Translumbar inferior vena cava catheters: experience with 58 catheters in peripheral stem cell collection and transplantation

Most patients who need peripheral stem cell transplantation do not have peripheral venous access to allow apheresis for stem cell collection. Subclavian apheresis catheters have an unacceptably high incidence of thrombosis-related access failure. We have used a technique for translumbar insertion of permanent, subcutaneously tunnelled silicone rubber apheresis catheters into the inferior vena to place 58 catheters in 54 patients for stem cell collection. 37 catheters have been left in place for venous access during the transplantation procedures. These catheters had a very low rate of apheresis-related complications (3.6%). Access failure occurred due to thrombosis in 14 catheters (24%) and mechanical complications in 8 (14%) but these responded to standard therapy in all except 3 cases. Catheters functioned well as venous access devices during transplantation with only rare complications during this time. Withdrawal venograms at time of removal of 20 catheters showed a fibrin sheath in 17 cases but caval occlusion in none. There was no clinical or CT scan evidence of bleeding after placement or removal of the catheters. Percutaneously placed translumbar inferior vena cava apheresis catheters are an effective route for peripheral stem cell collection and can be left in place for venous access during transplantation.     

Double-lumen inferior vena cava catheters for peripheral stem cell apheresis and transplantations

No previously published studies have described double-lumen hemodialysis/apheresis catheters for use with continuous-flow apheresis collection of peripheral stem cell (PSC). We prospectively evaluated experiences with these catheters during both PSC collection and transplantation. Because of previously-described successful experiences with single-lumen apheresis catheters placed in the inferior vena cava, all catheters evaluated in this study were placed in this anatomic location. Our experience demonstrated high rates of thrombotic occlusion (65%) and catheter-related infections (15%). This method of access should not be considered optimal in its present state of use. Further investigation into preferred catheter design, anatomic location, and thrombosis prophylaxis during continuous-flow apheresis is warranted.     

Image-guided central venous catheter placement for apheresis in allogeneic stem cell donors

Peripheral blood stem cell harvest by apheresis is an increasingly important procedure utilized in the treatment of many malignancies. Whether autologous or allogeneic, it is frequently performed via peripheral access because of concern over major complications associated with central venous catheter placement. This study was to determine the safety and success, complications and premature failure rates for radiolocally placed ultrasound-guided non-tunneled central venous catheters placed for apheresis in a donor (allogeneic) population. One hundred central venous catheters were placed in ninety-one individuals for allogeneic stem cell harvest. Procedural success and complications relating to placement were noted in all. In 97 cases the number of needle passes required for venous cannulation and whether this was achieved with a single wall puncture was noted. Duration of catheterization and reason for removal were recorded in all cases. All catheters were placed by a right transjugular route. Venous cannulation and functioning line placement was achieved in every case; 92/97 (95%) required only a single needle pass and 84/97 (87%) only a single wall puncture. There were no placement related complications; 94 catheters were removed the same day with the remainder removed within 48 hr. All completed apheresis. Our study demonstrates the safe use of central venous catheters for apheresis in normal donors if ultrasound guidance is used for the puncture and the duration of catheterization is short.     

Urokinase infusion restores function of thrombotically-occluded inferior vena cava apheresis catheters refractory to bolus urokinase therapy

Translumbar inferior vena cava catheters have been shown to be safe and effective in providing venous access for apheresis collection of peripheral blood stem cells for transplantation. Thrombotic occlusion of these catheters can limit their effectiveness for apheresis. While some of these occlusions respond to installation of the 5000 unit “Open-Cath^®” dose of urokinase, there are no guidelines for therapy of occluded catheters not responding to this treatment. We have performed low-dose urokinase infusion on 11 IVC apheresis catheters radiographically documented to be occluded by thrombus. These catheters had failed a mean of 1.5–5000 unit boluses of urokinase. Seven catheters underwent urokinase infusion at 40,000 units/ h for 12 h. All had complete restoration of catheter function and 6 had total dissolution of thrombus on post-therapy X-ray. Because of the initial success of the 12 h infusion, we treated 4 catheters with the same dose of urokinase for 6 h. All 4 had complete restoration of catheter function and 2 had total thrombus dissolution on X-ray. No bleeding complications were seen.For occluded IVC apheresis catheters, initial therapy should be the installation of at least one 5000 unit bolus of urokinase. For catheters not responding to this therapy, radiographic evaluation should be conducted. If thrombotic occlusion is found, a 40,000 unit/h infusion of urokinase for 6–12 h can safely salvage catheter function and allow continued apheresis.     

