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Management of Catheter-Related Complications: Perspective of an Interventional Radiologist

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

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Management of Catheter-Related Complications: Perspective of an Interventional Radiologist

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  1. 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

  2. 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

  3. Interventional Radiology • Evaluation of dysfunctional catheters • Treatment of catheter-related complications • - infection : catheter exchange • - stenosis : angioplasty / stents • - thrombosis : thrombolysis • Foreign body retrieval

  4. Evaluation of Dysfunctional Catheters Inspection - infection - catheter integrity Fluoroscopy - tip position - kinks Contrast injection - thrombus - fibrin sheath catheter tip in pulmonary artery

  5. Inspection of Catheter and Skin Exit Site Infected port exposed port purulent drainage from tunnel

  6. Catheter Related Venous Thrombosis

  7. Inspect Pinch Clamps Hemodialysis catheter kinked tubing Pinch clamps must be periodically moved to avoid causing permanent kinks in tubing

  8. Bring patient into angiography suite for fluoroscopy and contrast injection.

  9. Angiography Suite Portable ultrasound unit fluoroscopy

  10. 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

  11. Fluoroscopy of the entire catheter Patient referred because of difficulty with removing wire from PICC following the insertion procedure.

  12. severely twisted PICC

  13. Unusual appearance of PICC within the left arm.

  14. Course of PICC suggests left subclavian artery

  15. Pulsatile blood flow from PICC insertion site

  16. Yikes !!!! Who put in that PICC ?

  17. Kinked Catheters kinked tips kinked lumen High resolution fluoroscopy may be necessary to identify subtle kinks in the catheter lumens

  18. Use of an extra-stiff guidewire to reduce a kink in a central venous catheter extra stiff guidewire kink kink is reduced

  19. Snares • Used for intravascular retrieval / manipulation • Snare loop at 90° to shaft of guidewire • Nitinol - kink resistant • Used within snare catheter

  20. Catheter Tip RepositioningUse of an Endovascular Snare

  21. catheter looped into right internal jugular vein right chest port

  22. attempting to snare the catheter snare is used to pull catheter into position right femoral vein venous access site

  23. The loop in the catheter has been removed.

  24. Foreign Body Retrieval catheter snapped off Removal of broken catheter fragments.

  25. Snare inserted from the femoral vein

  26. pulled into the IVC and out of the femoral vein catheter fragment is pulled through the right atrium

  27. Evaluation of Dysfunctional Catheters Poorly functioning port. Port inserted through the right subclavian vein. Catheter tip in the SVC. “Ballooning” of catheter when injected

  28. “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

  29. “Pinch-Off” PhenomenonA Complication of Subclavian Catheters fractured port catheter due to “Pinch-Off” fractured port catheter

  30. Injection of X-ray Contrastto Evaluate the Dysfunctional Catheter

  31. 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

  32. 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

  33. 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

  34. High-Performance Hemodialysis Catheters Vaxcel Dura-Flow Maxid Ash Split Xpresso Hemostream

  35. Injection of venous (distal) lumen of a tunneled hemodialysis catheter

  36. port catheter Injecting x-ray contrast through the catheter will provide visualization of the catheter tip and surrounding venous anatomy. thrombus surrounding catheter tip

  37. Injection of arterial (proximal) lumen of a tunneled hemodialysis catheter

  38. 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

  39. Catheter-Induced Venous Stenosis

  40. Non-Aspirating Catheter (Port) Port catheter tip abutting vein

  41. 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.

  42. leakage of contrast Contrast injected through the catheter demonstrates prompt leakage from one lumen.

  43. Obstruction of Central Venous Catheters vein catheter tip thrombus

  44. Catheter Obstruction Thrombotic Mechanical • Catheter is kinked • Catheter malposition • Drug precipitation • Pinch-off syndrome kink

  45. 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

  46. Types of Thrombotic Occlusion catheter vein Intraluminal thrombus Thrombus or fibrin tail Fibrin Sheath

  47. Intraluminal Thrombus

  48. Thrombolytic Agents Injecting CathFlo into occluded catheter lumen

  49. 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.

  50. 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

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