Techniques, Materials, and Devices A
Simple Technique
to Redirect
Malpositioned Silastic Central Venous
Catheters BRAD W. WARNER, MD, From the Division
AND
FREDERICK C. RYCKMAN, MD, FACS
of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Children’s Hospital Medical Center, Cincinnati
ABSTRACT. A simple and noninvasive method to redirect malpositioned Silastic central venous catheters is described. A syringe is connected to the catheter hub, and burst injections of saline cause the tip of the catheter to flip into the correct intravascular position. The present technique has been applied
The use of soft, flexible Silastic (Broviac, Hickman) central venous catheters has become the standard of care for the long-term delivery of parenteral nutrition, blood products, antibiotics, and sclerosing chemotherapeutic agents, and for direct access to the bloodstream in patients who require frequent blood sampling. The delivery of hypertonic solutions through the catheter mandates that the tip of the catheter be positioned within a large vessel with high flow rates such as the superior vena cava or the right atrium. Infusion of these solutions into smaller vessels may increase the risk of endothelial cell injury and subsequent vessel thrombosis. In addition, cerebral cortical venous thrombosis has followed the infusion of hypertonic solutions into the internal jugular vein.’ Correct positioning of the central venous catheter tip is therefore very important. With attempts at subclavian venipuncture, aberrant placement of the catheter tip is reported to occur 5.5% to 29.0% of the time and is most commonly into the ipsilateral internal jugular vein. 2,1 Other aberrant ve nous sites include the contralateral subclavian or internal jugular, internal thoracic,’ azygous,55 accessory hemiazygous6 or vertebral.’ The catheter tip may be malpositioned at the time of catheter placement or migrate to an aberrant location after initial proper place-
ment.’ When silicone catheters are noted to be malpositioned at the time of placement or at a later date), difficulty may be encountered in their repositioning, because the catheter exit site from the skin is fixed to the surrounding subcutaneous tissue by a cuff and is remote from the entrance site of the catheter into the vessel. The catheter courses through a subcutaneous tunnel between these two sites and may assume an acute angle when entering the vessel. We have used a simple
(either
Reprint requests: Brad W. Warner, MD, Division of Pediatric Surgery, Children’s Hospital Medical Center, Elland and Bethesda Avenues, Cincinnati, OH 45229.
more than 30 pediatric patients with excellent results. A detailed description of the technique and case examples are Journal of Parenteral and Enteral Nutrition presented. (
to
473-476, 1992) 16:
and safe technique to reposition these catheters with the of fluoroscopy and a syringe of saline. Although we have used this method for several years, details of this technique have only recently been described in the interventional radiology literature.9
use
TECHNIQUE
Under fluoroscopic guidance, the catheter is briskly 2 to 5 mL of saline over a pulse period of 1/2 to 1 second. Several pushes may be necessary. The
injected with
injections are performed with a 6-mL Luer locking syringe. With each injection, the pressure head from the burst of saline
causes
within the vessel and
the end of the catheter to move ultimately flip into the correct
position (Fig. 1). We have used this technique to reposition Silastic catheters in more than 30 children with few failures. We used this technique most commonly in the operating room at the time of initial catheter placement, but have also repositioned catheters that had migrated to an aberrant location using fluoroscopy in the radiology department. The catheters that were successfully repositioned were both single- and double-lumen and ranged from 2.7 to 7 French. The sites from which the catheters were placed included the subclavian, internal jugular, external jugular, and facial veins. Early in our experience, two small (2.7-French) catheters ruptured during attempts to push large amounts of saline (10 mL) under high pressures through the catheter in a brief period. We have subsequently modified our technique to limiting the injected volume to less than 5 mL with each push. CASE REPORT 1
A 12-year-old patient with osteomyelitis and a need for long-term venous access for administration of antibiotics was referred for placement of a central line. A 4.2-French single-lumen Silastic catheter (Davol, Inc, Cranston, RI) was percutaneously inserted via a right subclavian approach without difficultv. Intraoperative 473
474
FIG. 1. The aberrantly placed Silastic central venous catheter tip within the contralateral internal jugular vein is repositioned using a burst injection of saline through the catheter (a). The hydraulic force of the injection causes the end of the catheter to move within the vessel during each injection (b, c). This movement, combined with the direction of blood flow, will usually result in optimal repositioning of the tip of the catheter into the superior vena cava/right atrial junction (d).
