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     

Totally implantable venous access devices implanted surgically: a retrospective study on early and late complications

BACKGROUND: The techniques used for the implantation of totally implantable venous access devices (TIVADs) are the percutaneous approach and surgical cutdown; however, the choice is still controversial. HYPOTHESIS: The surgical cutdown approach may be beneficial to reduce the rate of complications. DESIGN: Retrospective review. SETTING: A university hospital and a tertiary referral center. PATIENTS: Patients undergoing a TIVAD implant at the First Surgical Clinic of the University of Catania in Catania, Italy, between January 1995 and December 1999, were considered for the study. All of the devices were implanted in an operating room under fluoroscopic control. The vein of choice was the cephalic vein. When the cephalic vein was not suitable for implantation, the external jugular vein or the axillary vein and its branches were used. The percutaneous approach to the subclavian vein or internal jugular vein was considered a last resort to implant a catheter. RESULTS: During the study period, 346 TIVADs were implanted in 344 patients. The procedure was performed with local anesthesia in 341 cases (98.5%), and only 2 patients (0.6%) required sedation for psychological reasons. Three patients (0.9%) had their TIVAD placed during a laparotomy. In 326 patients (94.2%), the devices were implanted in the cephalic vein. In the remaining cases, other veins were used with surgical cutdown. The mean time for the procedure was 15 minutes. Percutaneous access was never used, and no early mechanical complications were recorded. Only 6 patients (1.8%) in our study group had late complications (1 case of migration of the catheter, 2 cases of infection, and 3 cases of withdrawal occlusion). The catheter life ranged from 6 to 1487 days (mean time, 348 days). CONCLUSION: Our results confirm the safety, speed, and low cost of the open cutdown technique. This surgical procedure avoids both early and late complications that frequently occur with percutaneous access. Surgical cutdown should be considered the technique of choice to implant the TIVAD, especially in cancer patients.     

Venous cutdown for pacemaker implantation

Two hundred sixty-eight dual-chamber pacemaker implants using polyurethane leads for atrium and ventricle were analyzed for the vein of entry for both atrial and ventricular leads. The cephalic vein was used for both leads in 61.2%, the external jugular vein for both leads in 8.6%, both veins in 7.8%, and the subclavian vein alone in 16.4%. The total for venous cutdown alone was 77.6%. There were no complications relevant to the vein of approach for the venous cutdown leads, but there was one pneumothorax requiring thoracic intubation for the subclavian puncture route. Venous cutdown is satisfactory for dual-chamber pacing requiring two lead systems.     

Komplikationen und Funktionsdauer intravenöser Portkathetersysteme in Abhängigkeit des Zugangswegs

Background

Totally implantable venous access devices (TIVAD), also referred to as Port-a-Cath systems, are widely used for chronically ill and cancer patients. The choice of insertion modalities and sites is usually empirical, and only limited general recommendations are available.

Patients and methods

In all, the records of 154 patient after TIVAD implantation were reviewed to determine the rates of complications and reoperations as well as longevity with a median follow-up of 541 days (“as-treated” analysis). Patients were grouped according to the access route: percutaneous landmark access to the internal jugular (n?=?71) vs. subclavian vein (n?=?32; Seldinger technique) vs. surgical cutdown access through the cephalic vein at the deltoid–pectoralis groove (n?=?51).

Results

No significant differences were found regarding the reoperation rate: internal jugular (15.5?%) vs. cephalic (15.7?%) vs. subclavian (9.4?%). Early complications were dominated by hemorrhage. Catheter or chamber infection was the most common complication during follow-up. Percentage of patients with at least one complication was 17.7?% after cephalic vs. 15.5?% after internal jugular vs. 9.4?% after subclavian vein access, respectively. The 3-year survival of the ports was 69.5?% (internal jugular vein) compared to 82.1?% (subclavian vein) after percutaneous cannulation vs. 76.9?% in patients with surgical cutdown access. There were no statistically significant differences regarding early and late complications as well as 3-year TIVAD survival according to the access route.

Conclusion

Due to the retrospective study design, interpretation of absolute complications rates is somewhat limited. Nevertheless, the access route for TIVAD implantation has no significant impact on early or late complications as well as longevity. Regardless of the implantation technique, catheter infection was the most common complication with subsequent need for port removal. We favor a surgical cutdown attempt because of the mandatory incision to implant the chamber in any case. In case of failure, the incision access can be used for direct puncture of the subclavian vein.     

