Permanent central venous catheters: complications and strategies using different accesses.

Transcription

1 Permanent central venous catheters: complications and strategies using different accesses. Poster No.: C-1038 Congress: ECR 2015 Type: Educational Exhibit Authors: M. D. Ferrer-Puchol, R. Ramiro, E. Garcia-Oliver, G Benedetto, P. León, P. Montesinos, P. Gallegos, E. Esteban ; 1 2 Alzira/ES, Algemesí/ES Keywords: Venous access, Complications, Catheter venography, Interventional vascular, Cardiovascular system, Embolism / Thrombosis DOI: /ecr2015/C-1038 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 48

2 Learning objectives 1. To review central venous access option: Tunnelled catheter for dialysis Tunnelled catheter with implanted port. 2. To describe major and minor complications Early complications (occurring within 30 days of placement) Late complications 3. To review technical approaches and unconventional venous access in difficult procedures describing different strategies. 4. To present our experience in 2212 imaging-guided permanent central catheters in the last 13 years. We describe our complications and our solutions in difficult access tunnelled catheter for dialysis 1209 tunnelled catheter with implanted port. Images for this section: Page 2 of 48

3 Fig. 1: Sonnography is mandatory for punction site and fluoroscopy is mandatory for tip position. Page 3 of 48

4 Fig. 2: Conventional phlebography is usefull to skow state of veins Page 4 of 48

5 Fig. 3: Use of sonnography is mandatory to plan site of punction. Page 5 of 48

6 Background A permanent central line is a tunnelled catheter placed in order to gain venous or dialysis access. Tunnelled catheters are defined as catheters that travel through a subcutaneous tract in the body with a small incision in the skin. Implanted ports are similar to tunnelled catheters; however, they do not exit the skin, but terminate with a device buried in the subcutaneous tissue. Central venous catheterization is an essential skill for many physicians. Despite the potential for serious complication the procedure is generally safe and successful. Realtime ultrasonography and fluoroscopy guidance reduce the risk for failure in placement, complications rate ad the need for multiple placement attempts. Conventional access includes the internal jugular and subclavian veins. However, in those patients who have undergone multiple previous central venous catheter placements, venous access can be a technical challenge. Once these usual access sites are no longer available, it may necessary use an unconventional access method including: Catheterization of the common femoral vein Catheterization of collateral vessel Recanalization of occluded vein Translumbar inferior vena cava catheter placement Hepatic vein catheter placement. Images for this section: Page 6 of 48

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8 Fig. 4: CASE 1. STENOSIS DUE TO PREVIOUS CATHETER Page 8 of 48

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10 Fig. 5: The guide-wire was advanced beyond stenosis Page 10 of 48

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12 Fig. 6: Balloon angioplasty was dilated in stenosis place Fig. 7: Balloon angioplasty can be successful in these cases allowing the catheter placement Page 12 of 48

13 Fig. 8: CASE 2. PLACEMENT WITH PREVIOUS STENT Page 13 of 48

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15 Fig. 9: Stent was broken with angioplasty balloon Page 15 of 48

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17 Fig. 10: Placement of catheter through stent net. Page 17 of 48

18 Fig. 11: CASE 3. CATHETER MISS-POSITIONED Fig. 12: With a guide-wire the wire tip was placed in correct position. Page 18 of 48

19 Fig. 13: CASE 4. RECANALIZATION OF OCCLUDED VEINS Page 19 of 48

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21 Fig. 14: Diagnostic phlebography is mandatory. Standard re-canalization techniques were used. Fig. 15: Tunneled catheter placed Page 21 of 48

22 Findings and procedure details Priority of accesses: Right and left internal jugular vein right and left subclavian vein occluded veins femoral veins inferior vena cava: translumbar access hepatic veins Planning: Paient evaluation: coagulation state prior central catheter or radiation treatment skin findings:scars, swelling, collateral veins conventional phlebography use of sonnography to plan site of punction Complications described in litetature Procedural Complications: blleding, arterial puncture, and AV fistula formation are uncommon with radiologic guidance (<3%) pneumothorax, hydrothorax, or hemotorax are also uncommon (1-2%) Air embolism is reported to occur in 1 %, it may be fatal in patients with a rihgt-to-left shunt Malpositioned catheter ere rare with image guidance. In some cases, the catheter is correctly positioned, the tip can migrate into other vein. Late complications 1. Infectious complications: exit site infections: the area should be treated with aggresive local wound and antibiotics. Catheter removal is rarely needed tunnel infectious: conservate therapy can be attempted, but the catheter usually require removal (65%) Catheter related bacteriemia is usually caused by contamination of the lumen of catheter. It is characterized by persistent fever witout other source (3-35%). It may be possible to treat the patient by changing the catheter followed by 3 weeks os systemic antibiotic therapy. 2. Catheter/venous thrombosis: Page 22 of 48