475
fluoroscopy and postoperative chest roentgenograms confirmed the tip of the catheter to lie within the superior vena cava. One week after catheter placement, a chest roentgenogram taken because of the development of pneumonia revealed that the tip of the catheter had migrated into the left subclavian vein (Fig. 2). The patient
was
taken to the
fluoroscopy suite, where
the cath-
tip was repositioned in less than 1 minute into the superior vena cava using the above technique (Fig. 3). Significantly, the patient required no sedation and tolerated the procedure well. The patient completed his 6week antibiotic course and the catheter was electively removed. The position of the catheter was confirmed to have remained in the superior vena cava up to the time of catheter removal by serial roentgenograms that were taken to follow the course of the patient’s pneumonia. eter
CASE REPORT 2
A 3-month-old infant with necrotizing enterocolitis and resultant short-bowel syndrome was taken to the operating room for central venous catheter placement. The previously placed catheter had been inadvertently pulled back, such that the cuff of the catheter was outside the skin. After removal of the catheter, central venous access was secured via a left subclavian venipuncture and a guide wire was threaded. Intraoperative fluoroscopy revealed the tip of the guide wire to reside in the
ipsilateral internal jugular vein. Multiple manipulations of the guide wire under fluoroscopy failed to direct the guide wire into the superior vena cava. The catheter introducer was threaded over the wire and the wire was removed. Contrast was injected through the introducer
MG. 0. The catheter cava
appropriately repositioned
into the superior vena
using the described injection technique.
to document
patency of the superior vena cava. The wire rethreaded through the introducer, and a 3.0-French Silastic catheter was installed with the tip residing in the ipsilateral internal jugular vein. Using the described technique, the tip of the catheter was flipped into the
was
superior vena cava without difficulty. DISCUSSION
Many methods have been used to reposition aberrantly silicone central venous catheters. Walker et all’ described the use of a pigtail catheter, which is introduced through a separate femoral venipuncture. The catheter tip is engaged by the pigtail and is pulled down into a correct position. The disadvantages of this technique include the necessity for a separate femoral venipuncture. In pediatric patients, this may necessitate general anesthesia. In addition, the malpositioned catheter might be subjected to a potential increased risk of infection when touched by a second catheter introduced through the groin. Finally, concern must be raised about the possibility of inducing arrhythmias from the catheter passing through the heart from the inferior vena cava to the superior vena cava. Lois et al&dquo; have described the use of standard interventional radiologic materials introduced through the catheter itself to manipulate the catheter tip into the correct position. Using J-, tip-deflector, and floppy wires as well as an occasional balloon catheter, these authors were successful in repositioning 88S~ of malpositioned catheters. Most catheters in this study had migrated into
placed
FIG. 2. Image from a video recording demonstrates the tip of the catheter malpositioned within the left subclavian vein.
a
subintimal
position only. whereas only 3 of 15 catheters
476
malpositioned into the internal jugular vein. The disadvantages of these techniques include the necessary skill of an interventional radiologist to reposition the catheter successfully. In addition, the soft catheter may be at risk for perforation during attempts to thread wires or stiff balloon catheters. It may be impossible to thread a wire through a catheter that has been inserted via a neck site because of the acute angle the catheter must take to enter the vessel. Finally, catheter sizes frequently used for children (2.7, 3.0, 4.2, and 5 French) may be too
SUMMARY
were
small to allow passage of a useful wire. Other approaches in managing malpositioned catheters include complete removal of the catheter and placement of a new catheter. However, this would not be ideal for the pediatric patient with limited sites for central venous access. Vazquez and Brodski8 advocate observation only with the expectation of spontaneous correction of the malposition. We do not share this experience and because many catheters that have migrated to an aberrant position usually manifest themselves with symptoms of catheter malfunction, pain from local phlebitis, or swelling of an extremity from venous thrombosis, we feel strongly that the catheter should be repositioned. It should be emphasized that this technique should only be applied with the soft, silicone catheters (Hickman, Broviac). We would not advocate this method for repositioning the stiffer catheters composed of polyvinyl chloride, polyethylene, or polyurethane. Finally, this method should only be used for catheters whose tip is still within the lumen of the blood vessel. If any question exists as to the exact location of the malpositioned catheter tip, injection of a small amount of contrast material through the catheter under fluoroscopy should provide the answer.