Complications in large-bore catheters for extracorporeal detoxification methods

Catheters for large vessels have become essential tools for the management of hospitalized or chronically ill patients requiring intensive medical treatments such as extracorporeal detoxification procedures. The increased use of such devices has been accompanied by a corresponding increase in complications, such as infection, sepsis, and thrombosis. In two retrospective studies, the first (1979-1990) with 1672 patients and 2626 large-bore catheters and the second (1996-2001) with 182 patients and 332 acute catheters, the frequency of infections, thrombosis, bleeding, and other side-effects were investigated. All complications and side-effects are presented. In total, the complication rate was in the first study 27.7% (internal jugular vein 23.8% in 2105 catheters, subclavian vein 43.5% in 521 catheters) and in the second study 32.2% (internal jugular vein 20% in 231 catheters, subclavian vein 60.6% in 94 catheters, femoral vein 57.1% in 7 catheters). The majority of complications were puncture not possible, puncture of the artery abscess, septicemia, bleeding, thrombosis, and faults in catheter material. To minimize these complication rates the handling of the inserted catheters before, during, and after the hemodialysis or apheresis treatment is minimized.     

Elimination of mechanical failure of the Hickman right atrial catheter

The double lumen Hickman right atrial catheter (Evermed Co., Palo Alto, Calif.) is usually inserted through an open venous cutdown into the internal jugular or cephalic vein. It is difficult to mechanically secure. Tight ligatures around the vein opening and catheter occlude the lumen of the Silastic rubber catheter while loose ligatures allow slippage. Migration of the tip into the vena cava or innominate vein causes fibrin sleeve formation and occlusion. Because of problems during the initial use of this catheter, we modified a subsequent series by placing a Silastic rubber bead on the catheter. The catheter is carefully trimmed so that the tip will lie in the right atrium and the bead is placed into the vein proximal to the securing ligature. Comparison of the two series of primarily leukemic patients revealed complete elimination of mechanical problems in patients with beaded catheters (0/18), and significant mechanical failure in unbeaded catheters (7/23). These data indicate that adequate fixation of the Hickman catheter at the level of the venotomy and placement of the tip in the right atrium eliminates mechanical failure and markedly improves catheter function.     

Catheter malplacement during central venous cannulation through arm veins in pediatric patients

For successful catheter placement, central venous cannulation (CVC) through internal jugular vein and subclavian vein has been recommended in both adult and pediatric patients. But it carries a risk of serious complications, such as pneumothorax, carotid, or subclavian artery puncture, which can be life-threatening, particularly in critically ill children. So a prospective study was carried out to determine the success rate of correct catheter tip placement during CVC through antecubital veins in pediatric neurosurgical patients. A total of 200 pediatric patients (age 1-15 years) of either sex were studied. Basilic or cephalic veins of either arm were selected. All the patients were cannulated in the operation room under general anesthesia. Single lumen, proper size catheters (with stillete) were used for cannulation. The catheter was inserted in supine position with the arm abducted at right angle to the body and neck turned ipsilaterally. The length of insertion was determined from cubital fossa to the right second intercostal space. The exact position of the tip of the catheter was confirmed radiologically in ICU. Correct catheter tip placement was achieved in 98 (49%) patients. Multivariate logistic regression analysis of data shows that there was no statistically significant difference among correct and incorrect catheter tip placement in relation to factors including sex, side of cannulation (left or right), and type of vein (basilic or cephalic). The analysis of correct catheter tip placement in relation to age showed that the highest success rate was achieved in children of age group 6 to 10 years (60.2%) followed by 30.6% in the 11 to 15 year group. The lowest success rate of tip placement of only 9.2% was observed in younger children of age 1 to 5 years, which is statistically significant (P = 0.001). Of 102 incorrect placements reported, 37% were in 1 to 5 year age group versus 9.2% correct tip placements. The most common unsatisfactory placements were either in the ipsilateral internal jugular vein (N = 38, 37.2%) or in the ipsilateral subclavian vein (N = 27, 26.4%). In 10 patients the catheter crossed over to the opposite subclavian vein, in 16 patients the catheter tips were found in the axillary vein, and in 10 patients each the catheter tip was observed in right atrium and right ventricle. No major complication during and following CVC was observed. To conclude, CVC using single orifice catheter through arm veins in pediatric patients is easy to perform, but the proper catheter tip placement is highly unreliable, particularly in younger children 1 to 5 years of age.     