23 intracatheter, pericatheter, fibrin sheath, catheter kinking, and catheter malposition. 30 % are symptomatic. Can be treated with arm elevation and anticoagulant therapy. catheter removal is not always necesary and should de avoided if is possible. 3. Catheter breakage: abrupt angulation fracture of cather and embolization of catheter fragment external catheter rupture OUR RESULTS 1. Catheters with implanted port: Men: 59.9 %, Women: With a median age of years (25-92) Access right jugular vein in 90,8 %. To administer chemotherapy in 90.8 % of patients. Complications were detected in 6.3 % of cases, (median of days after catheter placement: 96,50 days): Thrombosis Port Infection Catheter infection Ulcer in point of puncture Is was necessary the catheter removal in 2,1 %, changing point of puncture in 50 % 2. Dialysis Catheters 60.3 % men, 39.7% women. with a median age of (range 24-90). Median duration of HD treatment was 3.4 years. Access ight jugular vein in 77 % of cases, left jugular vein in 18.1% and others in 4.9 %. Complications were detected in 45.9% (median of days after catheter placement: 93.0 days) Page 23 of 48

24 Insufficient flow in 25 % infection on the implantation of catheter or bacteriaemia in 23 % thrombosis of catheter or obstruction of caheter in 20.3 % accidental extrusion of catheter in 3 % profound venous thrombosis in 2 % It was necessary remove the catheter in 53.1 %. Images for this section: Page 24 of 48

25 Fig. 16: CASE 6. PATIENT WITHOUT VENOUS ACCESSES, translumbar approach. A 18-gauge trocar was avanced under CT guidance toward the IVC. In Interventional Radiology room a wire was introduced. Page 25 of 48

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27 Fig. 17: A catheter with of appropriated length was tunneled subcutanoeusly from the right flank and inserted with a peel-away catheter. Page 27 of 48

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29 Fig. 18: Procedure scheme Fig. 19: CASE 7. PATIENT WITHOUT VENOUS ACCESSES, FEMORAL APPROACH. Page 29 of 48

30 Fig. 20: Compared with permanent catheters in the chest, femoral catheters are associated with a higher rate of infection and occlusion Page 30 of 48

31 Fig. 21: The tunnel should be made under abdominal skin Page 31 of 48

32 Fig. 22: To improve patency, the tip of catheter should be laced above the level of the confluence of the common iliac veins Page 32 of 48

33 Conclusion Venous accesses can be challenging for most interventional radiologists. It may be necessary to know possible complications and unconventional access routes. Images for this section: Page 33 of 48

34 Fig. 23: CASE 8. FIBRIN SHEATH FORMATION. Catheter malfunction in obese patient. Page 34 of 48

35 Fig. 24: to manipulated the tunnel to remove the catheter Page 35 of 48

36 Fig. 25: Catheter was threaded over the wire Page 36 of 48

37 Fig. 26: Fibrin sheath formation around long-term catheter Page 37 of 48

38 Fig. 27: CASE 9. FIBRIN SHEATH FORMATION Page 38 of 48

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40 Fig. 28: Fibrin sheath stripping using the loop snare technique was very useful to restore the catheter function Page 40 of 48

41 Personal information MD Ferrer Puchol, R Ramiro and E Esteban are members of staff in Radiology Department in Vascular and Interventional Radiology section. E García-Oliver, G Benedetto, P Leon, P Montesinos and P Gallegos are Residents in Radiology. Images for this section: Page 41 of 48

42 Fig. 29: CASE 10. CATHETER-INDUCED THROMBOSIS OF THE SCV. 67-year-old woman with a superior vena cava syndrome due to tunnelizaded post-catheter placement Page 42 of 48

43 (chemotherapy in breast cancer). Patient presented arm and facial swelling, stridor, burred vision, dysnea and chest pain. Fig. 30: Oral anticoagulation is the first choice therapy, thrombolysis is indicated in massive thrombosis and instability. This patient had a contraindication to anticoagulant therapy and required venous angioplasty with mechanical thrombolysis. Page 43 of 48

44 Fig. 31: After this treatment patient improved and their symptoms desappeared. Phlebography two months later showed complete resolution of veins Page 44 of 48

45 References J Vasc Interv Radiol 2013;24; J Vasc Interv Radiol 2013;24: Anesthesiology 2004;100: Crit Care Med 2010;38: BIIJ 2012;8:1-3 Images for this section: Fig. 32: CASE 11. CATHETER KINKING Page 45 of 48

46 Fig. 33: Kinking usually requires catheter replacement. However, since kinking may be due to the placement of tunnelizaded catheter with an acute angle with internal jugular vein and requires a new tunnelizaded catheter. Page 46 of 48

47 Fig. 34: Catheter kinked Page 47 of 48

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