A simple, noninvasive, and safe method has been described to reposition the tip of malpositioned silicone central venous catheters. It is easy to perform using a saline-filled syringe and fluoroscopy, thus avoiding additional central venipuncture, instrumentation, possible damage to the catheter with wires or balloons, or catheter replacement. The technique is effective and without significant complications. REFERENCES 1.
Connolly CK: Spreading cortical venous thrombosis due to infusion of hyperosmolar solution into the internal jugular vein. Br Med J 285:935-936, 1982 DJ, Holden RW: Aberrant locations and complications in
2. Conces
initial placement of subclavian vein catheters. Arch Surg 119:293-
295, 1984 RD, Mitchell R, Lavine M: Aberrant locations of central venous catheters. Lancet 1:711-715, 1981
3. Dunbar
4. Finch MT:
Subclavian-mammary
vein catheterization. JAMA
125:1001-1002, 1976 5.
Quigley RG, Petty C, Tobin G: Unusual placement of a central venous catheter via the internal jugular vein. Anesth Analg 53:478,
1974 6. Smith
7. 8.
9.
10.
11.
DC, Pop PM: Malposition of a total parenteral nutrition catheter in the accessory hemiazygous vein. JPEN 7:289-292, 1983 Mitchell SE, Clark RA: Complications of central venous catheterization. Am J Roentgenol 133:467-476, 1979 Vazquez RM, Brodski EG: Primary and secondary malposition of silicone central venous catheters. Acta Anaesth Scand S81:22-25, 1985 Olcott EW, Gordon RL, Ring EJ: The injection technique for repositioning central venous catheters: Technical note. Cardiovasc Intervent Radiol 12:292-293, 1989 Walker TG, Geller SC, Waltman AC, et al: A simple technique for redirection of malpositioned Broviac or Hickman catheters. Surg Gynecol Obstet 167:246-248, 1988 Lois JF, Gomes AS, Pusey E: Nonsurgical repositioning of central venous catheters. Radiology 165:329-333, 1987
Simple Technique
to Redirect
Malpositioned Silastic Central Venous
Catheters BRAD W. WARNER, MD, From the Division
AND
FREDERICK C. RYCKMAN, MD, FACS
of Pediatric Surgery, Department of Surgery, University of Cincinnati College of Medicine, Children’s Hospital Medical Center, Cincinnati
ABSTRACT. A simple and noninvasive method to redirect malpositioned Silastic central venous catheters is described. A syringe is connected to the catheter hub, and burst injections of saline cause the tip of the catheter to flip into the correct intravascular position. The present technique has been applied
The use of soft, flexible Silastic (Broviac, Hickman) central venous catheters has become the standard of care for the long-term delivery of parenteral nutrition, blood products, antibiotics, and sclerosing chemotherapeutic agents, and for direct access to the bloodstream in patients who require frequent blood sampling. The delivery of hypertonic solutions through the catheter mandates that the tip of the catheter be positioned within a large vessel with high flow rates such as the superior vena cava or the right atrium. Infusion of these solutions into smaller vessels may increase the risk of endothelial cell injury and subsequent vessel thrombosis. In addition, cerebral cortical venous thrombosis has followed the infusion of hypertonic solutions into the internal jugular vein.’ Correct positioning of the central venous catheter tip is therefore very important. With attempts at subclavian venipuncture, aberrant placement of the catheter tip is reported to occur 5.5% to 29.0% of the time and is most commonly into the ipsilateral internal jugular vein. 2,1 Other aberrant ve nous sites include the contralateral subclavian or internal jugular, internal thoracic,’ azygous,55 accessory hemiazygous6 or vertebral.’ The catheter tip may be malpositioned at the time of catheter placement or migrate to an aberrant location after initial proper place-
ment.’ When silicone catheters are noted to be malpositioned at the time of placement or at a later date), difficulty may be encountered in their repositioning, because the catheter exit site from the skin is fixed to the surrounding subcutaneous tissue by a cuff and is remote from the entrance site of the catheter into the vessel. The catheter courses through a subcutaneous tunnel between these two sites and may assume an acute angle when entering the vessel. We have used a simple
(either
Reprint requests: Brad W. Warner, MD, Division of Pediatric Surgery, Children’s Hospital Medical Center, Elland and Bethesda Avenues, Cincinnati, OH 45229.
