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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