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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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229
After confirming
tip placement with
fluoroscopy, what are
possible methods to close
the venotomy site and
secure the catheter?
Venotomy site:
Manual compression until
hemostasis is achieved.
For tunneled lines and ports,
close with preferred method, for
example, absorbable suture, Steri-
Strip, or skin glue
Catheter securement:
PICC:
StatLock dressing
Tunneled or non-tunneled central
venous catheter:
Nonabsorbable suture (e.g., 2-0
Prolene)
Figure-of-eight, U-stitch, etc.
(per preference)
Port:
Secure port in pocket (optional
step) with absorbable or
nonabsorbable suture
Deeper (dermal) closure:
Two to three deep
interrupted sutures with braided
absorbable suture material (e.g.,
3-0 Vicryl)
Skin closure:
Running subcuticular suture
with monofilament absorbable
suture (e.g., 4-0 Monocryl, Quill)
+/− Skin glue and/or
Steri-Strips (with or without
subcuticular suture, per
preference)
Dressing on catheter (including
biopatch, etc.)
What are recommended
methods to lock the
catheter to prevent
future complication (air
embolism, clot formation)
before use (may be
institutional dependent)?
Normal saline for large-/small-bore
CVCs, PICCs, Groshong-tip ports
Heparin for all other ports
Citrate for dialysis catheters
(continued)
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What are unique features
of PICC placement
(as compared to CVC
placement)?
Positioning: usually nondominant
arm if able, abducted, and externally
rotated (can ask patient to put the
hand behind the head)
Use of tourniquet on upper arm
How are central venous
catheters removed?
Inject local anesthetic along the
tract.
PICCs and non-tunneled
catheters:
Cut sutures securing catheter
in place.
Tunneled catheters:
Cut sutures (at the skin, and
any deep sutures).
Dissect (bluntly, with sharp
dissection as needed) around the
cuff.
Port:
Cut the skin over previous port
pocket incision, as able.
Dissect out port, with care
taken to avoid cutting the
catheter.
Cut sutures securing port into
pocket, as needed.
Pull the catheter out while patient
exhales, with simultaneous manual
pressure at the venotomy site.
Continue holding pressure over
venotomy site and along the tract
until hemostasis is achieved.
Ensure the entire catheter is
removed and intact.
Close/dress skin wound with
preferred method:
For ports: suture pocket closed,
usually using the same method as
pocket was initially closed during
placement
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What should be done if the
cuff of a tunneled catheter
stays in the skin?
Removal, if able without further
dissection
Otherwise, can usually be left
behind, with notification of patient
and primary providers
Only must come out in the setting
of:
Cosmetic concerns
Failure of tract closure
Infection
How can the subclavian
vein be accessed using
fluoroscopy?
Puncture a distal vein in the
ipsilateral arm/hand.
Inject contrast under fluoroscopy to
confirm position of subclavian vein.
Use fluoroscopy for puncture (can
use roadmap function if available).
Advance the needle until blood
return, or tip contacts the first rib.
How can the subclavian
vein be accessed without
fluoroscopy?
Place the patient in Trendelenburg.
Use a roll or pillow to elevate the
patient’s thoracic spine, and lower
the ipsilateral shoulder.
Turn the patient’s head away.
Puncture the skin 1cm caudal to the
junction of the medial and middle
clavicle using palpation.
Advance the needle along toward
the sternal notch.
(continued)
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232
How can the common
femoral vein be accessed,
without sonography?
Place the patient supine with hip in
neutral position.
Palpate the CFA below the inguinal
ligament.
Start 1cm below the inguinal
ligament, and 0.5–1cm medial to
the CFA.
Palpate or locate the lower third of
the femoral head using fluoroscopy.
Direct the needle cephalad at a
45-degree angle.
Aspirate for return while keeping
the CFA localized and going medial
to this.
What is unique post-
procedural care after
common femoral venous
access?
