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9 Central Venous Access
123
while surgeons may employ a surgical cutdown technique
(with an associated 70–94% success rate) or percutaneous
techniques with or without image guidance. IRs also use
uoroscopy to guide catheter tip placement, while this is
not readily available in an OR during surgical placement
[29, 30]. Once again, results indicated radiologic placement was effective and comparable to surgical placement.
Initial studies showed radiologic placement of chest ports
was successful in 99–100% of cases, with similar, and in
some cases favorable, complication rates between ports
placed radiologically and those placed surgically [30, 31].
As IRs improved their techniques through use of the jugular vein for access (rather than the cephalic/subclavian
veins) and ultrasound guidance for venous puncture, the
rate of complications such as pneumothorax and arterial
puncture decreased below that of surgically placed chest
ports [32]. When all other venous access points fail, ports
can be placed in alternative locations such as translumbar
to maintain long-term venous access for the patient.
IR offers benets in port placement similar to those
offered for tunneled catheters in terms of cost reduction, as
both radiologically placed arm ports and chest ports were
found to be 50–60% cheaper than surgical chest ports due to
the elimination of operating room, anesthesia, and recovery
room costs [21, 33]. The ease of scheduling in the IR suite
compared to the operating room also allows expedited port
placement for referred patients [28].
PICCs
As mentioned earlier, PICCs were traditionally inserted into
veins of the antecubital fossa, at or below the elbow, via
palpation, and advanced through the veins of the upper arm,
eventually reaching the central veins. Therefore, poor
venous access at or below the elbow would exclude a patient
from receiving a PICC. This changed in 1992, when
Andrews etal. reported their experience placing PICCs in
the veins of the upper arm. The idea had come from the
author’s experience placing arm ports, where it was noted
that patients with inadequate venous access below the elbow
would often maintain patent veins in the upper arm that
were suitable for catheter placement [22]. These veins are
not easily seen or palpated and were therefore not previously used for bedside PICC or IV placement. Fluoroscopy
allowed visualization of these vessels and resulted in the
successful placement of PICCs in the upper arm in 99% of
patients [22]. Since that time, ultrasound has replaced uoroscopy for vessel visualization and puncture guidance during PICC placement as it is less invasive (uoroscopy
required an additional lower-arm IV for contrast administration) and does not require contrast or an IR suite. While a
number of studies later showed that ultrasound-guided
PICC placement by IRs resulted in higher primary success
rates than ultrasound-guided bedside placement, bedside
teams remain highly successful, with primary placement
rates exceeding 90% [34]. Additional advances, such as
catheter tip tracking devices, have further increased bedside
accuracy and success. As bedside placement has proven reliable, the substantial number of PICCs required by inpatient
services and the increased cost of IR placement compared to
bedside placement have resulted in the continued placement
of the large majority of PICCs by bedside nursing teams. In
many hospitals, IR’s role is limited to a supportive one,
placing those PICCs in which bedside placement has failed,
in patients where peripheral access is contraindicated to
reserve or protect peripheral veins (e.g., end-stage renal disease) or in patients with conditions making PICC placement
more complex [8, 34].
IR’s Increasing Role inCentral Venous Access
As evidence built for interventional radiology’s ability to
deliver safe and reliable central venous access in less time
and at less expense than other specialties, IR’s role in placing
these devices increased exponentially. In 2011, IR placed
32.6% of temporary central catheters (NTCCs and PICCs)
and 37.6% of long-term central catheters (TCCs and ports)
compared to 0.4% and 0.7% in 1992 [3]. IR is now the primary provider of tunneled catheters, placing nearly 50% of
all TCCs, the remainder being placed largely by surgery, and
is responsible for placing increasing percentages of NTCCs
and ports.
Pre-procedural Prep
History
When considering central venous access for a patient, a thorough history can reveal a number of ndings to guide one’s
clinical decision-making. A good history should include
questions regarding prior venous access, including type and
location, and whether the patient has any history of venous
disease, such as venous thrombosis, and any history of bleeding disorders. Medications should be reviewed and note
should be made of any anticoagulant or antiplatelet agents. A
thorough past medical history can reveal the presence of conditions pertinent to venous access decision-making, such as
chronic kidney disease (consider vein preservation for future
124
D. M. DePietro and S. O. Trerotola
Fig. 9.6 Ultrasound images of different venous access sites. (a)
Ultrasound image of a patent internal jugular vein (blue dotted line) and
carotid artery (red dotted line). (b) Ultrasound image of a thrombosed
internal jugular vein (blue dotted line) and patent carotid artery (red
arteriovenous stula formation), chronic TPN/cystic brosis
(often an extensive history of prior venous access is present
in such patients), or prior radiotherapy (leading to scarring/
stenosis). A surgical history should reveal whether any procedures that may alter venous anatomy have been performed.
