management of catheter-related complications: perspective of an interventional radiologist thomas m....
TRANSCRIPT
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 - thrombus - fibrin sheathcatheter tip in
pulmonary artery
Inspection of Catheter and Skin Exit SiteInfected
port
purulent drainage from tunnel exposed port
Catheter Related Venous Thrombosis
Inspect Pinch Clamps
Hemodialysis catheter
Pinch clamps must be periodically movedto avoid causing permanent kinks in tubing
kinked tubing
Bring patient intoangiography suite
for fluoroscopy andcontrast injection.
Angiography Suite
fluoroscopy
Portableultrasound
unit
Evaluation of Dysfunctional Catheters
Early problems are usually technical:
- catheter kinking - tip malposition
Late problems are usually due to:
- intraluminal thrombus - pericatheter thrombus - fibrin sheath formation
kinked
malpositioned
Patient referred because of difficulty with removing wire from PICC following the insertion procedure.
Fluoroscopy of the entire catheter
severely twistedPICC
Unusual appearanceof PICC within theleft arm.
Course of PICC suggests left subclavian artery
Pulsatile blood flow from PICC insertion site
Yikes !!!!Who put in that PICC ?
Kinked Catheters
kinked lumen
kinked tips
High resolution fluoroscopy may be necessaryto identify subtle kinks in the catheter lumens
Use of an extra-stiff guidewire to reduce a kink in a central venous catheter
kinkextrastiff
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
RepositioningUse of an Endovascular
Snare
right chestport
catheter loopedinto right internal
jugular vein
right femoral vein venous access site
attemptingto snare the
catheter
snare is used to pullcatheter into position
The loop in the catheter has beenremoved.
Foreign BodyRetrieval
Removal of brokencatheter fragments.
cathetersnapped
off
Snare inserted
from the
femoral vein
catheter fragmentis pulled throughthe right atrium
pulled intothe IVC
and out of thefemoral vein
Evaluation of Dysfunctional Catheters
Poorly functioning port.
Port inserted through theright subclavian vein.
Catheter tip in the SVC.
“Ballooning”of catheter
when injected
“Pinch-Off” is due to entrapment of the catheter in the
subclavius muscle – costoclavicular ligament complex
“Pinch-Off” PhenomenonA Complication of Subclavian Catheters
subclavian vein
pinchingof vein
pinching
of vein
catheter in veincompressed byligaments and bones
fractured port catheterdue to “Pinch-Off”
“Pinch-Off” PhenomenonA Complication of Subclavian Catheters
fracturedport catheter
Injection of X-ray Contrast to Evaluatethe Dysfunctional Catheter
Evaluation of Dysfunctional Catheters
Always aspirate the heparinfrom the catheter before injecting contrast material.
Catheters are routinely “locked” with heparin solution.
1.5 ml per lumen X 5000u heparin /ml
= 7500 units heparin per lumen
Hemodialysis catheters :
SYRINGE PRESSURE
Syringe Pressure SuctionSize 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 contrastthrough the catheterwill provide visualizationof the catheter tip andsurrounding venousanatomy.
injectionthroughvenous lumen
visualizationof right atrium
High-Performance Hemodialysis Catheters
Vaxcel Dura-Flow Maxid Ash SplitXpressoHemostream
Injection of venous (distal) lumen
of a tunneled hemodialysis catheter
Injecting x-ray contrastthrough the catheterwill provide visualizationof the catheter tip andsurrounding venousanatomy.
portcatheter
thrombus surroundingcatheter tip
Injection of arterial
(proximal) lumen
of a tunneled hemodialysis
catheter
An upper extremityvenogram should beperformed to evaluatethe entire vein in which the catheter is located.
left upperextremityvenogram
right upper extremityvenogram
Catheter-Induced Venous Stenosis
Non-Aspirating Catheter (Port)
catheter tipabutting vein
Port
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.