Bed rest with leg immobile for
3–4hours
How can the IVC be
accessed via a translumbar
approach?
Place the patient prone or in a left
lateral decubitus position.
Palpate the right iliac crest and the
spinous process superior to it.
Insert a long puncture needle about
10cm to the right of the spinous
process.
Under fluoroscopy, advance the
needle at a 45-degree angle toward
the top of the L3 vertebral body,
but anterior to this, until blood is
aspirated.
What is unique post-
procedural care after
translumbar IVC access?
Bed rest for 4–6hours
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Complications
What are the overall and major
complication rates in image-
guided central venous access?
Overall: ~7%
Major: ~3%
What are possible complications
in CVC placement?
Immediate, or procedure-
related:
Bleeding
Pneumothorax
Hemothorax
Access site hematoma
Vein injury or perforation
Air embolism
Inadvertent arterial injury
Procedure-induced sepsis
Delayed:
Venous thrombosis
Phlebitis (especially in
PICCs)
Venous stenosis
Occlusion/fibrin sheath
Wound dehiscence
Tunnel infection/sepsis
Catheter malfunction (can be
immediate)
What catheter tip positions may
cause complications?
Deep (i.e., distal right atrium)
placement can cause ectopy
and arrhythmia.
Shallow (i.e., proximal/mid
SVC) placement can increase
chance of venous stenosis and
catheter malfunction or poor
flow due to vessel collapse.
(continued)
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What are some possible site-
specific complications?
IJ
Carotid artery trauma
Pneumothorax (less likely
than subclavian access)
Subclavian
Pneumothorax
Hemothorax
Chylothorax (especially in
left-sided access)
Puncture of subclavian artery
Femoral
Femoral nerve or artery
trauma (with higher risk
of hematoma and/or
pseudoaneurysm than at the
neck)
Thrombosis of femoral or
iliac veins
Translumbar IVC
Psoas or other
retroperitoneal hematoma
Puncture of visceral artery or
organ, including the aorta
Other than
immunocompromised patients,
which patient group has
the highest risk of catheter-
associated infection?
Patients on TPN
How can an air embolism be
managed immediately?
Place the patient in left lateral
decubitus position.
Keeps the air bubble trapped
against the nondependent
aspect of the right ventricle
and away from the right
ventricular outflow tract.
Use a catheter to access the
bubble under fluoroscopy and
suction out.
G. Gadodia
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How can suspected catheter-
associated infections be
managed?
Non-tunneled CVC:
Exchange catheter (over
wire, or with new access site)
Tunneled CVC:
Remove and place
temporary access (non-
tunneled) as needed.
Dialysis catheter:
Bacteremic or infected
tunnel: exchange catheter
over wire +/− new tunnel.
If symptoms persist over
36hours, remove tunneled
catheter; place non-tunneled
dialysis catheter if needed.
48-hour line holiday before
replacing
Septic patient with any type of
catheter: remove emergently;
place temporary access as
needed.
What are possible causes of
catheter malfunction (i.e., not
flush and/or aspirate)?
Poor positioning (too
superficial, causing vessel
collapse, or too deep)
Tip against vessel wall
Catheter kink/fracture
Catheter thrombosis
Fibrin sheath
What is the first step
in troubleshooting a
malfunctioning line?
Obtain chest X-ray to evaluate
if kinked, fractured, or poorly
positioned.
What can be done if a line
is kinked in superficial soft
tissues?
Attempt manual reduction;
otherwise dermotomy and
open reduction if the kinking
is superficial versus catheter
exchange over wire if it is
deeper.
(continued)
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What can be done in a
malfunctioning catheter that is
not kinked/fractured and is in
proper position?
Attempt declotting agents:
tPA (alteplase) 2mg in each
port for 30–120min
Repeat x 1 if flow does not
improve.
What is the next step if
declotting agents fail?
