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Central venous access: techniques and indications in oncology

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Eur Radiol (2008) 18: DOI /s ONCOLOGY Pierre-Yves Marcy Central venous access: techniques and indications in oncology Received: 27 November 2007 Accepted: 21 March 2008
Eur Radiol (2008) 18: DOI /s ONCOLOGY Pierre-Yves Marcy Central venous access: techniques and indications in oncology Received: 27 November 2007 Accepted: 21 March 2008 Published online: 6 May 2008 # European Society of Radiology 2008 P.-Y. Marcy (*) Department of Radiodiagnostics and Interventional Radiology, Antoine Lacassagne Anticancer Research Institute, 33 Avenue Valombrose, Nice, Cedex 1, France Tel.: Fax: Abstract Long lines can be inserted centrally or peripherally through patent veins into the central venous system down to the atrial caval junction. Traditionally surgeons, anesthetists, cardiologists and more recently interventional radiologists have been placing them using vein cutdown or percutaneous needle puncture techniques. Typical candidates for implanted venous catheters are cancer patients undergoing long-term chemotherapy. The most important issues, in addition to the patency of central veins and the history of previous indwelling catheters, pacewires or venous thrombosis, are the patient s performance status, body mass index, medical history and respiratory status, and the relevant technique. The present article will give an overview of the radiological and surgical implantation techniques and will highlight the impact of imaging means on the technical feasibility, assessment and treatment of device-related complications. Keywords Catheters and venous catheterisation. Central venous access. Catheters and catheterisation, complications. Catheters and catheterisation, technology. Veins, thrombosis Introduction Traditionally, long lines have been inserted by surgeons, anaesthetists or cardiologists under heavy sedation or local anaesthesia, in the operating room. More recently, interventional radiologists have been placing them using local anaesthesia, real-time fluoroscopy and ultrasound guidance. These devices can be inserted peripherally (extremity long lines) or centrally (chest long lines) through patent veins into the central venous system down to the atriocaval junction. The aim of this review is to report the main techniques and indications of venous port placement and to look for the advantages of radiological means over surgery. Long-line insertion techniques Consultation defines key-point questions before deciding the best device approach and the non-symptomatic side of device insertion (Table 1): The chest X-ray analysis allows us to assess the patient s mediastinum (venous stents, occluded catheters, pacing wires, cardiomegaly, kinking arteries), lungs (emphysema, pneumectomy cavity, atelectasia), thoracic wall (rib resection, bone metastasis) and congenital anomalies (Fig. 1) [1]. Coagulation abnormalities will be corrected, and written informed consent must be obtained before procedure begins. The procedure includes the choice of the target vein, the access vein technique and the right positioning of the catheter tip by using tips and tricks whenever required. Selecting the target vein depends on the operator s experience, the type of the technique, i.e., surgical or radiological, percutaneous needle puncture or venous cutdown accesses and the patient s profile. Regarding the radiological technique, the procedure consists of a singlewall vein needle puncture under real-time image guidance using split-sheath technology and local anaesthesia (Fig. 2), whereas the surgeons perform either a Seldinger venous puncture or a venous cutdown. Ultrasound (US) guidance (Fig. 3a,b,c) compared to the landmark-guided 2334 Table 1 Patient assessment checklist History Physical examination Biological parameters Present and previous carcinomas Breast, head and neck or thoracic surgery (rotation flap) Radiation therapy Clavicle fracture, algodystrophy Patient s dominant arm Age, gender, weight loss Respiratory insufficiency Renal insufficiency Hypercoagulable conditions (previous catheter/venous stent/pace wires) The non-symptomatic side* Surgical wound, scars, tracheostomy Radiodermatitis, simulation tattoos Anatomy distortion Patient s arms and subclavicular areas Patient habitus, BMI**, pendular breasts*** Supine position tolerance, kyphosis, Valsalva manoeuvre Haemodialysis shunt SVC syndrome#, oedema, adenomegaly, Prothrombin time 70% performance status, previous access scar Hypocoagulable conditions Cephalin kaolin time 38s Purpura, haematoma Absolute platelet count /l Neutropenia Absolute neutrophile count /l Mode and duration of planned use: in/outpatient basis Patient s ability to maintain the catheter *The non-symptomatic side is the route of potentially chosen venous access, which should be contralateral to the surgical wound, lymph node excision, myocutaneous flap, tumour growth, radiodermatitis, thrombotic or excised veins, algodystrophy and