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 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 Catheter-Related Complications
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 - thrombus - fibrin sheath catheter tip in pulmonary artery
Inspection of Catheter and Skin Exit Site Infected port exposed port purulent drainage from tunnel
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 problemsare usually technical: - catheter kinking - tip malposition Late problemsare usually due to: - intraluminal thrombus - pericatheter thrombus - fibrin sheath formation kinked malpositioned
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.
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 extra stiff guidewire kink 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 looped into right internal jugular vein right chest port
attempting to snare the catheter snare is used to pull catheter into position right femoral vein venous access site
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 and out of the femoral vein catheter fragment is pulled through the right atrium
Evaluation of Dysfunctional Catheters Poorly functioning port. Port inserted through the right subclavian vein. Catheter tip in the SVC. “Ballooning” of catheter when injected
“Pinch-Off” PhenomenonA 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 of vein catheter in vein compressed by ligaments and bones
“Pinch-Off” PhenomenonA Complication of Subclavian Catheters fractured port catheter due to “Pinch-Off” fractured port catheter
Injection of X-ray Contrastto 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 Pressure Suction Size Generated Generated (ml) (atm) (atm) 50 5.2 0.98 10 9.4 0.90 3 21.0 0.67 1 40.0 0.50
Injecting x-ray contrast through the catheter will provide visualization of the catheter tip and surrounding venous anatomy. visualization of right atrium injection through venous lumen
High-Performance Hemodialysis Catheters Vaxcel Dura-Flow Maxid Ash Split Xpresso Hemostream
Injection of venous (distal) lumen of a tunneled hemodialysis catheter
port catheter Injecting x-ray contrast through the catheter will provide visualization of the catheter tip and surrounding venous anatomy. thrombus surrounding catheter tip
Injection of arterial (proximal) lumen of a tunneled hemodialysis catheter
An upper extremity venogram should be performed to evaluate the entire vein in which the catheter is located. right upper extremity venogram left upper extremity venogram
Non-Aspirating Catheter (Port) Port catheter tip abutting vein
Patient with a pheresis catheterin 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 EventsMechanicalThrombus Crain (’96)44 4 40 Suhocki (’96)42 4 38 Rockall (’97)31 7 24 Trerotola (’97)63 23 40
Types of Thrombotic Occlusion catheter vein Intraluminal thrombus Thrombus or fibrin tail Fibrin Sheath
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 74% success with 2nd dose 90% success 74 patients received placebo 17% success COOL = The Cardiovascular Thrombolytic to Open Occluded Lines Efficacy Trial J Vasc Int Radiol 2001; 12: 951 - 955