As with any clinical decision, the patient or healthcare proxy
should be involved in all aspects of decision-making. Patients
may have preferences regarding what type of device would
least interfere in their lifestyle while still meeting their treatment goals, may prefer a device on their right or left side, and
may have concerns regarding the maintenance of a central
venous catheter once it is placed [5]. The patient should be
counseled regarding both the immediate risks of placing a
central venous access device and the long-term complications of such devices, as well as alternatives.
Key Point
Pertinent PMH/PSH:
• CKD
• History of extensive prior venous access
• Radiotherapy including planned therapy
• Bleeding disorders
• Venous disease
• Lymphatic disease
• Vascular surgery
dotted line). (c) Ultrasound image of the basilic vein (blue dotted line),
brachial veins (blue dashed lines), brachial artery (red dotted line), and
humerus (white dotted line)
Physical Exam
The physical exam should focus on the venous system. One
should look for evidence of prior venous access, such as
scars from prior catheter placement, and signs of venous
obstruction (collateral veins in the arms, legs, or chest as
well as unilateral swelling in the extremities). One should
make note of any cardiac devices (pacemaker/AICD), as
these may affect the available veins for central venous access.
Imaging
Duplex Doppler ultrasonography can provide useful information regarding the patency of the veins of the upper
extremities and neck (and less commonly the lower extremities) when planning central venous access (Fig. 9.6). A
review of any relevant prior imaging, such as CT, MR, or
prior venography, should be performed prior to central
venous access placement as it may aid in the placement of
the device.
Labs andCoagulation Guidelines
Guidelines will vary between institutions, and each institution may have their own specic guidelines for pre- procedural
labs and medications depending upon available recommendations, literature, and attending preference. The Society of
Interventional Radiology (SIR) guidelines are included
below.
PICCs and NTCCs are considered to be low risk for
bleeding. The SIR guidelines for percutaneous image-guided
interventions recommend the following [35]:
9 Central Venous Access
125
• Check INR in patients receiving warfarin; INR goal is
<2.0.
• Check PTT in patients receiving IV unfractionated heparin. Goal PTT should be <1.5 times the control.
• Platelet counts are not routinely recommended, but transfusion is recommended if platelet counts are <50,000/μL.
• Do not withhold aspirin or other antiplatelet agents.
• Low molecular weight heparin (therapeutic dose) should
be withheld for one dose.
Tunneled catheters and ports are considered to be moder-
ate risk for bleeding. The SIR guidelines for percutaneous
image-guided interventions recommend the following [35]:
• Check INR in all patients. INR goal is <1.5.
• Check PTT in patient receiving IV unfractionated heparin; goal PTT should be <1.5 times the control.
• Platelet counts are not routinely recommended, but transfusion is recommended if platelet counts are <50,000/μL.
• Do not withhold aspirin.
• Withhold antiplatelet agents for 5 days before the
procedure.
• Low molecular weight heparin (therapeutic dose) should
be withheld for one dose.
Determining aVenous Access Site
The internal jugular vein (IJV) is the preferred insertion site
for NTCCs, TCCs, and ports as it provides the lowest risk of
thrombotic complications and pneumothorax [10, 36]. The
right IJV is preferred over the left as it has a more direct
route to the cavoatrial junction. If the IJVs cannot be
accessed, the external jugular veins may be used. Use of the
subclavian vein (SCV) is associated with a higher risk of
pneumothorax and thrombosis when compared to IJV access.
It carries a risk of “pinch-off” with TCCs and ports (fracture
of subclavian catheters due to compression between the clavicle and rst rib) but may be used if the jugular veins cannot
be accessed [10, 36]. Femoral venous access is associated
with an increased risk of infection and is used only in specic situations, such as emergencies and when other access
sites have failed [10]. The basilic vein is generally preferred
for PICC placement. The brachial vein is the second choice
as it has a theoretically increased risk for arterial and nerve
injury as it lies next to the brachial artery and median nerve.
The cephalic is the vein of last choice as it is prone to spasm
and thrombosis [37]. Veins of the non-dominant arm are typically preferred by the patient.
Special Considerations RegardingVenous Access
Sites
While IRs avoid the subclavian vein in nearly all patients
secondary to its associated risks (pneumothorax, thrombosis,
pinch-off), it is particularly important in patients who are or
may become dialysis dependent to prevent subclavian vein
thrombosis or narrowing. This can lead to arm, face, or breast
swelling once a dialysis stula/graft is created in the ipsilateral arm [10, 36]. PICCs are also absolutely contraindicated
in this population, as PICCs frequently result in venous
thrombosis and arm veins should be preserved for future
arteriovenous stula formation [8]. An alternative to PICC
placement in this population is a small-bore (4-5 Fr) tunneled central catheter, which is inserted into the jugular vein
[38–40]. These are also indicated in other populations when
there are no available peripheral veins and a large-bore central catheter is not indicated.
