Download Placement of Central Catheters in Patients with

J Tisnado, MD, FACR, FACC, FSIR, FAHA1
J Tisnado2, D J Komorowski1, M K Sydnor1
1MCV
Hospitals/VCU Medical Center, Richmond VA
2Hartford Hospital, Hartford CT
Central catheterization, a well-established procedure managing
clinical entities, such as: hemodialysis, total parenteral nutrition,
IV access, blood draws, and apheresis, among others. Procedures
are simple and straight forward in patients with “normal” or
“conventional” cardiac and central venous anatomy. We place
central catheters in patients with different and varied congenital
cardiac and venous vascular abnormalities, both congenital and
acquired. A review of our experience with central catheterization
in these circumstances is in order. We briefly discuss some
interesting instances of cardiovascular problems, and provide
guides for successful insertions.
Patients with different cardiac anomalies, i.e. transposition of
great vessels, “double” SVC, left-sided SVC, Tetralogy of Fallot,
post-Fontan and post-mustard procedures and others. Many
patients with left ventricular assist devices, aortic balloon
pumps, and “artificial hearts” are also illustrated in this
educational exhibit.
Successful placements can be achieved in most, if not all, patients with
different cardiac and central venous vascular anomalies if one is aware of the
vascular anatomy and cardiac malformation and base some information about
the different operations to “correct” congenital heart disease.
Placement of central catheters in patients with cardiac and central venous
vascular anomalies is relatively easy and safe, especially if one has a basic
knowledge of the anatomical configuration prior to placement. Noninvasive
imaging: US, CTA, MRA are the main pre-procedure imaging methods to plan
the approach. Digital subtraction venography is necessary in complicated and
confusing cases. We present a brief review with “actual” examples and
describe some of the “tricks-of-the-trade” to be successful in the placement of
central catheter in these uncommon situations.
Percutaneous translumbar placement of central venous catheters can be done
also without any differences in complication rates than the "routine"
placements of central catheter placement. The translumbar placement is safe
and reliable in children.
In general, children with congenital heart disease need long-term
indwelling catheters for a long time for a long-term administration of
IV fluids and drugs, samplings of blood and/or TPN. Sometimes the
central veins are no longer available for us. Sometimes the patients
need preservation of the SVC or IVC for future interventions, surgery
and/or catheterizations.
Central venous catheterization is nowadays "routine" management in
the armamentarium of an aggressive health care team.
A) percutaneous non-tunneled catheter placement in the SVC, IJV, External
jugular veins (EJV), femoral veins (FV)
B) peripherally inserted central catheters (PICCs)
C) percutaneous tunneled catheters
valved: Groshong
non-valved: Hickman, Broviac
D) implantable ports
If the access is difficult or depleted or needs to be preserved,
alternative approaches are needed. The translumbar approach to the
IVC and right atrium may be the ideal in some aspects.
In general, 9 out of 1000 (1%) babies are born with a congenital heart abnormality. In
order to prevent the death of those babies, 2.3 of those babies need some type of
treatment of the congenital heart disease.
Further, 1 million of people in USA were born with some type of congenital heart
defects.
Furthermore,
 15% of children 12-17 are smokers already;
 1/2 of children 12-21 do not exercise daily;
 30% of children in USA are obese.
About 3.5-5 million of central venous catheters are placed annually in USA -- 250,000
CVC related infections in this group.
The Fontan procedure is initially a connection between the right atrium to the
pulmonary arteries.
Variations:

A cavopulmonary connection with a tunnel either intracardiac or extracardiac.

Placement of an external conduit bypassing the right atrium completely.
Central venous catheter placement is preferred from the IJV in to the brachiocephalic
veins only. No attempts to place catheters into the SVC should be made.
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VCU is one of the leading institutions in the country in placing TAH.
Usually the TAH is powered by a large, 400 lbs console.
Hopefully, in the near future, it will be powered by a 13-pound backpack so the
patients can go home to wait for a heart.
TAH is indicated as a bridge to a human heart transplant, in patients dying from
end-stage biventricular failure.
Average waiting time for a heart is about 3 months for patients with artificial heart.
Since the console to drive the TAH is a large one, 400 lbs., the patients must stay in
the hospital awaiting for an organ.
With the new back pack power, the patients could go home to await for a heart.
SynCardia: Total temporary artificial heart. Therefore, in the future, we may see
outpatients with TAH and we must be prepared to insert central venous catheters
in those patients. Furthermore, it is very important to know the anatomy of those
patients before insertion of central catheters.
