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Central Venous Catheters: A Closer Look at the Subclavian ... · Amr Mahmoud Abdel Samad, Yosra...
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CASE REPORT Central Venous Catheters: A Closer Look at the Subclavian Vein Approach KEVIN SUN, MD; GREGORY M. SOARES, MD KEYWORDS: Central venous catheter, Subclavian vein, internal jugular vein INTRODUCTION Central venous catheters (CVCs) are commonly used and have a range of outpatient and inpatient indications. A subclavian vein approach has tradi- tionally been used for placement of these cathe- ters; however, this method exposes the patient to the high risk of subclavian stenosis as well as an increased risk for catheter fracture. In this report, we describe a patient with a chemotherapy port placed in the subclavian vein that underwent spon- taneous fracture. We therefore advocate for the use of an internal jugular approach for CVCs. CASE REPORT A 62-year-old man with a history of Kaposi’s sar- coma was referred to interventional radiology for a percutaneous chemotherapy port study. The per- cutaneous port was originally placed through the left subclavian vein for adjuvant chemotherapy. Port malfunction was first noticed during a routine follow-up appointment with the patient’s hematol- ogy oncologist. Blood return was sluggish and there was a noticeable soft lump at the upper sternum after flushing. A Port study was performed under fluoroscopic guidance. The initial AP view of the chest (Figure 1) revealed luminal narrowing and “pinch off” sign at the intersection of the clavicle and first rib. Digital subtraction acquisition with contrast confirmed the location of the fracture (Fig- ure 2). Contrast extravasation was documented at the location of the soft swelling. (Figure 3). The device was removed in the interventional radiology suite. Gentle traction was used to remove the cath- eter, given the known damage and possible risk for embolization of the catheter tip. Upon removal, parallel 1cm long longitudinal fractures were iden- tified at the fluoroscopically identified point of extravasation (Figure 4). Figure 1. AP chest under fluoroscopy showing a chemotherapy port placed in the subclavian vein illustrating the “pinch off” sign. Fracture occurred at the location of the clavicle and first rib. Figure 2. Digital subtraction angiography showing extravasation of contrast revealing the catheter fracture. 31 MAY 2018 RHODE ISLAND MEDICAL JOURNAL RIMJ ARCHIVES | MAY ISSUE WEBPAGE | RIMS 31 MAY 2018 RHODE ISLAND MEDICAL JOURNAL RIMJ ARCHIVES | MAY ISSUE WEBPAGE | RIMS
Transcript of Central Venous Catheters: A Closer Look at the Subclavian ... · Amr Mahmoud Abdel Samad, Yosra...
CASE REPORT
Central Venous Catheters: A Closer Look at the Subclavian Vein ApproachKEVIN SUN, MD; GREGORY M. SOARES, MD
KEYWORDS: Central venous catheter, Subclavian vein, internal jugular vein
INTRODUCTION
Central venous catheters (CVCs) are commonly used and have a range of outpatient and inpatient indications. A subclavian vein approach has tradi-tionally been used for placement of these cathe-ters; however, this method exposes the patient to the high risk of subclavian stenosis as well as an increased risk for catheter fracture. In this report, we describe a patient with a chemotherapy port placed in the subclavian vein that underwent spon-taneous fracture. We therefore advocate for the use of an internal jugular approach for CVCs.
CASE REPORT
A 62-year-old man with a history of Kaposi’s sar-coma was referred to interventional radiology for a percutaneous chemotherapy port study. The per-cutaneous port was originally placed through the left subclavian vein for adjuvant chemotherapy. Port malfunction was first noticed during a routine follow-up appointment with the patient’s hematol-ogy oncologist. Blood return was sluggish and there was a noticeable soft lump at the upper sternum after flushing. A Port study was performed under fluoroscopic guidance. The initial AP view of the chest (Figure 1) revealed luminal narrowing and “pinch off” sign at the intersection of the clavicle and first rib. Digital subtraction acquisition with contrast confirmed the location of the fracture (Fig-ure 2). Contrast extravasation was documented at the location of the soft swelling. (Figure 3). The device was removed in the interventional radiology suite. Gentle traction was used to remove the cath-eter, given the known damage and possible risk for embolization of the catheter tip. Upon removal, parallel 1cm long longitudinal fractures were iden-tified at the fluoroscopically identified point of extravasation (Figure 4).