Use of permanent dual lumen catheters for long-term haemodialysis.

Permanent dual lumen catheters (PDLC) provide alternative vascular access in patients considered unsuitable for arteriovenous fistula, arteriovenous graft or peritoneal dialysis. Experience with their use for long-term haemodialysis is presented. Between January 1990 and April 1994, 101 catheters were inserted into 63 patients (median age 62 years). A PDLC was the primary vascular access type in 5 patients. Of the first catheters, 70% were inserted percutaneously into the subclavian vein. The median duration of catheter use was 168 days (range 5-1582 days). The overall cumulative observed catheter survival rate was 94% at 6 months, 89% at 1 year and 75% at 4 years following insertion. The major complications were blockage and catheter related infection occurring in 28% and 15% of catheters, respectively. Death and blockage were the commonest reasons for catheter removal. PDLC play a vital role in the provision of access for long-term dialysis and should be considered the access type of choice in patients with limited life expectancy.     

Long-term central venous catheters: size and location do matter

BACKGROUND: Right or left side of placement for subclavian vein catheterization for placement of long-term central catheters and size of the catheters has not been analyzed completely. METHODS: The records of 502 consecutive long-term central venous catheters placed in patients while in the operating room over a 1-year period were reviewed and 230 subclavian vein tunneled catheters were analyzed. Technical difficulties in placing the catheters were defined as arterial puncture, guidewire malposition, catheter malposition, need to switch site of access, sheath difficulty, and inability to place the catheter. RESULTS: Three complications were identified (1%) and technical difficulties occurred in 15% of the patients. More difficulty was associated with the insertion of larger triple-lumen catheters than smaller single-lumen catheters (31% vs. 11%, respectively; P < .009). Right subclavian placement was associated with a 24.4% technical difficulty rate versus a 10.4% technical difficulty rate for left subclavian placement (P < .005). CONCLUSIONS: This study supports placing the smallest catheter necessary via the left subclavian vein.     

Complications related to subclavian catheters for hemodialysis. Report and review

Personal experience with subclavian vein cannulations for hemodialysis are given, and the pertinent literature on the subject is reviewed. Two hundred subclavian dialysis catheters were placed in 148 patients who kept them in place for a total of 2,798 days. Immediate complications were two pneumothoraxes and two hemothoraxes due to subclavian artery puncture. Seventeen cases of bacteremia were related to subclavian catheter infections. In 1 case, a complication of sepsis was a vertebral osteomyelitis. Clinical evidences of subclavian vein thrombosis occurred in 5 cases. Life-threatening complications were met in 2 cases: 1 with pericardial tamponade due to right atrium perforation and 1 with mediastinal hematoma and right hemothorax due to superior vena cava perforation. Review of the literature indicates that pneumothoraxes and/or hemothoraxes occurred in 1.7% of the catheter insertions and that sepsis related to subclavian dialysis catheters occurred in 8.9% of the patients. As systematically investigated subclavian vein thrombosis involved at least 50% of the patients. Our 2 personal cases of life-threatening complications and 14 similar cases of the literature were analyzed: left subclavian catheters were associated with superior vena cava perforation with right hemothorax or mediastinal hematoma, while right subclavian catheters gave atrial perforation with pericardial tamponade. Death occurred in 3 of 16 cases, and emergency surgery was required in 5 of 16 cases. Taking into account all these complications, recommendations are made for the use of subclavian dialysis catheters.     

The Incidence of Subclavian Vein Stenosis Using Silicone Catheters for Hemodialysis

Abstract: Complications related to the use of silicone subclavian catheters for hemodialysis were prospectively studied in 21 consecutive patients with acute and chronic renal failure. Between July 1991 and December 1992, 34 double-lumen silicone catheters (Medcomp; 12 French; 20 or 24 cm) were inserted in 21 patients. The mean duration of catheterization was 20 days (range, 2–58 days). Venograms were performed in 16 patients (22 subclavian veins) within 6 months following removal of the catheter. Excluded from angiography were patients whose catheters had been in place less than 1 week or who underwent fewer than 3 dialysis sessions because of minor risk of stenosis. Patients who had ipsilateral repeated catheters were also excluded. Two angiographies showed subclavian vein stenosis, both occurring in the same patient. One showed 50% stenosis with collaterals; one showed 50% stenosis without collaterals. One other complication was a pneumothorax. Catheter thrombosis was observed in 3 patients; catheter sepsis did not occur. We conclude that use of silicone catheters for subclavian cannulation is safe and effective to provide temporary vascular access for acute hemodialysis. The incidence of subclavian vein stenosis is lower compared with polytetrafluoroethylene and polyurethane catheters.     