Complex Venous Access
Patients may have thrombosis or stenosis of preferred venous
access sites for a variety of reasons, the most common being
previous central catheter placement (particularly in dialysis
patients and chronically ill patients). Establishing long-term
venous access in such individuals is essential. Recanalization
of the preferred central veins through balloon dilation of stenoses +/− stent placement is often a consideration. If recanalization efforts fail, alternative sites for access include the
translumbar IVC, collateral veins, direct brachiocephalic
vein puncture, and transhepatic IVC (last choice due to poor
results) [41–43].
Post-procedural Management
As IRs become the dominant player in central catheter placement, we must also maintain the responsibility of caring for
these catheters as well as their future removal. Proper catheter ushing is necessary to maintain catheter patency. The
frequency of ushing and the use of saline or heparin ushes
are dependent upon catheter type and local practice. Insertion
site care is imperative in decreasing catheter-associated
infection and is also catheter dependent. The provider and
care team should be well educated in these matters and provide proper patient education for device self-care. Patients
with long-term central venous access should follow-up with
IR in the outpatient setting for proper post-procedural management of the device and regarding removal of the device
when appropriate.
126
D. M. DePietro and S. O. Trerotola
The How To: Achieving Central Venous Access
The common steps for initial central venous access are
described, followed by specific steps for the placement
of NTCCs, TCCs, and ports followed by a separate
section for the placement of PICCs.
1. Confirm patency of the access vein with ultrasound.
Surgically prep the venous access site.
2. Using the Seldinger technique discussed in Chap. 8,
access the appropriate vein under ultrasound guidance.
Successful puncture will result in the free return of
venous blood return into the syringe.
3. Under fluoroscopic guidance, advance a 0.018 in. wire
into the IVC. Remove the micropuncture needle over
the wire and place the coaxial micropuncture sheath
4. Remove the inner core of the micropuncture sheath
along with the wire, and place a 0.035 in. stiff wire
such as a Rosen into the right atrium or IVC, again
under fluoroscopic guidance
The How To: Non-tunneled Catheters
1. Once venous access is achieved, advance a dilator over
the wire.
2. Advance an appropriate length catheter over the wire.
A 15 cm catheter is typically used for the right IJV, but
measurement is recommended using the 0.018
micropuncture wire prior to selecting a catheter length.
Remove the wire and assess catheter tip position,
ideally at the cavoatrial junction, although for
hemodialysis catheters atrial position is preferred.
3. Verify catheter function via aspiration. Suture the
catheter to the skin. Flush and dress the catheter per
local protocol.
Key Point
It is always good practice to use fluoroscopic
guidance whenever advancing a dilator over the wire
to avoid injuring the vessel. Always stop if you meet
resistance.
The How To: Tunneled Catheters
1. Once venous access has been achieved, anaesthetize
the planned subcutaneous tract where the catheter
will be tunneled.
2. Make a small incision in the chest wall where the
external portion of the catheter will enter the skin.
Advance the tunneling device through this incision
toward the venotomy site.
3.
Attach the catheter to the end of the tunneling
device and pull the catheter through the subcutaneous tunnel exiting at the venotomy site. The
catheter may be attached prior to tunneling and is
based on operator preference. Using blunt dissection,
ensure that there is no skin or fibrous tissue between
the catheter and venotomy site which may result in
catheter kinking once placed. The polyester cuff should
lie 1–2 cm from the skin entry site.
4. Advance a dilator over the wire, then advance an
appropriately sized peel-away sheath over the wire
under fluoroscopic guidance.
5. Remove the wire and dilator. If no aerostatic valve is
present, maintain aerostasis by pinching the sheath
or placing your finger over the opening. Advance the
catheter through the peel-away sheath until the tip of
the catheter lies in the RA. “Crack” the peel-away
sheath to remove it and position the catheter tip to
the desired location, which will be mid-right atrium
for most patients receiving infusion catheters and
low right atrium for hemodialysis catheters [8, 44].
6. Close the neck venotomy site with surgical glue (pre erred) or absorbable suture.
7. Verify catheter function via aspiration. Suture the
catheter to the skin. Flush and dress the catheter per
local protocol.
Key Point
A simple aspiration technique can be used to assess
adequate hemodialysis catheter flow after placement.
With the catheter clamp closed, pull back on the
plunger of an attached 20 ml syringe and open the
clamp. Measure the time it takes to fill the syringe.