Contrast injected through the catheter demonstrates prompt leakage from one lumen.
leakageof contrast
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
Intraluminalthrombus
Thrombus orfibrin tail
Fibrin Sheath
vein catheter
Intraluminal Thrombus
Thrombolytic Agents
Injecting CathFlo intooccluded catheter lumen
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.
Thrombolytic Agents
Use of Thrombolytic Agents for Treatment of Occluded
CathetersResults of the COOL 1 Trial
COOL = The Cardiovascular Thrombolytic to Open Occluded Lines Efficacy Trial J Vasc Int Radiol 2001; 12: 951 - 955
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
High-Performance Hemodialysis Catheters
Vaxcel Dura-Flow Maxid Ash SplitXpressoHemostream
MultisideholeHemodialysis
Catheters
Heparin (or TPA) will exit catheter through proximal side holes. Drug will not fill tip of catheter.
thrombusoccludingtip of catheter
contrast exitsthrough proximal
side holes
Examples of Intraluminal Thrombus
Endoluminal Brushes
- useful for multi-sidehole catheters
Occluded Hemodialysis
Catheter
occludedtip
Afterbrushing
catheter tipwidely patent
Fibrin Tail
Fibrin tail
intraluminal thrombus
Thrombus at Catheter Tip
Hickman cathetercatheter tip
thrombuscatheter
tip
thrombus
Examples of fibrin sheaths
obtained during
removal of hemodialysis
catheters
Fibrin Sheathsthin fibrin sheath
thick rind of fibrin
Ultrasound of Fibrin Sheath
“Dual” fibrin sheaths extending fromsubcutaneous tissue into jugular vein
Fibrin Sheath
fibrinsheath
fibrin sheath extendsfrom jugular veininto subcutaneous tissue
jugularvein
Residual fibrin sheath
followingremoval of
catheter
Catheter Dysfunction Due to Fibrin Sheath
Fibrin sheathenvelopes the
tip of the catheter
Injected drugwill flow inside of fibrin sheath.
May be difficultto inject.
Aspirationwill suck
fibrin sheathagainst
catheter tip.
Treatment of Fibrin
Sheath or Pericatheter Thrombus
•Stripping with endovascular
snare
•Exchange catheter + disruption of fibrin sheath
• Infusion of thrombolytic drug
EndovascularSnare
Fibrin Sheath Stripping
PTA of Fibrin Sheath
Fibrin sheath
12mm x 4cmPost-PTAIntraluminal
debris
Replacecatheter
Angioplasty of
Catheter-Induced
Stenoses
High Pressure Angioplasty Balloons
Rated burst pressure : 20 atm (4 – 8 mm)
Angioplasty of Central Venous Stenoses
Using catheterto direct guidewirethrough occlusion
Short segmentocclusion ofleft subclavian vein
positioningballoon
inflating balloon
Post-angioplasty 12mm
persistent narrowingand irregularity ofthe stenosis
Fluoroscopic image Digital subtraction image
occlusion of rightbrachiocephalic vein
Recanalization of Occluded Veins
advanced guidewireacross occlusion
occludedvenoussegment
Angioplasty of stenosis
Created channelin vein
Insertcatheter
Endovascular Stents
Endovascular Stents
Wallstent (Boston Scientific)
S.M.A.R.T. stent(Cordis / J & J)
- stainless steel- self-expanding
- nitinol- self-expanding
LuminexxBard Peripheral Vascular
- nitinol - self-expanding
12mm x 4cmPost-PTA : 12mm12mm x 40mm
SMART stent
Mural Thrombus
thrombussurrounding
catheter
Thrombus extends fromthe catheter to the wall
of the adjacent vein.
Mural Thrombus
catheter
thrombus
catheter
thrombus
Venous Thrombolysis
MultisideholeInfusion Catheter
Pulse-spraythrombolysis
Central Venous Occlusion
Thrombolysis
Endovascular Recanalization
Angioplasty
Endovascular Recanalization