Thrombotic complications of subclavian apheresis catheters in cancer patients: prevention with heparin infusion

Twenty-two silicone rubber apheresis catheters were placed into the subclavian veins of 18 cancer patients to allow serial leukapheresis for collection of circulating hematopoietic stem cells. The tips of the catheters were placed in the innominate vein to avoid reinfusion of citrate into the right atrium and the resulting tendency to cardiac arrhythmias. Sixteen catheters were placed without prophylactic anticoagulation. Anticoagulation was prematurely discontinued in one patient because of the inconvenience of the portable heparin infusion pump. Six of these 17 catheters developed venographically proven thrombotic complications and five others had presumed thrombosis-related access failure or caused symptoms of venous obstruction, but confirmation of the presence of a thrombus with venography was not obtained. Three catheters spontaneously withdrew from the vein, one during urokinase infusion for thrombosis. Only three catheters had uncomplicated apheresis courses. Prophylactic heparin infusions via portable infusion pumps were given after placement of six catheters. As long as the heparin infusions were continued all patients had uncomplicated apheresis courses. One patient's heparin was prematurely discontinued. Within 3 days of its discontinuance, radiographically proven thrombotic catheter occlusion occurred. Patients given heparin were less likely to develop complications (P less than 0.001). No unexpected complications of apheresis were encountered as a result of the use of these catheters. Silicone rubber subclavian catheters can be used for peripheral stem cell collection but have a high frequency of thrombotic complications. Systemic anticoagulation with heparin can minimize the likelihood of these complications.     

Collection of blood mononuclear cells by leukapheresis for transplantation in a yucatan miniature swine model

A large animal model is needed to evaluate new apheresis technologies. These technologies include novel methods of harvesting the blood mononuclear cell population which contains the hematopoietic stem cells needed to restore hematopoiesis in recipients of hematopoietically lethal therapy and the use of cytokines to provide a safe and predictable method of manipulating these circulating hematopoietic stem cells. We describe the methods used to collect mononuclear cells by leukapheresis from Yucatan miniature swine. These animals are of sufficient size to tolerate the procedures and have many physiologic and hematologic similarities to man. They are of good temperament and are easily trained. Long-term venous access was obtained using single lumen silicone rubber catheters placed in the inferior vena cava. The animals were apheresed while fully awake using a Haemonetics Model V50 machine and a modified lymphocyte collection protocol. The procedure was highly efficient for the collection of mononuclear cells and a 10 pass procedure yielded a product which contained 19.7 × 10⁹ mononuclear cells, 10.7 × 10⁹ granulocytes, and 17 ml of erythrocytes in a volume of approximately 100 ml. This product can be cryopreserved and used for subsequent transplantation. The content of four apheresis procedures provides hematopoietic reconstitution of lethally irradiated swine on a time scale equivalent to transplantation of optimal numbers of bone marrow cells. © 1992 Wiley-Liss, Inc.     

Pulmonary artery catheter placement with two-dimensional echocardiographic guidance: a technique applicable in critically ill neonates

In nine critically ill neonates with persistent fetal circulation, femoral venous catheters were inserted at the bedside to initiate treatment and provide venous access. After femoral vein puncture or cutdown, a 5-F sheath was placed in the inferior vena cava through the femoral vein. With use of two-dimensional echocardiographic guidance, a 5-F balloon angiographic catheter was advanced through the inferior vena cava into the right atrium and subsequently manipulated through the tricuspid valve and into the main pulmonary artery. No major complications were attributable to the procedure. When performed by a pediatric cardiologist, this technique is as safe as umbilical catheter placement.     