Less than 2 s to fill the syringe is highly
sensitive and specific for predicting adequate catheter
flow [45].
9 Central Venous Access
127
The How To: Ports
1. Once venous access has been achieved, anesthetize
both the planned subcutaneous pocket that will
house the port and the tunneling tract.
2. Make an appropriately sized incision at the planned
port site and create a subcutaneous pocket to house
the port using blunt dissection. Size depends on if
the port is single or dual lumen. Advance a tunneling
device from the pocket toward the venotomy site.
3. Attach the catheter to the end of the tunneling device
and pull the catheter through the subcutaneous tunnel.
4. Advance a dilator over the wire, and then advance an
appropriately sized peel-away sheath over the wire.
5. Remove the wire and dilator. If no aerostatic valve is
present, maintain aerostasis by pinching the sheath or
placing a finger over the opening. Advance the cathe ter through the peel-away sheath until the tip of the ca theter lies in the right atrium. Remove the peel-away
sheath and position the catheter tip to the desired loca tion, which for most patients will be the mid-right
atrium [44].
6. Cut the catheter tubing at the level of the port pocket,
attach the catheter to the port reservoir, access and
check the port for leaking/normal function, and then
place the port in the subcutaneous pocket.
7. Close the port pocket with a two-layer closure (deep
dermal absorbable suture and surgical glue). Close
the neck venotomy site with surgical glue (preferred)
or absorbable suture.
8. Verify port function by accessing with a noncoring
(Huber) needle and aspirating. Instill an appropriate
volume heparin solution into the reservoir. Dress the
site, keeping needle in place if therapy is imminent or
removing needle if not.
Key Point
Port catheters that are too long were previously
removed, as there was no way of shortening catheter
length without port removal and reinsertion. However, new techniques describing percutaneous revision and shortening of port catheter lengths have been
developed, allowing for uninterrupted port use [46].
The How To: PICCs
1. Place a tourniquet on the upper arm. Under ultrasound
guidance, advance a micropuncture needle into the
vein, several cm above the elbow to avoid crossing
the joint.
2. Under fluoroscopic guidance, advance a 0.018 in.
guidewire centrally. Remove the needle.
3. Advance the peel-away sheath over the wire.
4. Use the guidewire to measure the appropriate length of
catheter. The ideal PICC tip position is at or just below
the cavoatrial junction. Remove the guidewire and trim
the catheter to the appropriate length.
5. Advance the catheter through the peel-away sheath,
with the aid of a stiffening stylet or guidewire if neces sary. “Crack” the peel away-sheath and remove it.
6. Verify catheter function. Secure the catheter to the skin
with an adhesive lock or suture. Flush and dress the
catheter per local protocols.
Key Point
The final step of every catheter placement is to capture
a completion spot image to document proper catheter
tip position. Proper tip positions for a supine patient
are detailed below:
• NTCC: cavoatrial junction
• TCC/Port: mid-right atrium
• HD catheter: low right atrium
• PICC: at or just below the cavoatrial junction
(assuming arm abducted)
Complications
Key Point
Acute complications:
• Pneumothorax
• Hemothorax
• Air embolism
Chronic complications:
• Fibrin sheath formation
• Catheter-related thrombosis
• Infection
128
D. M. DePietro and S. O. Trerotola
Acute Complications
• Pneumothorax: Extremely rare (<1/10,000) with realtime US-guided puncture. Results from needle puncture
of the pleura. The presence of pneumothorax can be
immediately assessed under uoroscopy [4]. Treatment
may require placement of a chest tube (discussed in
Chap. 42).
• Hemothorax: Extremely rare (<1/10,000) with real-time
US guidance. Results from needle or guidewire perforation of the vein or adjacent artery. Can be recognized on
uoroscopy.
• Air embolism: Occurs in up to 1% of tunneled catheter
and port insertions even with imaging guidance. Occurs
when intrathoracic pressure drops during catheter insertion. Decrease risk by using aerostatic sheaths or by
pinching the peel-away sheath after dilator and guidewire
removal [47, 48].
Long-Term Complications
• Fibrin sheath formation: Common cause of catheter
malfunction, often related to tip malposition/suboptimal
position. Catheters can typically infuse but not aspirate.
Fibrinolytics and vigorous injection may be helpful, but
denitive treatment is an over-the-wire catheter exchange
with brin sheath disruptionunless the affected device is
a port, in which case transfemoral brin sheath stripping
can be effective [48, 49].
• Catheter-related thrombosis: May result in SVC syndrome or arm swelling but most often presents as a “stiff
neck” as only the IJ is thrombosed. The symptoms of
SVC syndrome include swelling and venous distension in
the upper extremity, face, or neck, skin discoloration,
numbness, and tingling [48, 50]. Management varies with
severity of symptoms.
