Transcript Slide 1

Management of Catheter-Related Complications:
Perspective of an Interventional Radiologist
Thomas M. Vesely, M.D.
Mallinckrodt Institute of Radiology
Washington University School of Medicine
Saint Louis, Missouri
Catheter-Related Complications
• Catheter Insertion
- malposition
- pneumothorax
- vascular injury
- air embolism
- arrhythmias
- bleeding
- access site thrombosis
• Catheter Removal
- catheter fracture
- bleeding
- air embolism
• Catheter Use
- infection
- air embolism
• Catheter Duration
- dysfunction
- thrombosis
- fibrin sheath
- infection
- venous stenosis
- catheter fracture
Interventional Radiology
• Evaluation of dysfunctional catheters
• Treatment of catheter-related complications
- infection :
catheter exchange
- stenosis :
angioplasty / stents
- thrombosis : thrombolysis
• Foreign body retrieval
Evaluation of Dysfunctional Catheters
Inspection
- infection
- catheter integrity
Fluoroscopy
- tip position
- kinks
Contrast injection
catheter tip in
pulmonary artery
- thrombus
- fibrin sheath
Inspection of Catheter
Infected
port
purulent drainage from tunnel
and Skin Exit Site
exposed port
Catheter Related Venous Thrombosis
Inspect Pinch Clamps
Hemodialysis catheter
kinked tubing
Pinch clamps must be periodically moved
to avoid causing permanent kinks in tubing
Bring patient into
angiography suite
for fluoroscopy and
contrast injection.
Angiography Suite
Portable
ultrasound
unit
fluoroscopy
Evaluation of Dysfunctional Catheters
Early problems are usually technical:
- catheter kinking
- tip malposition
kinked
malpositioned
Late problems are usually due to:
- intraluminal thrombus
- pericatheter thrombus
- fibrin sheath formation
Fluoroscopy of the entire catheter
Patient referred because of difficulty with removing wire
from PICC following the insertion procedure.
severely
twisted
PICC
Unusual appearance
of PICC within the
left arm.
Course of PICC suggests left subclavian artery
Pulsatile blood flow from PICC insertion site
Yikes !!!!
Who put in that PICC ?
Kinked Catheters
kinked tips
kinked lumen
High resolution fluoroscopy may be necessary
to identify subtle kinks in the catheter lumens
Use of an extra-stiff guidewire to reduce
a kink in a central venous catheter
kink
extra
stiff
guidewire
kink is
reduced
Snares
• Used for intravascular retrieval / manipulation
• Snare loop at 90° to shaft of guidewire
• Nitinol - kink resistant
• Used within snare catheter
Catheter Tip Repositioning
Use of an Endovascular Snare
catheter looped
into right internal
jugular vein
right chest
port
attempting
to snare the
catheter
right femoral vein
venous access site
snare is used to pull
catheter into position
The loop in the
catheter has been
removed.
Foreign Body
Retrieval
catheter
snapped
off
Removal of broken
catheter fragments.
Snare inserted
from the
femoral vein
pulled into
the IVC
catheter fragment
is pulled through
the right atrium
and out of the
femoral vein
Evaluation of Dysfunctional Catheters
Poorly functioning port.
Port inserted through the
right subclavian vein.
Catheter“Ballooning”
tip in the SVC.
of catheter
when injected
“Pinch-Off ” Phenomenon
A Complication of Subclavian Catheters
“Pinch-Off ” is due to entrapment of the catheter in the
subclavius muscle – costoclavicular ligament complex
subclavian
vein
pinching
of vein
pinching
catheter in vein
of vein
compressed
by
ligaments and bones
“Pinch-Off ” Phenomenon
A Complication of Subclavian Catheters
fractured port catheter
due to “Pinch-Off ”
fractured
port catheter
Injection of X-ray Contrast to Evaluate
the Dysfunctional Catheter
Evaluation of Dysfunctional Catheters
Always aspirate the heparin
from the catheter before
injecting contrast material.
Catheters are routinely
“locked” with heparin
solution.
Hemodialysis catheters :
1.5 ml per lumen X 5000u heparin /ml
= 7500 units heparin per lumen
SYRINGE PRESSURE
Syringe
Size
Pressure
Generated
Suction
Generated
(ml)
(atm)
(atm)
50
5.2
0.98
10
9.4
0.90
3
21.0
0.67
1
40.0
0.50
visualization
of right atrium
injection
through
venous lumen
Injecting x-ray contrast
through the catheter
will provide visualization
of the catheter tip and
surrounding venous
anatomy.
High-Performance Hemodialysis Catheters
Vaxcel
Dura-Flow
Maxid
Ash Split
Xpresso
Hemostream
Injection of venous (distal) lumen
of a tunneled hemodialysis catheter
port
catheter
thrombus surrounding
catheter tip
Injecting x-ray contrast
through the catheter
will provide visualization
of the catheter tip and
surrounding venous
anatomy.
Injection of arterial (proximal) lumen
of a tunneled hemodialysis catheter
right upper
extremity
venogram
left upper
extremity
venogram
An upper extremity
venogram should be
performed to evaluate
the entire vein in which
the catheter is located.
