Journal of Vascular and Endovascular Therapy

Description

There is continuing debate among physicians, nurses, and federal regulatory agencies regarding the correct position for the tip of a central venous catheter. The traditional approach has been to place the catheter tip within the superior vena cava. However, many internationalists believe that the performance and durability of the catheter will be improved by positioning the catheter tip within the upper right atrium. Recently, this variability in clinical practice has become an increasingly divisive issue among physicians who insert these catheters and nurses who use them. This article is intended to elucidate the controversial issues and provide a brief review of the extensive literature on this important topic. The complications of central venous catheterization are discussed in a review of experience and of the literature. The anatomy surrounding the subclavian and internal jugular veins is described. Indications and contraindications of catheterization are reported. Common and unusual complications are discussed and illustrated. Laceration of pleura, subclavian artery puncture, hematoma, catheter malposition, fragment embolization, air embolism, venous thrombosis, and infection are included. The radiologist is responsible for recognizing immediate, as well as delayed, complications of central venous catheterization.

Thrombogenicity

Twenty-five previously unreported cases of CT from CVC were reviewed. The chest radiographs and post-mortem records were reviewed when available. Two hundred physicians were interviewed about their knowledge of CT from CVC. They were specifically asked if they had reviewed the three-volume video, “CVC Complications,” that was sent by the Food and Drug Administration to all hospitals where CVC are inserted. Four studies were performed to evaluate the thrombogenicity of different central venous catheter materials. Two of these studies consisted of evaluating the amount of platelet deposition on different catheter materials, firstly in vitro and then in vivo using dogs. In these studies, 51-chromium was used to label the platelets. In the following study, the volume of clot and the degree of fibrin sheath were determined by placing catheters in both arteries and veins of dogs for two to four weeks before removing the vessels and performing a quantitative analysis. For the fourth study, indium labelled platelet deposition with scintillation counting was performed on six dogs in whom catheters had been placed in the femoral and carotid arteries. The vessels in three of these animals were removed 48 hours after imaging was completed to correlate the scintigraphic findings with a quantitative analysis of the clot and fibrin sheath on each catheter. There was a high degree of correlation between all these studies. The most consistently thrombogenic catheter material was polyurethane, and the least thrombogenic catheter material was polyurethane coated with hydromer. Silicone was the next least thrombogenic material examined. Central venous catheters have become indispensable for the management of the critically ill patient and for the delivery of parenteral nutrition and chemotherapy. Unfortunately, infection of the central line can be a dangerous complication of this therapy. The various techniques of central venous catheterization are reviewed, with particular attention to the infectious complications

Hemodialysis

Central venous catheters (CVCs) are used to provide temporary or long-term vascular access. They are useful in the management of various conditions, such as those requiring regular blood sampling, total parenteral nutrition, chemotherapy, and long-term antibiotics. Tunnelled hemodialysis CVCs are undesirable when compared to native arterio-venous fistulae, but may sometimes be required.1, 2, 3 The emergence of image-guided vascular access has brought the insertion and the management of CVCs into the realm of interventional radiology, with the advantages of shorter procedure times, techniques for placement in difficult cases, and reduced complication rates.4, 5, 6 The aim of this review is to describe the range of complications associated with CVCs and to discuss the radiological catheter salvage techniques. PICCs are essentially long intravenous lines that are inserted in a forearm or upper arm vein and extend to the distal superior vena cava (SVC). They are commonly used for intermediate term indications such as chemotherapy. In many UK hospitals, PICCs are inserted by clinical nurse specialists, with radiological involvement for the more difficult cases, so obviating the need for an internal jugular or subclavian approach. Temporary nontunnelled CVCs are usually inserted in the internal jugular, subclavian or femoral veins and are typically for short-term access. This type of catheter is usually used for drug delivery, haemodynamic monitoring and short-term haemodialysis. Temporary non-tunnelled CVCs insertion is usually performed by many different teams within the hospital, including anaesthetists, intensivists, physicians and surgeons.