• Infection: Can occur at catheter exit site, tunnel (if present),
or in the bloodstream (central line-associated bloodstream
infection or CLABSI). Common causative agents are coagulase-negative Staphylococcus and Staphylococcus aureus
[50]. Catheter-associated sepsis has a high mortality rate
[6]. Management varies by catheter type but typically the
line is removed for source control.
Key Point
Infection risk: NTCC > TCC/PICC > Port.
Device Removal
As mentioned earlier, removal of central venous access
devices is the responsibility of those who insert them.
Indications for removal of a central venous access device
may include, but are not limited to, the following:
• Completion of therapy
• Broken or faulty device
• Unresolvable device occlusion
• Dwell time>recommended dwell time
• Infection (proven line infection, tract infection, unresolved bacteremia)
In general, central venous catheters should be removed with
the patient in the supine position. After catheter removal, pressure should be applied over the catheter exit site until hemostasis is achieved– 5min is the minimum amount of time pressure
should be held [51]. After manual pressure application and
achievement of hemostasis, a dressing should be placed.
PICC andNon-tunneled Catheter Removal
NTCCs and PICCs can generally be removed at the bedside
using manual traction. While holding slight pressure over the
catheter exit site, the catheter should be slowly and steadily
removed, and pressure should be held. PICC length should
be conrmed to ensure complete removal.
Tunneled Catheter Removal
TCCs can be removed using the traction removal technique
[51, 52]. The area around the cuff and tunnel as well as the
exit site should be inltrated with local anesthetic. The catheter is withdrawn using steady traction until the cuff comes
free and the catheter is removed. Rarely (<5% with polyurethane catheters), dissection of the cuff with a hemostat may
be needed; dissection should always be performed for silicone
catheters (now infrequently used). After catheter removal,
pressure should be held over the venous entry site for at least
5min or until hemostasis is achieved [51]. Cuff retention may
occur and is usually inconsequential, but it may be removed
through a small incision over the cuff site if desired [52].
Port Removal
The port pocket should be inltrated with local anesthetic
making sure to anesthetize behind the port as well as around
it. An incision is made (typically using the scar site from port
insertion); the catheter is dissected free and removed.
Hemostasis is achieved with manual compression at the catheter entry site in the neck, as for any catheter. The port is then
dissected free and removed. The pocket is then closed (usually one deep layer of absorbable suture and surgical glue).
9 Central Venous Access
Key Point
If a non-hemodialysis catheter is removed because of
concern for infection, the catheter tip should be sent
for culture. If the device is a port, the tip and port itself
should be sent separately.
References
1. Cheung E, Baerlocher MO, Asch M, Myers A. Venous access: a
practical review for 2009. Can Fam Physician Médecin Fam Can
[Internet]. 2009;55(5):494–6. Available from: http://www.pubmed-
central.nih.gov/articlerender.fcgi?artid=2682308&tool=pmcentrez
&rendertype=abstract.
2. Dudrick SJ. History of vascular access. J Parenter Enter Nutr.
2006;30(1):S47–56.
3. Duszak R Jr, Bilal N, Picus D, Hughes DR, Xu BJ.Central venous
access: evolving roles of radiology and other specialties nationally
over two decades. JAm Coll Radiol. 2013;10(8):603–12.
4. Mauro MA, Jaques PF.Radiologic placement of long-term central
venous catheters: a review. JVasc Interv Radiol. 1993;4(1):127–37.
5. Denny DF Jr. Placement and management of long-term central venous access catheters and ports. AJR Am J Roentgenol.
1993;161(2):385–93.
6. The Joint Commission. Preventing central line-associated bloodstream infections: a global challenge, a global. Perspective.
2012;136. Available from: http://www.jointcommission.org/
assets/1/18/CLABSI_Monograph.pdf.
7. Chopra V, Ratz D, Kuhn L, Lopus T, Chenoweth C, Krein S.PICCassociated bloodstream infections: prevalence, patterns, and predictors. Am JMed [Internet]. 2014;127(4):319–28. Available from:
https://doi.org/10.1016/j.amjmed.2014.01.001.
8. Chopra V, Flanders SA, Saint S, Woller SC, O’Grady NP, Safdar N,
etal. The Michigan appropriateness guide for intravenous catheters
(MAGIC): results from a multispecialty panel using the RAND/
UCLA appropriateness method. Ann Intern Med. 2015;163(6):
S1–39.
9. Hickman R, Buckner C, Clift R, Sanders J, Stewart P, Thomas E.A
modied right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet. 1979;148(6):871–5.