Complications associated with central venous catheters used for the collection of peripheral blood progenitor cells to support high-dose chemotherapy and autologous stem cell rescue

 The purpose of this study was to review the incidence and type of complications associated with the insertion and use of central venous catheters for leukapheresis and high-dose chemotherapy with stem cell rescue. One hundred sixty-seven central venous catheters placed either at the transplant center or by various community surgeons were studied for insertion complications, inability to perform leukapheresis and incidence of infection. The overall incidence of hemo- or pneumothorax was 3.6%. Inability to pherese occurred in 13% of catheters placed by outside surgeons and 6.5% of catheters inserted at the transplant institution. Most often, these were due to malposition of the catheter too high in the superior vena cava or in other veins. Deep venous thrombosis was often related to this malposition and occurred in 4.8% of all patients. Pulmonary embolism was not seen in these patients despite the fact the catheters were often left in place during the thrombotic episode. Early or late-onset infections occurred in 6.5% of patients and were most often exit site infections. The incidence of complications of pheresis catheters is high but might be reduced by more attention to proper placement of the catheter closer to the right atrial/superior vena cava junction, and limiting insertion to a cadre of surgeons familiar with leukapheresis requirements.     

恶性肿瘤患者下腔静脉滤器的应用研究

目的研究下腔静脉滤器在恶性肿瘤患者中的应用,探讨其在预防肺栓塞发生中的作用。方法回顾性分析1998年至2004年,经病理学或细胞学确诊为恶性肿瘤,并于治疗前存在血栓栓塞性疾病的37例患者,安放下腔静脉滤器后肺栓塞的发生情况。结果下腔静脉滤器全部安全置入下腔静脉内,随访1～36个月,滤器无移位,无肺栓塞发生。结论对恶性肿瘤合并血栓栓塞性疾病的患者放置下腔静脉滤器,能安全有效地预防肺栓塞的发生。     

下腔静脉滤器置入结合下肢深静脉插管溶栓治疗下肢深静脉血栓形成

【目的】探讨下腔静脉滤器置入结舍下肢深静脉插管溶栓治疗下肢深静脉血栓形成的效果。[方法]2009年10月至2011年2月,对12例急性下肢深静脉血栓患者行下腔静脉滤器置入后经胭静脉顺行插管后予尿激酶溶栓术。【结果】所有患者均成功置放下腔静脉滤器及溶栓导管,血栓完全溶解4例（33．3％）,部分溶解8例（66．7％）,无致死性肺动脉栓塞及其他并发症发生。【结论】下腔静脉滤器置入结舍下肢深静脉插管溶栓治疗下肢深静脉血栓形成疗效显著。     

Ultrasound‐guided peripheral venous access for therapeutic apheresis procedures reduces need for central venous catheters

Therapeutic and donor apheresis requires adequate vascular access to achieve inlet flow rates of ～50—100 mL/min. While central dialysis‐type venous catheters can usually provide such access, their use includes several associated risks. Some of these risks can be avoided or diminished if adequate peripheral venous access can be established. Some patients have adequate peripheral veins for apheresis that cannot be readily identified visually or by palpation. We hypothesized that ultrasound‐guided peripheral venous access would benefit such patients and would lead to placement of fewer central venous catheters. The technique of ultrasound‐guided peripheral access for apheresis has been in use at Houston Methodist Hospital since 2012. We performed a prospective review of patients undergoing inpatient and outpatient apheresis at Houston Methodist Hospital from July 1, 2015 to September 30, 2015, to assess its benefit. During this time, we performed 831 procedures on 186 patients, including 787 therapeutic plasma exchanges, three red blood cell exchanges, 41 peripheral stem cell collections. Ultrasound‐guided vascular access was used for 68 procedures (8% of all procedures), including 62 therapeutic plasma exchanges, 4 peripheral stem cell collections, and 2 red blood cell changes. Use of ultrasound‐guided peripheral access prevented the placement of central venous catheters in 37 (20%) patients, demonstrating its utility in a busy transfusion service.     