Andropoulos et al reported 450 central venous catheter placements in children with
congenital heart disease. They recommended that the tip of the central catheter be
placed in the SVC, just above the right atrium. They presented an interesting
formula to predict the placement of the tip of the catheter and to prevent serious
perforations of the heart or great vessels. Other complications mentioned are:
dysrhythmia, extravasation of IV fluids, thrombosis, inaccurate measurements of
central venous pressures and tamponade due to cardiac perforation. They
recommend to place the central venous catheters with the patients in
Trendelemburg and using anatomic landmarks or palpation of the carotid arteries
or with Doppler US guidance.
This is routine for us as we always use US to access the central veins. We
assume that those guidelines are for those operators inserting central
venous catheters with no imaging guidance which is not recommended
by us, especially when one is dealing with children with congenital heart
disease.
Qureshi et al advocate a transhepatic placement of central catheters to avoid
or prevent central venous thrombosis and also to preserve the central
veins for future use, specially in children with complex congenital heart
diseases. In their experience 32 children had 40 transhepatic placements.
A complication rate of 8.8% was reported.
We have not done this since we believe that the transhepatic approach is too
aggressive and drastic and we reserve these optional approaches such a
transhepatic and translumbar for patients with depleted central veins.
An interesting study comparing thrombotic complications between heparincoated central catheters vs. non-heparin-coated catheters was reported
recently. No advantage of one over the other was demonstrated in infants
with congenital heart diseases. Both exhibited similar rates of
complications (42% vs 44%).
Some patients with patent foramen ovale (PFO) who need central venous
catheters must have continued treatment with "blood thinning" drugs
such as clopidogril , aspirin or Coumadin. These patients have a high rate
(40%) of stroke. In addition these patients must have "endocarditis
prevention" with antibiotics, specially if they are having dental work, any
"invasive" test, or minor or mayor surgery. Otherwise, the methods of
placement of central catheters are the normal ones, i.e. the tip of the
catheter in the right atrium-SVC junction or in the right atrium.
Regarding PICCs they must be placed always under fluoroscopic guidance. A
study of 843 PICCs placed in 698 children by the "PICC" team or
operators without fluoroscopy showed that 86% of central catheters were
misplaced and needed repositioning under fluoroscopy to achieve a 90%
success of correct central venous catheter placement.
Conclusion of the study: PICCs must be placed under fluoroscopy. This
applies to children with and without congenital heart disease.
By the way. The tips of the PICC were considered as central if placed
anywhere within the SVC. Superior border limited by the right
tracheobronchial angle. The inferior border defined at slightly below the
right lateral border of the heart in the chest X ray.
VADs are used to assist the failing heart, usually
temporarily after a MI or permanently in patients with
end-stage heart failure. VAD aid the heart in
maintaining the ventricular output. Initially, and still
are used temporarily to help the ventricle to recover or
as a bridge for heart transplantation. Sometimes the
VAD are permanent is some patients who are not
candidates for heart transplant and whose heart will
not recuperate.
In general the indications for a VAD are:
a) temporary to recovery of the heart (days and weeks).
b) temporary, as a bridge for heart transplantation. Patients are
awaiting for an organ.
c) permanent for patients no candidates for transplant. Use until
death.
The device is normally inserted in the thorax and abdomen. The
inflow cannula is connected into the tip of the ventricle and
the outflow cannula returns the blood to the ascending aorta
or main pulmonary artery. The pump is usually located in
the abdomen either intra- or extra-peritoneal.
In general there are two types of VAD.
a) continuous flow
b) pulsatile flow
Regardless of the type of VAD, the patients may have, the
placement of central catheters is rather straightforward. The
access can be the IJV or the EJV or the SCV for central
catheters and the arm veins (basilic) for PICCs. The tip of the
catheter is placed usually in the SVC-right atrial junction or
preferable in the middle of the right atrium as we prefer.
Placement of central catheters in patients with patent
foramen ovale (PFO) is rather straightforward.
However, care must be taken to make sure no clot or
foreign body (fibrin deposits) form around the catheter.
Otherwise, serious paradoxical emboli may occur. A
small clot could embolize and result in a stroke if enter
the cerebral arteries or a MI if enter the coronary
arteries.
There have been studies demonstrating that heparincoated-bonded central venous catheters do not reduce
thrombosis incidence, at least in infants less than one
year-old with congenital heart diseases. Therefore,
special care is needed in these infants since they
usually require for a much longer time the central
venous catheters.
The total artificial heart (TAH) is a temporary device for
patients who have lost the function of both ventricles and,
therefore, cannot have a VAD. The TAH allows the recovery
of patients for them to be in better shape for a heart
transplant be done in about 2-3 months ideally. More than
20 patients have been done at our institution.
The patients must remain in the hospital as the console to drive
the unit is huge. Portable devices are being developed now.