the non-dominant arm. **BMI: body mass index = weight/(size) 2. When BMI is 18 (denutrition), the risks of sepsis and delayed wound healing over the port may increase; when BMI is 30 (morbid obesity), the risks of port twisting, catheter retraction and needle dislodgement may be higher ***Pendular breasts may induce catheter retraction when the chest-port patient moves upright #SVC syndrome: superior vena cava syndrome technique improves the overall success rate and the success rate of first attempt, decreases the average access time and decreases the complication rate [2 4]. Venography is helpful in upper extremity and subclavian vein (SCV) access [5 7] to monitor venous puncture and network patency. Real-time US guidance offers several benefits over venographic guidance: internal jugular vein (IJV) access, identification of both vein and artery, no risk of allergic medium reactions and/or renal impairment, and no need of a small-bore intravenous line. Nevertheless, venography is mandatory in case of difficult venous access (venous spasm, haematoma) or catheterisation (venous kinking, aberrant pathways) in patients presenting with superior vena cava (SVC) syndrome and/or with morbid obesity. In case of renal impairment, a minimal dose of low- or iso-osmolar contrast media or carbon-dioxide gas should be injected [8]. Regarding the placement of the catheter tip, fluoroscopy helps to monitor catheterisation, to orientate the peel-away sheath almost parallel to the accessed target vein in case of kinking and to prevent any catheter misplacement. As for the catheter elasticity, the operator needs to test it under fluoroscopy guidance namely in case of kinking mediastinal veins and left-sided access. As a matter of fact, in these cases, the inserted catheter backend may move 2 cm downwards into the superior vena cava while the operator is pushing the catheter only 1 cm forward. After performing this test, the catheter tip has to be located in the lower third of the SVC or right below it (Figs. 4, 6a). Preoperative sedation, analgesia and use of conscious sedation are not usually required in adults and are rarely required in teenagers; thus, the patient should eat a light meal before the procedure. Prophylactic antibiotic therapy has been found unnecessary [5]. Supra cardiac long-line insertion Central venous access should be attempted in the supra cardiac area according to the venous chart (Table 2). The use of US guidance has made internal jugular vein cannulation a straightforward and relatively risk-free process [2, 4, 11 13]. Right IJV access is preferred because it provides a more direct route into the right atrium and therefore helps prevent sheath kinking and further catheter secondary shift. Left access is more time consuming than right IJV access and is associated with a higher incidence of complications [14]. Reported technical failure rates are 4% when using only the right side [15] and 0.2% when using both sides [13]. In patients with a high risk of venous thrombosis, the IJV approach has been shown to be superior to the SCV approach [16, 17]. 2335 obesity, severe kyphosis) and/or who are contraindicated for chest-port insertion. Techniques include insertion in the arm or forearm using US guidance (patient with seemingly no veins) or venography [5, 24, 25]. Three possibilities of venous access include the basilic, brachial or cephalic veins during a single session [26]. The procedure will be eventually finalised with a chest X-ray to document catheter position and evaluate any related complications (Figs. 4, 6b,c, 7a c, 8, 9a b, 12). Regarding the tips and tricks related to catheter malposition prevention, real-time fluoroscopy is mandatory indeed. Solutions to kinking of peel-away sheaths (left IJV or right SCV access) include to lower and pull the sheath back proximal to where it is kinked and then advance the catheter or to use a hydrophilic stiff guidewire. Wrong direction of the guidewire and catheter is corrected by pulling back the catheter, enabling the patient to cough or turn the neck to the opposite side, and using stiff hydrophilic guidewire (Fig. 5). Catheter elasticity testing is still performed before definitive length trimming to prevent any risk of further secondary catheter malposition (Figs. 6a, 8) [27 30]. One specific case is central vein occlusion management, which is a real asset for radiologists over surgeons. There is no consensus whether the operator should go through the contralateral healthy veins with a risk of bilateral vein occlusion or should try to recanalize the occluded vein, keeping the other side patent. Recanalization is feasible in Fig. 1 a Chest X-ray in a left breast cancer patient with lung metastasis, previous occluded catheter (blind SCV needle puncture) and axillary lymph node excision. Note the catheter retraction due to a large pendular breast. The non-symptomatic side for choosing a new venous access should be the right side. SCV patency (US Doppler) is recommended before attempting any venous access in this case. b Chest X-ray in a lung