10. Galloway S. Long-term central venous access. Br J Anaesth
[Internet]. 2004;92(5):722–34. Available from: http://bja.oxford-
journals.org/lookup/doi/10.1093/bja/aeh109.
11. Reeves AR, Seshadri R, Trerotola SO. Recent trends in central
venous catheter placement: a comparison of interventional radiology
with other specialties. JVasc Interv Radiol. 2001;12(10):1211–4.
12. Aubaniac R. Subclavian intravenous transfusion: advantages and
technic. Afr Fr Chir. 1952;8(3–4):131.
13. Broviac JW, Cole JJ, Scribner BH.A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet.
1973;136(4):602–6.
14. Maki DG, Kluger DM, Crnich CJ.The risk of bloodstream infection in adults with different intravascular devices: a systematic
review of 200 published prospective studies. Mayo Clin Proc
[Internet]. 2006;81(9):1159–71. Available from: http://www.ncbi.
nlm.nih.gov/pubmed/16970212.
15. Hawkins J, Nelson EW.Percutaneous placement of Hickman catheters for prolonged venous access. Am JSurg. 1982;144(6):624–6.
16. Stellato T, Gauderer M, Cohen A.Direct central vein puncture for
silicone rubber catheter insertion: an alternative technique for broviac catheter placement. Surgery. 1981;90(5):896–9.
129
17. Kirkemo A, Johnston M.Percutaneous subclavian vein placement
of the Hickman catheter. Surgery. 1982;91:349–51.
18. McBride KD, Fisher R, Warnock N, Wineld DA, Reed MW,
Gaines PA. A comparative analysis of radiological and surgical
placement of central venous catheters. Cardiovasc Intervent Radiol.
1997;20(1):17–22.
19. Niederhuber J, Ensminger W, Gyves J, Liepman M, Doan K,
Cozzi E. Totally implanted venous and arterial access system to replace external catheters in cancer treatment. Surgery.
1982;92(4):706–12.
20. Brothers T, Von Moll L, Niederhuber J, Roberts J, Walker-Andrews
S, Ensminger W. Experience with subcutaneous infusion ports in
three hundred patients. Surg Gynecol Obstet. 1988;166(4):295–301.
21. Foley MJ. Radiologic placement of long-term central venous
peripheral access system ports (PAS port): results in 150 patients.
JVasc Interv Radiol [Internet]. 1995;6(2):255–62. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/7787360.
22. Andrews JC, Marx MV, Williams DM, Sproat I, Walker-Andrews
SC.The upper arm approach for placement of peripherally inserted
central catheters for protracted venous access. Am JRoentgenol.
1992;158(2):427–9.
23. Robertson LJ, Mauro MA, Jaques PF. Radiologic placement of
Hickman catheters. Radiology [Internet]. 1989;170(3 Pt 2):1007–9.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/2916052.
24. Skolnick ML.The role of sonography in the placement and management of jugular and subclavian central venous catheters. Am
JRoentgenol. 1994;163(2):291–5.
25. Page AC, Evans RA, Kaczmarski R, Mufti GJ, Gishen P. The
insertion of chronic indwelling central venous catheters (Hickman
lines) in interventional radiology suites. Clin Radiol. 1990;42(2):
105–9.
26. Cockburn JF, Eynon CA, Virji N, Jackson JE. Insertion of
Hickman central venous catheters by using angiographic techniques in patients with hematologic disorders. Am JRoentgenol.
1992;159(1):121–4.
27. Andrews JC. Long-term central venous access with a peripherally placed subcutaneous infusion port: initial results. Radiology.
1990;176:45–7.
28. Funaki B, Szymski GX, Hackworth CA, Rosenblum J, Burke
R, Chang T, et al. Radiologic placcement of subcutaneous infusion chest ports for long-term central venous access. AJR Am
JRoentgenol. 1997;169(5):1431–4.
29. Morris SL, Jaques PF, Mauro MA. Radiology-assisted placement
of implantable subcutaneous infusion ports for long-term venous
access. Radiology. 1992;184:149–51.
30. Seiler CM, Frohlich BE, Dorsam UJ, Kienle P, Buchler MW,
Knaebel H-P. Surgical technique for totally implantable access
ports (TIAP) needs improvement: a multivariate analysis of 400
patients. JSurg Oncol. 2006;93:24–9.
31. Shetty PC, Mody MK, Kastan DJ, Sharma RP, Burke MW,
Venugopal C, et al. Outcome of 350 implanted chest ports placed
by interventional radiologists. JVasc Interv Radiol JVIR [Internet].
1997;8(6):991–5. Available from: http://www.ncbi.nlm.nih.gov/
pubmed/9399468.