Slow pathway ablation for atrioventricular nodal reentry using a right internal jugular vein approach: a case series

BACKGROUND: Inferior venous access to the right heart is not possible in some patients due to congenital or acquired obstruction of the inferior vena cava (IVC). Although right-sided electrophysiology procedures have been performed successfully in patients with a previously placed IVC filter by direct placement of catheters through the filter, an alternative approach is necessary in some patients. METHODS: This case series describes three patients with an IVC filter who underwent successful ablation of the slow pathway for typical atrioventricular (AV) nodal reentrant tachycardia using a superior vena cava (SVC) approach via the right internal jugular (IJ) vein. Two separate introducer sheaths were placed into the IJ vein using separate punctures. This permitted placement of a standard deflectable ablation catheter and an additional catheter in the right atrium to monitor for ventriculoatrial conduction during the junctional rhythm associated with ablation of the slow AV nodal pathway. RESULTS: Catheter ablation was successful in each patient. The number of radiofrequency current applications was 7, 17, and 27. There were no procedural complications and no patient had recurrent tachycardia during follow-up. CONCLUSIONS: Catheter ablation of the slow AV nodal pathway can be performed successfully and safely in patients with inferior venous barriers to the right heart using an SVC approach via the right IJ vein.     

Vascular erosion caused by a double-lumen central venous catheter during therapeutic plasma exchange

BACKGROUND: The use of large-bore double-lumen dialysis catheters has simplified the procedure of therapeutic plasma exchange, but these catheters are associated with unusual and possibly life-threatening complications. CASE REPORT: A 46-year-old black man was admitted to the hospital with acute onset of paresthesia and weakness. A diagnosis of Guillain-Barre syndrome was made. Plasma exchange therapy was instituted by peripheral venous access. After three such exchanges, a double-lumen central venous catheter was placed via the left subclavian vein on hospital Day 7. The patient experienced a sudden onset of severe chest pain and dyspnea during the fourth plasma exchange. He became diaphoretic and hypotensive and experienced tachycardia. The apheresis procedure was stopped. Because of worsening respiratory distress, endotracheal intubation was performed. A chest x-ray revealed a large right pleural effusion. The central venous catheter was removed. A chest tube was placed, and a large amount of bloody fluid was drained. Several days later, the endotracheal and chest tubes were removed. CONCLUSION: An unusual complication of the use of a central venous catheter, erosion of the superior vena cava, occurred during therapeutic plasma exchange. Prompt recognition of this complication and appropriate therapy can be life-saving.     

下腔静脉滤器在下肢深静脉血栓溶栓治疗中的应用

目的：探讨经导管溶栓治疗下肢深静脉血栓中下腔静脉滤器的应用价值。方法：采用经导管溶栓治疗下肢深静脉血栓10例,术前经健侧股静脉置人下腔静脉滤器于肾静脉平面下方的下腔静脉内,并观察有无肺栓塞症状。结果：10例均成功置人,无肺栓塞发生。9例下肢静脉血栓症状和体征消失,1例下肢肿胀减轻。结论：经导管溶栓治疗下肢深静脉血栓前置人下腔静脉滤器,能有效预防肺栓塞。     

Large-bore central venous catheters for the collection of peripheral blood stem cells

In order to establish a peripheral blood stem cell graft, repeated aphereses are necessary in the majority of patients. Each apheresis requires withdrawal and reinfusion of blood with high flow rates. To guarantee these flow rates, large-bore catheters are needed for central venous access. Subcutaneously tunneled silicone catheters (Hickman) caused venous thrombosis in 10–40% of the patients. We therefore used polyurethane large-bore catheters only for the time of peripheral blood stem cells (PBSC) collection. Via a Seldinger guidewire following delineation of the right (160 patients) or left (23 patients) internal jugular vein by ultrasound, 183 apheresis catheters have been inserted when the white blood cell count was >1.0 × 10⁹/L and a measurable population of CD34⁺ cells was detected by fluorescence-activated cell sorter analysis. The median flow rate was 70 ml/min (range 50–80 ml/min). We observed the following complications: puncture of the carotid artery in 2%, pneumothorax in 0.5%, local infection in 3%, and catheter-related septicemia in only 2% of the patients. At the time of the removal of the catheters, we detected thrombosis of the internal jugular vein in 5% of the patients by ultrasound. The collection of PBSC with short-term, large-bore catheters is effective and is associated with a low incidence of infection and thrombosis.     

A case of non-lethal pulmonary air embolism after leukapheresis catheter removal

Mononuclear cell leukapheresis requires good-quality venous access. Catheter placement and removal of the catheter may be associated with life-threatening local or systemic complications. Thus, prompt recognition of these complications and appropriate therapy can be life-saving. We report the case of a young man who presented with an air embolism following removal of a jugular venous catheter after peripheral blood stem cell collection. We have reviewed the signs and symptoms presented by the patient and the methodology used to remove the catheter. Catheter removal requires careful attention in order to avoid potentially serious complications.     