cancer patient who underwent pneumonectomy and anterior rib resection that precluded right-sided chest port placement. Arm device was inserted under venography. CVC technique could be another option As regards subclavian venous access (Fig. 3), it is usually performed by the infraclavicular approach [6, 19, 20], but a supraclavicular approach can be used in children [21]. A lateral approach [22] virtually eliminates the risk of pneumothorax or puncture of thoracic duct or internal thoracic artery, minimises risk of pinch-off syndrome [23] and enables the operator to compress manually the vessels in case of inadvertent arterial puncture. A less fashionable technique that consists of upper extremity catheter placement prevents the risks of pneumothorax and pinch-off syndrome. This procedure is still efficient even on patients in an upright position (morbid Fig. 2 Comparison between the (blind) Seldinger technique and the real-time image-guided venous access. During blind access (a,b,c), needle motion will collapse both front and back walls of the target vein. The needle will completely traverse the vein, whereas real-time image guidance permits a less traumatic single-wall vein puncture. After blood backflow is obtained, a peel-away sheath is advanced over a wire into the vein. To prevent air embolism while removing the sheath, the patient is asked to hum and the catheter is pushed into the peel-away sheath 2336 the catheter [48]. Otherwise, in limited life expectancy patients, the SVC stent should be deployed against the catheter with no risk of catheter dysfunction. SVC tumour invasion is a contraindication of stenting and the indication for infra-cardiac port insertion. Despite some short-term and long-term complications, central venous access techniques are efficient and safe. Procedure complications (Table 3) include pneumothorax and bleeding, which are the most frequent reported complications, particularly in blind percutaneous and venography-guided attempt of SCV access [19, 34]. Pneumothorax risk is virtually non existent in case of IJV or SCV attempts performed under real-time US guidance (Fig. 3c) [13, 22]. Haematoma usually results from inadvertent arterial puncture when attempting vein puncture under fluoroscopy guidance or from a skin vessel that has been disrupted during tunnelling. Reported risks of iatrogenic subclavian artery injury are virtually zero with procedures performed under real-time US [22], 0.3% under venography [34] and 7.8% in case of a blind attempt [19]. Also, life-treatening SVC thrombosis and pulmonary embolism have been reported in less than 0.4% of the literature s largest series [5, 20, 31]. Long-term complications occur in approximately 7% of patients when image guidance is used. They include the Fig. 3 a Normal spectral Doppler signals of SCV. Neck and arm veins are characterised by two phasic variations in amplitude (cardiac and respiratory phasicity), which will diminish in case of downstream central vein occlusion [18]. Needle must access SCV during full expansion of the vein. b Longitudinal US monitoring of right supraclavicular SCV access in an infant. Real-time US guidance decreases the bleeding risk by decreasing the risk of failure on first attempt, the number of needle passes and the inadvertent arterial puncture, which are the main cause of haemorrhagic complication in blind venous access [4]. c Sagittal US colour Doppler sections show subclavian artery (a), implanted catheter (arrow) and cyclic variations of SCV diameter. US monitoring lowers the risk of iatrogenic pneumothorax. Note the extreme closeness of the pleura (double arrow) recent venous thrombotic occlusion using various guidewires and J-shaped tip glide catheters [46]. In case of SCV stenosis, forceful saline injection and balloon angioplasty should be helpful. Anticoagulant or antiplatelet therapy should be given to the patient to prevent reocclusion. On the other hand, there is a risk of bilateral vein occlusion, especially in patients with a hypercoagulable state, when considering placement through the contralateral healthy veins. This is nevertheless mandatory in patients with persistent ipsilateral upper limb oedema and/or presenting with venous tumour compression/invasion. SVC syndrome can be successfully treated by means of interventional radiological procedures [47]. Usually, the catheter should be placed through a fully expanded SVC stent. SVC stenting should also be performed in the presence of a port catheter using temporary displacement of Fig. 4 Chest X-ray documents the correct position of the left-sided IJV long line. The right mainstem bronchus (black rectangle) and vertebral body associated with the carina are identified. Regular catheter tip position (grey arrow) is measured by dividing the spine in quarter units, from the superior end plate of one vertebrae (black line) to the superior end plate of the next, ideally, 2,00 vertebrae below the carina. When catheter curves are more pronounced (obese patient, bulky mediastinal tumour, age 50 years), the catheter tip may be placed 