32. Gebauer B, El-Sheik M, Vogt M, Wagner HJ.Combined ultrasound
and uoroscopy guided port catheter implantation-high success and
low complication rate. Eur JRadiol. 2009;69(3):517–22.
33. LaRoy JR, White SB, Jayakrishnan T, Dybul S, Ungerer D, Turaga
K, etal. Cost and morbidity analysis of chest port insertion: interventional radiology suite versus operating room. JAm Coll Radiol
[Internet]. 2015;12(6):563–71. Available from: http://www.scien-
cedirect.com/science/article/pii/S1546144015000277.
34. Cardella JF, Cardella K, Bacci N, Fox PS, Post JH. Cumulative
experience with 1,273 peripherally inserted central catheters at a
single institution. JVasc Interv Radiol [Internet]. 1996;7(1):5–13.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/8773968.
130
D. M. DePietro and S. O. Trerotola
35. Malloy PC, Grassi CJ, Kundu S, Gervais DA, Miller DL, Osnis RB,
etal. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided
interventions. J Vasc Interv Radiol [Internet]. 2009;20(7):S240–
9. Available from: http://linkinghub.elsevier.com/retrieve/pii/
S1051044308010944.
36. Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT,
Kneebone PH.Tunneled infusion catheters: increased incidence of
symptomatic venous thrombosis after subclavian versus internal
jugular venous access. Radiology [Internet]. 2000;217(1):89–93.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/11012428.
37. Kandarpa K, Machan L, Durham JD.Central access devices: nontunneled. In: Handbook of interventional radiologic procedures. 5th
ed. Philadelphia: Wolters Kluwer; 2016. p.302.
38. Sasadeusz KJ, Trerotola SO, Shah H, Namyslowski J, Johnson
MS, Moresco KP, et al. Tunneled jugular small-bore central catheters as an alternative to peripherally inserted central catheters for
intermediate- term venous access in patients with hemodialysis and
chronic renal insufciency. Radiology. 1999;213:303–6.
39. Trerotola SO, Patel AA, Shlansky-Goldberg RD, Solomon JA,
Mondschein JI, Stavropoulos SW, et al. Short-term infection in
cuffed versus noncuffed small bore central catheters: a randomized
trial. JVasc Interv Radiol [Internet]. 2010;21(2):203–11. Available
from: https://doi.org/10.1016/j.jvir.2009.10.020.
40. Chick JFB, Reddy SN, Yam BL, Kobrin S, Trerotola SO.Institution
of a hospital-based central venous access policy for peripheral vein
preservation in patients with chronic kidney disease: a 12-year
experience. J Vasc Interv Radiol [Internet]. 2016:1–6. Available
from: https://doi.org/10.1016/j.jvir.2016.11.007.
41. Denny DF Jr, Greenwood LH, Morse SS, Lee GK, Baquero
J. Inferior vena cava: Translumbar catheterization for central
venous access. Radiology [Internet]. 1989;172(3 II):1013–4.
Available from: http://www.scopus.com/inward/record.url?eid=2-
s2.0-0024360459&partnerID=40&md5=989403b79781abefdefd4
d68ea38db89.
42. Stavropoulos SW, Pan JJ, Clark TWI, Soulen MC, ShlanskyGoldberg RD, Itkin M, et al. Percutaneous transhepatic venous
access for hemodialysis. JVasc Interv Radiol. 2003;14:1187–90.
43. Kaufman JA.Central venous access. In: Vascular and interventional
radiology: the requisites. Philadelphia: Saunders; 2014. p.147.
44. Schutz JCLL, Patel AA, Clark TW II, Solomon JA, Freiman
DB, Tuite CM, et al. Relationship between chest port catheter
tip position and port malfunction after interventional radiologic
placement. J Vasc Interv Radiol [Internet]. 2004;15(6):581–7.
Available from: http://linkinghub.elsevier.com/retrieve/pii/
S1051044307603285.
45. Smith JC, Sullivan KL, Michael B.Postprocedural aspiration test to
predict adequacy of dialysis following tunneled catheter placement.
Cardiovasc Intervent Radiol. 2006;29(4):576–9.
46. Duncan C, Trerotola SO.Outcomes of a percutaneous technique
for shortening of totally implanted indwelling central venous chest
port catheters. JVasc Interv Radiol [Internet]. 2016;27(7):1034–7.
Available from:https://doi.org/10.1016/j.jvir.2016.02.025.
47. Kolbeck KJ, Stavropoulos SW, Trerotola SO. Aerostasis during
central venous access: updates in protective sheaths. JVasc Interv
Radiol. 2006;17(Cvc):1155–63.
48. Bhutta ST, Culp WC. Evaluation and management of central
venous access complications. Tech Vasc Interv Radiol [Internet].
2011;14(4):217–24. Available from: https://doi.org/10.1053/j.
tvir.2011.05.003.