Misplacement of a femoral venous catheter into the ascending lumbar vein: repositioning using ultrasonographic guidance

A 5-week-old infant with congenital chylothorax required long-term intravenous access for parenteral nutrition. Cannulation of the inferior vena cava via the left femoral vein was attempted, but the catheter was misplaced into the left ascending lumbar vein. Catheter removal is advised when such malposition is identified. We were able successfully to redirect the catheter into the inferior vena cava using ultrasonographic guidance. This procedure has not been described previously in children. We propose that repositioning of incorrectly placed vascular catheters can be achieved using ultrasound guidance at the bedside.     

Use of hand-held ultrasonography to confirm the correct placement of a central venous catheter tip

To avoid severe complications resulting from malpositioning of a central venous catheter, removal and recannulation of the catheter may be necessary, thus wasting medical equipment and increasing stress on the patient. Therefore, central venous catheters should be inserted correctly the first time. We tested whether real-time hand-held ultrasound-guided confirmation of the location of the tip of a central venous catheter inserted from the femoral vein could reduce the rate of malpositioning. Catheters were inserted using conventional methods for 65 patients, and using ultrasound guidance for 29 patients. For the latter group, when a central venous catheter was inserted, the ultrasound examiner first identified its tip located dorsal to the liver in the inferior vena cava and then fixed the catheter in position. We considered a central venous catheter to be malpositioned when its tip appeared in neither the inferior vena cava nor the right atrium–inferior vena cava junction in X-rays. Flexed or inverted catheters were also considered to be malpositioned. We compared the malpositioning rates for the ultrasound and conventional groups. Malpositioning was identified for two (6.9%) patients in the ultrasound group and 19 (29.2%) patients in the conventional group. The relative risk of ultrasound-guided versus conventional catheter insertion was 0.23 (95% confidence interval, 0.09–0.62). Our data suggest that real-time ultrasound monitoring is useful for avoiding malpositioning of central venous catheters inserted from the femoral vein.     

Left-sided superior vena cava: a not-so-unusual vascular anomaly discovered during central venous and pulmonary artery catheterization.

OBJECTIVE: To report our ICU experience with patients noted to have a left-sided superior vena cava after central venous and pulmonary artery catheterization. DESIGN: Retrospective review. SETTING: Surgical ICUs in a University and Veterans Administration Medical Center. PATIENTS: Five patients who had insertion of central venous or pulmonary artery catheters were noted to have abnormal placement. RESULTS: Five patients were noted to have a left-sided superior vena cava that was not appreciated on preinsertion radiography after central venous (two patients) or pulmonary artery catheterization (three patients). The finding of left-sided superior vena cava was confirmed by computed tomography scan (one patient), transesophageal echocardiography (one patient), bolus contrast injection (two patients), and intraoperative inspection (one patient). CONCLUSIONS: Left-sided superior vena cava occurs infrequently, most often in association with a right-sided superior vena cava. It is often associated with cardiac septal defects. The intensivist should be aware of its occurrence in order to not mistake catheters placed in it as being present in the arterial circulation or malpositioned outside of the venous circulation.     

永久性下腔静脉滤器放置预防肺栓塞

目的评价永久性下腔静脉滤器置入术在下肢深静脉血栓形成(DVT)患者中预防肺栓塞(PE)的有效性和安全性。方法 48例下肢深静脉血栓形成(DVT)患者全部行永久性下腔静脉滤器置入术,采用B/BRAUN VENA TECHTM LP滤器,滤器均位于肾静脉水平以下的下腔静脉中。结果 48例滤器经健侧股静脉穿刺置入,手术均获成功,无滤器释放不全、穿孔、脱落、移位、出血和滤器释放通路血栓形成。术后随访48例,随访时间1~26个月,未出现滤器移位、倾斜、下腔静脉血栓形成和肺栓塞(PE)。结论永久性下腔静脉滤器置入术可以安全和有效预防肺栓塞(PE)的发生,且手术操作简便,并发症少。