surgical cutdown in the cephalic or external jugular vein is standardized, our experience placing 102 catheters in the last 40 months has led us to evolve and adopt a percutaneous method that we have now applied to almost all catheter placements. Operative time has been dramatially reduced, patient discomfort minimized, and no change in short- or long-term morbidity has been noted. The procedure has been described in detail, and our overall experience with placement of the Hickman catheter in a variety of clinical situations has been reviewed. We now consider this percutaneous technique to be the primary method of Hickman catheter placement unless specifically contraindicated.     

THE ROLE OF OXYBUTYNIN IN SPINAL CORD INJURED PATIENTS WITH INDWELLING CATHETERS

Purpose

The long-term benefits of oral oxybutynin in spinal cord injured patients with indwelling catheters is unknown. We reviewed our experience with this population of men and present the results of our analysis.

Materials and Methods

A total of 109 male spinal cord injured patients at the Houston Veterans Affairs Medical Center have been treated with chronic indwelling catheters (80 transurethral and 29 suprapubic). Thirty-eight patients (35%) were identified as using oxybutynin on a regular basis. These patients were compared to those not using oxybutynin with regard to urodynamic parameters and upper tract deterioration. Specifically examined were bladder compliance, bladder leak point pressure, vesicoureteral reflux, hydronephrosis, urolithiasis, febrile urinary tract infections and serum creatinine greater than 2 mg./dl.

Results

The mean duration of indwelling catheter use was 11.9 years (12.4 without oxybutynin and 10.9 on oral oxybutynin). Of the 31 patients with normal compliance (greater than 20 ml./cm. water), 24 (77%) were using oxybutynin (p = 0.001). Bladder leak point pressures were abnormal (greater than 35 cm. water) in 5 of 32 patients (16%) on oxybutynin versus 34 of 60 (57%) without it (p <0.001). Hydronephrosis was present in 15 of 66 patients (23%) without oxybutynin versus 1 of 36 (3%) with oxybutynin (p = 0.009). Febrile urinary tract infections occurred in 4 of 35 patients (11%) versus 17 of 62 patients (27%) with or without oxybutynin, respectively (p = 0.077). No significant differences were found between the 2 groups with regard to reflux, renal scars, stones or elevated serum creatinine.

Conclusions

It appears that regular use of oxybutynin may be beneficial in spinal cord injured patients who require chronic indwelling catheters for bladder management. Our analysis reveals that patients who take oxybutynin regularly have better bladder compliance, lower bladder leak point pressures and less hydronephrosis. Until a prospective, randomized trial reveals contradicting outcomes, empiric use of oxybutynin in all spinal cord injured patients requiring chronic indwelling catheters seems justified.     

Hickman catheter embolism in a child during stem cell transplantation

The majority of stem cell recipients rely on indwelling central venous catheters situated in superior vena cava or right atrium. Semi-permanent tunneled silicone rubber Hickman catheters are widely used to provide durable central venous access for patients undergoing stem cell transplantation. A case of 5 years old child with diagnosis of severe aplastic anemia is reported. The patient received peripheral blood stem cells (PBSC) and had successful engraftment with complete hematological recovery. He had Hickman catheter embolism in the pulmonary circulation following unsuccessful attempt to remove the line. The catheter was successfully removed by midsternostomy operation. The child is normal with sustained remission on day +218 post stem cell transplant.