49. Nadolski G, Shlansky-Goldberg RD, Stavropoulos SW, Soulen
MC, Farrelly C, Trerotola SO.Chest radiograph-based algorithm
for managing malfunctioning ports. JVasc Interv Radiol [Internet].
2013;24(9):1337–42. Available from: https://doi.org/10.1016/j.
jvir.2013.05.060.
50. Kandarpa K, Machan L, Durham JD. Central access devices:
tunneled. In: Handbook of interventional radiologic procedures.
Philadelphia: Lippincott Williams & Wilkins; 2016. p.317.
51. Stecker MS, Johnson MS, Ying J, Mclennan G, Agarwal DM,
Namyslowski J, et al. Time to hemostasis after traction removal
of Tunneled cuffed central venous catheters. JVasc Interv Radiol.
2007;18(10):1232–9; quiz 1240.
52. Kohli MD, Trerotola SO, Namyslowski J, Stecker MS, Mclennan
G, Patel NH, etal. Outcome of polyester cuff retention following
traction removal of tunneled central venous catheters 1. J Vasc
Interv Radiol. 1997;219(3):651–4.
Part III
Venous Disease
Venous Thromboembolism: Deep
Venous Thrombosis andPulmonary
Embolism
AryaF.Derakhshani, AmishPatel, andAkhileshSista
Pathophysiology
Venous thromboembolism (VTE) encompasses deep vein
thrombosis (DVT) and subsequent pulmonary embolism (PE).
Historically, the rst description of DVT was in the Ayurveda
medical texts of ancient India (~600–900BC) [1, 2]. It was not
until the 1850s that Rudolf Virchow described his famous triad
of thrombosis: hypercoagulability, vessel injury, and stasis [3].
The rst documented case of DVT was in the Middle
Ages. It described a 20-year-old Norman cobbler named
Raoul suffering from right calf pain and swelling that progressed to the thigh and resulted in ulceration [4]. This was
treated with intense prayer at the tomb of King Saint Louis.
After several days, Raoul applied dust from the tomb directly
onto the ulcer, which led to a miraculous cure. In the centuries that followed, treatment for DVT moved away from
bloodletting toward therapies that are more recognizable by
today’s standards [1, 4].
VTE is a disease that affects a considerable number of
people annually in the USA.It is the third most common
life- threatening cardiovascular disease in the USA, after
myocardial infarction and stroke [5]. Approximately
900,000 cases of lower extremity DVT are reported annually. Pulmonary embolism, a serious consequence of DVT,
occurs in up to 600,000 people annually, resulting in the
mortality of 50,000 individuals. Furthermore, VTE can
develop into a chronic disease for many patients. One-third
of patients with VTE will have some form of recurrent disease within 10years, and 50% of patients with DVT will
10
experience long-term complications such as post-thrombotic syndrome or venous ulcers [5, 6].
The three components involved in thrombosis are venous
stasis, hypercoagulability, and abnormalities of the venous
endothelium. Venous stasis can occur as a consequence of
external compression on a vein by enlarged lymph nodes or
bulky tumors, a May-Thurner lesion or May-Thurner variant, or prior thrombosis leading to luminal narrowing.
Trauma or foreign body within a vein (e.g., venous catheter,
inferior vena cava (IVC) lter) can also cause abnormal
venous blood ow. Lastly, venous stasis can occur with prolonged immobilization (e.g., patients who have undergone
recent major surgery). Hypercoagulable states are associated
with a myriad of hematologic disorders not limited to factor
V Leiden deciency, antithrombin III deciency, or protein
C or S deciency. Hypercoagulability can also be a result of
oral contraceptive use, pregnancy, postpartum state, or
underlying malignancy. Finally, abnormalities of the venous
endothelium can result from prior trauma secondary to
venous catheters, prior DVT or injury from the infusion of
deleterious agents such as chemotherapeutic drugs or total
parenteral nutrition [6–8].
Key Point
The three factors leading to venous thromboembolism
(Virchow’s triad):
• Venous stasis
• Hypercoagulability
• Abnormalities of the venous endothelium
A. F. Derakhshani
NYU Langone Medical Center, Department of Radiology,
New York, NY, USA
e-mail: ahrya.derakhshani@nyumc.org
A. Patel · A. Sista (
NYU Langone Medical Center, Department of Radiology/Vascular
and Interventional Radiology, New York, NY, USA
e-mail: amish.patel@nyumc.org; akhilesh.sista@nyumc.org
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_10
*)
Clinical Indication
The presentation of VTE can be variable, but clinical hallmarks of the disease reect its pathophysiology. DVT typically presents with pain, erythema, tenderness, and swelling
133