Injection study
Evidence of fibrin sheath:
Strip sheath with a snare*
Exchange over wire if this
fails
No fibrin sheath:
Exchange over wire
If TDC, a different brand
or make of catheter can be
attempted
*Note: Snares are generally
more expensive than catheters,
so exchanging may be cheaper.
What can be done in the event
of CVC occlusion if both
thrombolysis and exchange fail?
Resite the catheter, with or
without venography if central
venous stenosis or occlusion
is suspected as the underlying
cause.
Landmark Research
Sasadeusz KJ, Trerotola SO, Shah H, Namyslowski J, Johnson
MS, Moresco KP, Patel NH (1999) 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
Insufficiency. Radiology 213:303–306.
G. Gadodia
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What did Sasadeusz etal. find
regarding the placement of
tunneled small-bore central
venous catheters as compared
to PICCs in patients on HD or
CKD?
Tunneled catheters are a
viable alternative to peripheral
catheters in patients with renal
issues, and preserve future
upper extremity HD access.
Lund GB, Trerotola SO, Scheel PF, Savader SJ, Mitchell
SE, Venbrux AC, Osterman FA (1996) Outcome of tunneled
hemodialysis catheters placed by radiologists. Radiology
198:467–472.
What are important findings by
Lund etal. and Trerotola etal.
with regard to the placement of
tunneled hemodialysis catheters by
interventional radiologists?
Tunneled dialysis catheters
placed by interventional
radiologists, especially in
the right internal jugular
vein, had equal or better
complication and success
rates as those placed by
surgeons.
Routine use of a single
dose of prophylactic
antibiotics was found to be
unnecessary:
Use of antibiotic
prophylaxis by Lund etal.
was associated with a
higher infection rate than
the study by Trerotola
etal. not using antibiotics,
0.08/100 vs. 0.14/100
catheter days, respectively.
Ramos ER, Reitzel R, Jiang Y, etal. (2011) Clinical effec-
tiveness and risk of emerging resistance associated with pro-
longed use of antibiotic-impregnated catheters: More than
0.5 million catheter days and 7years of clinical experience*.
Critical Care Medicine 39:245–251.
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238
What did
Ramos
etal. find in
regard to the
prolonged use
of antibiotic-
impregnated
catheters?
Significant decrease in central line-associated
bloodstream infections in the medical ICU
(from 8.3/1000 to 1.2/1000, p<0.001) in
patients with catheters coated with minocycline
and rifampin, without increased bacterial
resistance
Haas B, Chittams JL, Trerotola SO (2010) Large-bore
Tunneled Central Venous Catheter Insertion in Patients with
Coagulopathy. Journal of Vascular and Interventional
Radiology 21:212–217.
What did Haas etal.
find in regard to
placing large-bore
tunneled central
venous catheters
in coagulopathic
patients?
Placement of such catheters is safe
even in patients with INR between 1.5
and 2.0, and/or platelet counts between
25,000/dL and 50,000/dL, without need
for transfusion of coagulopathic blood
products (no bleeding complications
found in coagulopathic group of 626
patients).
Ponec D, Irwin D, Haire WD, Hill PA, Li X, Mccluskey ER
(2001) Recombinant Tissue Plasminogen Activator
(Alteplase) for Restoration of Flow in Occluded Central
Venous Access Devices: A Double-Blind Placebo-Controlled
Trial—The Cardiovascular Thrombolytic to Open Occluded
Lines (COOL) Efficacy Trial. Journal of Vascular and
Interventional Radiology 12:951–955.
Blaney M, Shen V, Kerner JA, Jacobs BR, Gray S, Armfield
J, et al. Alteplase for the Treatment of Central Venous
Catheter Occlusion in Children: Results of a Prospective,
Open-label, Single-arm Study (The Cathflo Activase Pediatric
Study). Journal of Vascular and Interventional Radiology.
2006;17:1745–51.
G. Gadodia
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