Long-term hyperalimentation in children through saphenous central venous catheterization

During a 3.5 year period, 151 Silastic central venous catheters were inserted into the inferior vena cava through the saphenous vein in 132 children younger than age 19 years at UCLA Hospital. The major indications for catheter insertion included inflammatory bowel disease, cancer or bone marrow transplantation, and short bowel syndrome. The 151 catheters were used for a total of 13,288 days of fluid administration (mean 88 days). Complications requiring removal of the catheter occurred in 31 patients, but there were no deaths attributable to complications from the catheters. The total incidence of complications was one per 225 days of catheter use, less than that occurring in catheters placed in the external jugular and cephalic veins in young children in our hospital. The ease of insertion, the low complication rate and the simplicity of patient management when catheters are placed into the vena cava through the saphenous vein appear to make this an optimal site for administering parenteral nutrition in infants and children.     

Approach to fragmented central venous catheters

Prolonged venous access devices are needed in cancer patients for central venous access. Catheter fragmentation leading to catheter malfunction represents a rare problem. Herein we present our experience in the management of fragmented catheters. Between 2001 and 2003, 183 catheters were placed via the subclavian vein, and five cases of fragmented catheters were observed. Fragments were removed by an Amplatz gooseneck snare (Microvena, St. Paul, MN) with angiographic intervention. The diagnosis of the breakage was made by chest radiography. The incidence of catheter breakage was 2.7%. All fragments were removed by the snare, without any complications. Catheter narrowing and breakage owing to its medial positioning in the subclavian vein were the main causes of catheter malfunction. In any case of catheter malfunction, radiologic evaluation of the catheter must be done to rule out its rupture. Removal of the fragments using the Amplatz snare is a safe and easily applied procedure.     

Cardiac tamponade caused by caval catheter--a radiological demonstration of an unusual complication.

An adult male developed shock some hours after the start of intravenous alimentation. The caval catheter, which had been inserted through the right subclavian vein, was later radiographically demonstrated to be in the pericardial sac. We reviewed the literature on this and other complications of caval catheters. From this information and our own experience we offer some suggestions for prevention and management of some of the complications of caval catheters.     

An audit of percutaneous central venous catheters in paediatric patients

A prospective audit of all central venous catheters placed percutaneously by anaesthetists was conducted at the Hospital for Sick Children over a three-month period in 1990. A total of 443 attempts at catheter insertion were made of which 394 catheters were successfully sited in 182 children. Patients ranged in weight from 1.5 kg to 83 kg and in age from 12 h to 17 years. 85.8% of catheters were inserted into the internal jugular, 10.1% into the femoral, and 3.5% into the subclavian veins. Complications of insertion occurred with 14.7% of attempts of which 11.0% resulted in failure at that site. Later complications were found with 17.2% of catheters. Failure to cannulate any central vein occurred in 5 patients (1.1% of all attempts).     

Transthoracic cuffed hemodialysis catheters: a method for difficult hemodialysis access

BACKGROUND: Recurrent vascular access failure is a major cause of morbidity in patients receiving long-term hemodialysis. Central venous catheters are often necessary for dialysis, and easily accessed vessels (ie, the internal jugular vein and subclavian vein) frequently occlude because of repeated cannulation. When standard access sites occlude, unconventional access methods become necessary. We report a technique of placing hemodialysis catheters directly into the superior vena cava (SVC). METHODS: Between January 2002 and December 2004, 22 patients with documented bilateral jugular and subclavian vein occlusion underwent transthoracic SVC permanent catheter placement. Femoral vein access was obtained, and a sheath was placed. Under fluoroscopic guidance, a diagnostic catheter was then inserted into the SVC, and a venogram was obtained. By using the fluoroscopic image as a reference guide, supraclavicular access directly into the SVC was performed with lateral and anteroposterior views to better localize the SVC. Once venous blood was obtained, a hydrophilic wire was passed into the inferior vena cava. A 5F sheath was then placed, and, with the use of an exchange catheter, the wire was switched for a stiffer wire. The hemodialysis catheter was then placed in the standard fashion over this wire. RESULTS: In a 24-month period, 22 patients underwent transthoracic permanent catheter placement. All patients had the permanent catheters successfully inserted. Two major complications occurred. One patient experienced a pneumothorax, and another patient experienced a hemothorax. Both patients were successfully treated with chest tube decompression. All permanent catheters functioned immediately with a range of 1 to 7 months. CONCLUSIONS: Transthoracic permanent catheter placement is an appropriate alternative for patients in whom traditional venous access sites are no longer available.     