In these patients care must be taken during placement of the
central catheters as a too long catheter into the right atrium
could result in prolapse of the catheter into the artificial
heart creating problems for functioning.
Ideally the central venous catheters in these patients should be
in the SVC-right atrial junction. Placement of the tip in
the right atrium is also acceptable.
Two infants with congenital heart disease had thrombosis of the veins after
placement of a central catheter in the L IJV.
One woman with a persistent L SVC died due to extensive thrombosis of the
coronary sinus after placement of a central venous catheter in the L SVC.
Another infant with a total anomalous venous return had placement of a
central venous catheter in the L IJV which drained into a persistent L
SVC, which became occluded after central venous catheter
placement with a resultant left upper lobe consolidation due to
obstruction of the venous outflow of the left upper lobe. Therefore, a
complete evaluation of the venous anatomy, the systemic and the
pulmonary venous anatomy is important before inserting central venous
catheters in children with congenital heart disease, particularly in cases of
total or partial anomalous venous return.
Perhaps in these infants, placement of central catheters in the right side veins,
such as R IJV, R SCV, R EJV, is preferred or else the central veins should
be avoided altogether and the central catheters inserted into the IVC and
other alternate places like transhepatic, translumbar.
AC is a localized "diaphragm-like" stenosis of the
thoracic aorta occurring usually just distally to
the origin of the L SC artery. In addition there
is usually a bicuspid aortic valve. Most patients
are asymptomatic due to development of
collaterals. In these patients the placement of
central venous catheters is rather simple and
straightforward as in the "normal“ patients.
Total pulmonary venous return occurs when all the
pulmonary veins return to the right atrium directly
or indirectly via the SVC or IVC.
Partial anomalous venous return occurs when not all
the pulmonary veins return to the systemic
circulation such as to the right atrium, SVC or IVC.
In these patients it is better not to place central
venous catheters in the neck or chest, i.e. into the
central veins, since thrombotic complications of
central venous catheterization could result in
serious and even lethal "paradoxical" emboli. It is
better to place catheters in the IVC or in the
femoral veins.
The ductus arteriosus in the fetal stage usually connects
the left pulmonary artery with the proximal
descending aorta, distally to the origin of the L SC
artery. During fetal life the blood form the left
pulmonary artery bypasses the lungs directly into the
descending aorta.
In patients with PDA (left to right shunt) the placement of
central venous catheters should be straightforward.
Unless there has been a reversal of flow (right to left
shunt, Erlenmeyer complex).
In these cases care must be taken to prevent thrombi
forming in the central catheter. A small thrombus
associated with the central catheter could be very
serious, indeed.
Are communications between the atria. ASD
are the most common congenital heart diseases
in adults, at least.
There are 3 types of ASD:
1.
2.
3.
Ostium primum,
Ostium secundum, and
sinus venosus.
Are the most common congenital heart diseases in
children. The VSD can be located in the
membranous or in the muscular septum or above
the atrioventricular septum or near the mitral and
tricuspid valves.
The placement of central catheters in patients with
ASD or VSD should be straightforward too.
However, in adults with large VSD with
enlargement and hypertrophy of the right ventricle
and pulmonary hypertension, special care must be
taken to make sure no thrombi form in the central
venous catheter. Otherwise, serious paradoxical
emboli could occur.
Consists of four anomalies:
1.
2.
3.
4.
subpulmonary infundibular stenosis,
VSD,
right ventricular hypertrophy, and
overriding aorta.
Patients with T of F usually are operated early in
life; therefore, the placement of central
catheters can be done with no special or
particular problems or precautions.
In these patients a single vessel (trunk) originates
from the heart. The patients are usually
operated early in life. The placement of central
catheters in these patients is done by puncture
of the IJVs or the EJVs in either side. Ideally,
short catheters with the tip in the innominate
veins or the SVC should be used.
Is one of the most common congenital heart
diseases. In these patients the aorta originates
from the right ventricle and the pulmonary
artery originates from the left ventricle. Most
patients have no other cardiac anomalies. A left
to right shunt is necessary for life. Since the
great vessels are reversed, one can place central
venous catheters in the IJVs or EJVs or the SCV
or SVC. It is better not to place catheters in the
atria as thrombi can develop and embolize
with resultant rather serious complications.
ASD comprises about 19% of all congenital heart
diseases. There is a risk of paradoxical emboli.
VSD is one of the most common congenital heart
diseases. There are 4 types, depending on
where in the septum is the defect.
PDA is a communication between the left
pulmonary artery and the descending
aorta which usually obliterates within 2-3
weeks of life. It represents about 5-10% of all
congenital heart diseases.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
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