Figure 1. AP chest under fluoroscopy showing a chemotherapy port placed in the
subclavian vein illustrating the “pinch off” sign. Fracture occurred at the location of
the clavicle and first rib.
Figure 2. Digital subtraction angiography showing extravasation of
contrast revealing the catheter fracture.
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DISCUSSIONVarious factors leading to catheter fracture have been rec-ognized. It has been well established that catheters placed in the subclavian vein are exposed to high mechanical fric-tion from the clavicle and first rib. 1 Compressive forces can cause transient obstruction. Over time, repetitive stress on the catheter causes structural degradation leading to frac-ture. Previously reported incidences for catheter fracture have ranged from .1–1.3%.2,3
Occult fracture may first be noticed with difficulty admin-istering or aspirating fluid through the line. More serious symptoms may present as extravascular administration of medications through the fractured line or embolization of the catheter tip.
Early diagnosis of catheter fracture is key to manage-ment. Chest x-ray can provide the earliest radiographic evi-dence for possible catheter fracture with a positive “pinch off” sign. Patients with a positive “pinch off” sign have an estimated 40% risk for catheter fracture and such catheters should be removed and replaced using another vessel.4 If fracture is suspected and complete transection has occurred, the patient should undergo emergent percutaneous retrieval by interventional radiology, which has been shown to be a highly successful and safe procedure.5
Catheter fractures are a rare event. Stenosis is a more com-mon and insidious complication of subclavian venous cath-eter placement. Venous stenosis in the setting of subclavian catheters has a reported incidence of 32–50%, typically seen with catheters used for greater than 2 weeks of duration.6,7
The mechanism for stenosis is catheter-induced throm-bosis and intimal fibrosis due to the presence of a foreign
Figure 3. Extravasation of contrast into the subcutaneous tissue. Figure 4. Extent of the catheter fracture after removal.
object in a narrow vessel lumen at the restricted anatomic space between the first rib and clavicle. Utilization of larger caliber vessels such as the internal jugular vein for catheter placement has been shown to minimize this complication, with reported stenosis rates as low as 3%.8
Though the subclavian vein has been the preferred site for many proceduralists, given the evidence of complica-tions with long-term use, many have advocated for the internal jugular vein as the first-line approach. 1,9,10 It is well documented that an internal jugular approach with image guidance provides a safe and reliable method for long-term central venous catheters. The course of the internal jugular vein is free of anatomic features that may cause compression or catheter damage. It has a large caliber and high flow to reduce the risk for thrombosis. Other risks such as infection are comparable to the subclavian approach, while pneumo-thorax risk is diminished. 11 Finally, complications such as brachial plexus injuries and thoracic duct injuries are unique to a subclavian catheter and are also avoided.
CONCLUSIONCentral venous catheter placement through the subclavian vein has a high rate of vein stenosis and increased risk for catheter fracture. Catheter fracture is less common, but may lead to dangerous complications such as extravascular extrav-asation of medication or embolization. Subclavian stenosis can severely limit venous access which becomes problem-atic for patients requiring long-term parenteral therapy. The Internal Jugular approach with imaging guidance minimizes risk and provides a proven, safe and reliable alternative.
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4. Fazeny-Dörner B, Wenzel C, Berzlanovich A, Sunder-Plassmann G, Greinix H, Marosi C, Muhm M. Central venous catheter pinch-off and fracture: recognition, prevention and management. Bone Marrow Transplant. 2003 May;31(10):927-30. Review.
5. Dinkel HP, Muhm M, Exadaktylos AK, Hoppe H, Triller J Emer-gency percutaneous retrieval of a silicone port catheter fragment in pinch-off syndrome by means of an Amplatz gooseneck snare. Emerg Radiol. 2002 Sep;9(3):165-8.
6. Beenen L, van Leusen R, Deenik B, Bosch FH. The incidence of subclavian vein stenosis using silicone catheters for hemodialy-sis. Artif Organs. 1994 Apr;18(4):289-92.
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8. Surratt RS, Picus D, Hicks ME, Darcy MD, Kleinhoffer M, Jen-drisak M. The importance of preoperative evaluation of the sub-clavian vein in dialysis access planning. AJR Am J Roentgenol. 1991 Mar;156(3):623-5.
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AuthorsKevin Sun, MD, Department of Internal Medicine, Roger Williams
Medical Center, Providence, RI.
Gregory M. Soares, MD, Associate Professor of Diagnostic & Interventional Radiology, Warren Alpert Medical School of Brown University; Rhode Island Medical Imaging.
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