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

www.vascularaccessdoc.com

Tom Vesely, M.D.veselyt@wustl.edu