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.     

380例次长期深静脉留置导管临床应用的生存分析

目的提高对长期静脉留职导管的置管、使用、护理的认识，延长其使用寿命。方法随访本院血液净化中心患者380例次深静脉置管并长期留置的情况和并发症，记录导管使用终点。应用Kaplan-Meier法绘制导管使用寿命的生存曲线，计算中位生存时间。log-rank检验比较导管使用寿命的差异。分析评价置管方法、感染发生率、导管退出原因及透析充分性。结果导管静脉入路途径包括颈内、颈外、锁骨下及股静脉。3种静脉入路中位生存时间分别为颈内（31．0±2．8）月，颈外（30．0±4．0）月，锁骨下（19．0±2．9）月。log-rank生存曲线检验结果显示，颈内与锁骨下进路比较差异有统计学意义（P〈0．05）。导管使用终点113例次，其中患者死亡60例（53．1％），感染14例（12．4％），导管功能不良13例（11．5％），肾移植13例（11．5％），内瘘2例（1．8％），导管意外拉脱7例（6．2％），导管破损4例（3．5％）。导管内感染61例次，隧道感染2例次。结论长期留置导管首选颈内静脉入路，其次为颈外静脉入路。导管终点以患者死亡、感染及导管功能不良占绝大多数。     

Routine chest X-rays after insertion of implantable long-term venous catheters: necessary or not?

Can long-term subcutaneous venous (Mediport) catheters be safely inserted without routine chest X-ray (CXR) verification? An estimated 500,000 Mediport catheters are inserted yearly in the United States, and elimination of unnecessary radiographs would result in substantial savings of increasingly limited health care resources. A total of 513 consecutive Mediport catheters were inserted by a single surgeon over a 5-year period using a standardized protocol and selective indications for follow-up CXR that included unilateral chest pain, aspiration of air, decreased breath sounds, and difficult catheter insertion. The 513 catheters were inserted in 498 patients with 271 patients (53%) undergoing postprocedure CXR. Of the 513 catheters 461 (90%) were placed by percutaneous approach to the subclavian vein. Six pneumothoraces (1.2% incidence) occurred, all in patients who met criteria for immediate CXR. The overall complication rate was 3.1 per cent and included eight instances of catheter-tip malposition (seven of the eight were successfully repositioned by vascular radiology), one mediastinal hematoma, and one chest-wall hematoma. This largest single-surgeon-reported series demonstrates that Mediport insertion can be safely accomplished with minimal complications following a standardized protocol using selective radiologic evaluation.     

Clinical evaluation of percutaneous insertion and long-term usage of a new cuffed polyurethane catheter for central venous access.

A new, long-term venous access catheter was evaluated in clinical practice and the insertion time, complication rate and prospective follow-up recorded. Fifty novel polyurethane catheters (Cuff-Cath) were inserted in 48 patients, for cytotoxic chemotherapy in 36, long-term total parenteral nutrition in five and miscellaneous indications in seven. All catheters were inserted by a percutaneous technique under local anaesthesia. The mean insertion time was 18 min. There were three insertion complications; failure to cannulate, pneumothorax and malposition. Seven catheters required removal (sepsis in five, subclavian vein thrombosis in two) and one catheter fell out. Total catheter days to date has been 6607 (mean 132, range 18-831 days). Eleven catheters are still in use a mean of 154 days (range 38-490 days) after insertion. Furthermore, a new technique has been described which prevents inadvertent displacement. This new catheter combines the mechanical advantages of polyurethane, together with those of a Dacron cuff. Early results suggest that this catheter may be a useful alternative to silicone catheters of the Hickman/Broviac type for long-term central venous access.