Catheter-Induced Venous Stenosis
Non-Aspirating Catheter (Port)
Port
catheter tip
abutting vein
Patient with a pheresis catheter in the right internal jugular vein
which has been in use for several months. BMT resident calls
and states that there is now non-erythematous swelling
around the catheter tunnel.
leakage
of contrast
Contrast injected through the catheter
demonstrates prompt leakage from one lumen.
Obstruction of
Central Venous Catheters
vein
catheter
tip
thrombus
Catheter Obstruction
Thrombotic
Mechanical
•
•
•
•
Catheter is kinked
Catheter malposition
Drug precipitation
Pinch-off syndrome
kink
Etiology of Catheter Malfunction
Events
Mechanical
Thrombus
Crain (’96)
44
4
40
Suhocki (’96)
42
4
38
Rockall
(’97)
31
7
24
Trerotola (’97)
63
23
40
Types of Thrombotic Occlusion
vein
catheter
Intraluminal
thrombus
Thrombus or
fibrin tail
Fibrin Sheath
Intraluminal Thrombus
Thrombolytic Agents
Injecting CathFlo into
occluded catheter lumen
Thrombolytic Agents
Low doses of thrombolytic agents used for catheter clearance
are very safe and do not produce a systemic effect.1
The INR and PTT remain unchanged when using 2 – 4mg tPA
or 10,000 units of urokinase.1
Atkinson JB et al. J Parenter Enteral Nutr 1990; 14:310-311.
Use of Thrombolytic Agents
for Treatment of Occluded Catheters
Results of the COOL 1 Trial
Tissue plasminogen activator (Alteplase) 2 mg in 2 ml for 2 hours
75 patients received tPA
with 2nd dose
74 patients received placebo
74% success
90% success
17% success
COOL = The Cardiovascular Thrombolytic to Open Occluded Lines Efficacy Trial
J Vasc Int Radiol 2001; 12: 951 - 955
High-Performance Hemodialysis Catheters
Vaxcel
Dura-Flow
Maxid
Ash Split
Xpresso
Hemostream
contrast exits
through proximal
side holes
Multisidehole
Hemodialysis
Catheters
Heparin (or TPA) will
exit catheter through
proximal side holes.
thrombus
occluding
tip of catheter
Drug will not fill tip of
catheter.
Examples of Intraluminal Thrombus
Endoluminal Brushes
- useful for multi-sidehole catheters
Occluded Hemodialysis
Catheter
After
brushing
occluded
tip
catheter tip
widely patent
Fibrin Tail
Fibrin tail
intraluminal thrombus
Thrombus at Catheter Tip
Hickman catheter
catheter
tip
thrombus
catheter tip
thrombus
thin fibrin sheath
Fibrin Sheaths
Examples of
fibrin sheaths
obtained during
removal of
hemodialysis
catheters
thick rind of fibrin
Fibrin Sheath
“Dual” fibrin sheaths extending from
subcutaneous tissue into jugular vein
fibrin
sheath
jugular
vein
fibrin sheath extends
from jugular vein
into subcutaneous tissue
Ultrasound of Fibrin
Sheath
Residual
fibrin sheath
following
removal of
catheter
Catheter Dysfunction Due to Fibrin Sheath
Aspiration
Fibrin sheath Injected drug
will of
suck
envelopes the will flow inside
fibrin sheath
fibrin
sheath.
tip of the catheter
against
May be difficult
catheter tip.
to inject.
Treatment of Fibrin Sheath
or Pericatheter Thrombus
• Stripping with endovascular snare
• Exchange catheter
+ disruption of fibrin sheath
• Infusion of thrombolytic drug
Fibrin Sheath Stripping
Endovascular
Snare
PTA of Fibrin Sheath
Fibrin sheath
Replace
catheter
Post-PTA
12mm
x 4cm
Intraluminal
debris
Angioplasty of
Catheter-Induced
Stenoses
High Pressure Angioplasty Balloons
Rated burst pressure :
20 atm
(4 – 8 mm)
Angioplasty of Central Venous Stenoses
Short segment
occlusion of
left subclavian vein
Using catheter
to direct guidewire
through occlusion
positioning
balloon
inflating
balloon
Post-angioplasty 12mm
persistent narrowing
and irregularity of
the stenosis
Recanalization of Occluded Veins
occlusion of right
brachiocephalic vein
Fluoroscopic image
Digital subtraction image
occluded
venous
segment
advanced guidewire
across occlusion
Angioplasty of
stenosis
Created channel
in vein
Insert
catheter
Endovascular Stents
Endovascular Stents
Wallstent
(Boston Scientific)
- stainless steel
- self-expanding
S.M.A.R.T. stent Luminexx
(Cordis / J & J)
- nitinol
- self-expanding
Bard Peripheral Vascular
- nitinol
- self-expanding
12mm x 4cm
12mm :x12mm
40mm
Post-PTA
SMART stent
Mural Thrombus
thrombus
surrounding
catheter
Thrombus extends from
the catheter to the wall
of the adjacent vein.
Mural Thrombus
catheter
catheter
thrombus
thrombus
Venous Thrombolysis
Pulse-spray
thrombolysis
Multisidehole
Infusion Catheter
Central Venous Occlusion
Endovascular Recanalization
Thrombolysis
Angioplasty
Endovascular Recanalization
Tom Vesely, M.D.
[email protected]
www.vascularaccessdoc.com