1 to 2 cm below the regular position due to the risk of liberation of catheter elasticity 2337 Table 2 Chart of venous access Target vein Prime indication 2nd option 3rd option Contra indications RIJV* Hypercoagulable Left IJV or SCV Contralateral SCV Chest port C.I. Haemodialysis Arm veins Head and neck tumour SCV occlusion Ventriculo-peritoneal shunt Junior operator SCV** IJV occlusion Contralateral SCV Contralateral arm veins Chest port C.I. Senior operator Upper limb oedema Slim patient Arm veins Haemodialysis# ARM Veins*** Head and neck/breast tumour Contralateral Left IJV or contralateral SCV Haemodialysis# Upright/obesity RIJV or SCV Upper limb oedema Cosmesis/discretion Bone metastasis *Right IJV access has the highest (feasibility/procedural complication) ratio even in junior operators. Advantages over SCV access include a lower risk of pneumothorax and venous thrombosis and no risk of pinch-off syndrome. Also, RIJV access has the lowest rate of catheter malposition among all procedures (see Table 3) **SCV access is more operator- (learning curve) and patient-dependant (easier in slim patients) than IJV access ***Arm vein access has specific indications including head and neck and breast cancer patients [9, 10] #SCV and arm veins should be preserved in patients who may require haemodialysis Contraindications (CI) to chest port insertion include respiratory insufficiency, radiodermatitis, tracheostomy, superior vena cava syndrome and severe kyphosis following venous thrombosis mechanical and septic complications. Indwelling venous catheters may affect all three arms of Virchow s classical triad by alterating blood flow, damaging endothelial cells (catheter tip motions, loops and angulation) and serving as the surface upon which procoagulants promote thrombosis. Type of needle puncture (Fig. 2), number of needle attempts, left access and tip location (Figs. 6b, 8) (catheter/vein diameter) ratio, venous Fig. 5 Fluoroscopy guidance helps to prevent catheter malposition during SCV access. Note the unexpected catheterisation of the IJV (a) and sharp catheter tip angulation (b-contrast medium injection). Asking the patient to cough and using a guidewire will help to catheterise the right inominate vein (c) down to the atriocaval junction. Upper mediastinum CT sections (d,e) show a nipple-like compression of the SCV (arrow) by a tortuous arterial brachocephalic trunk (triple arrow). Goiter and bulky mediastinal tumours may also increase the risk of catheter malposition when image guidance is not used compression/invasion, type of fluid infusion and patient performance status may influence the risk of thrombosis [28, 35]. Regarding mechanical complications, imaging means can diagnose and treat most of them [36 38]. Every effort must be made to keep the central venous access functional. As a matter of fact, the sites of venous access become depleted as patients live longer and their primary cancer is treated. According to the literature data, there is no consensus concerning port flushing as monthly maintenance seems excessive and expensive. The rule is to perform catheter flushing before and after use, and to remove the device when it is no longer useful. Chest X-ray will document any mechanical complication. Catheter occlusion/dysfunction is defined as the inability to aspirate blood and/or freely inject fluid. Patients are brought to the interventional suite to assess catheter course and tip location, to depict any fibrin sheath (Fig. 7a), catheter misplacement (Figs. 6b c, 7a c, 10a) and pinching (Fig. 7b) [23]. Fibrin sheath occlusion can be treated by local fibrinolysis and percutaneous catheter stripping [38]. Fluoroscopy permits accurate positioning, but it does not completely prevent secondary catheter malposition. Secondary significant shifts in the catheter course have been described in the following: chest ports in obese women with large pendular breasts (Fig. 1a) [39, 40], left-sided access (Fig. 6b) [28], central vein tortuosity (old obese patient, bulky mediastinal tumour; Fig. 5), when the patient changes from the supine to upright position [39, 40] and during inspiration, expiration or coughing, and abduction of the patient s arm [41]. Those situations may lead to port 2338 3Fig. 6 a Chest fluoroscopy guidance helps to test the catheter elasticity reserve. When the catheter backend is pushed 1 cm, elasticity will cause its tip (arrow) to move further down another 2 cm (left access, obese patient, central vein kinking). b 3D- coronal MIP-CT reformation of the chest in a dyspneic cancer patient presenting with a too short implanted catheter. Incidence of SVC occlusion ranges from 3% to 29% when the catheter tip is located respectively in the right/left inominate vein [28]. c Chest scout-view and axial CT section, blind EJV access. Cancer patient presented with cardiac arrhythmia due to a too long implanted catheter. Adequate catheter length trimming is mandatory malfunction and fracture, venous thrombosis [28], perforation [42],
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