more than 30 pediatric patients with excellent results. A detailed description of the technique and case examples are Journal of Parenteral and Enteral Nutrition presented. (
to
473-476, 1992) 16:
and safe technique to reposition these catheters with the of fluoroscopy and a syringe of saline. Although we have used this method for several years, details of this technique have only recently been described in the interventional radiology literature.9
use
TECHNIQUE
Under fluoroscopic guidance, the catheter is briskly 2 to 5 mL of saline over a pulse period of 1/2 to 1 second. Several pushes may be necessary. The
injected with
injections are performed with a 6-mL Luer locking syringe. With each injection, the pressure head from the burst of saline
causes
within the vessel and
the end of the catheter to move ultimately flip into the correct
position (Fig. 1). We have used this technique to reposition Silastic catheters in more than 30 children with few failures. We used this technique most commonly in the operating room at the time of initial catheter placement, but have also repositioned catheters that had migrated to an aberrant location using fluoroscopy in the radiology department. The catheters that were successfully repositioned were both single- and double-lumen and ranged from 2.7 to 7 French. The sites from which the catheters were placed included the subclavian, internal jugular, external jugular, and facial veins. Early in our experience, two small (2.7-French) catheters ruptured during attempts to push large amounts of saline (10 mL) under high pressures through the catheter in a brief period. We have subsequently modified our technique to limiting the injected volume to less than 5 mL with each push. CASE REPORT 1
A 12-year-old patient with osteomyelitis and a need for long-term venous access for administration of antibiotics was referred for placement of a central line. A 4.2-French single-lumen Silastic catheter (Davol, Inc, Cranston, RI) was percutaneously inserted via a right subclavian approach without difficultv. Intraoperative 473
474
FIG. 1. The aberrantly placed Silastic central venous catheter tip within the contralateral internal jugular vein is repositioned using a burst injection of saline through the catheter (a). The hydraulic force of the injection causes the end of the catheter to move within the vessel during each injection (b, c). This movement, combined with the direction of blood flow, will usually result in optimal repositioning of the tip of the catheter into the superior vena cava/right atrial junction (d).
475
fluoroscopy and postoperative chest roentgenograms confirmed the tip of the catheter to lie within the superior vena cava. One week after catheter placement, a chest roentgenogram taken because of the development of pneumonia revealed that the tip of the catheter had migrated into the left subclavian vein (Fig. 2). The patient
was
taken to the
fluoroscopy suite, where
the cath-
tip was repositioned in less than 1 minute into the superior vena cava using the above technique (Fig. 3). Significantly, the patient required no sedation and tolerated the procedure well. The patient completed his 6week antibiotic course and the catheter was electively removed. The position of the catheter was confirmed to have remained in the superior vena cava up to the time of catheter removal by serial roentgenograms that were taken to follow the course of the patient’s pneumonia. eter
CASE REPORT 2
A 3-month-old infant with necrotizing enterocolitis and resultant short-bowel syndrome was taken to the operating room for central venous catheter placement. The previously placed catheter had been inadvertently pulled back, such that the cuff of the catheter was outside the skin. After removal of the catheter, central venous access was secured via a left subclavian venipuncture and a guide wire was threaded. Intraoperative fluoroscopy revealed the tip of the guide wire to reside in the
ipsilateral internal jugular vein. Multiple manipulations of the guide wire under fluoroscopy failed to direct the guide wire into the superior vena cava. The catheter introducer was threaded over the wire and the wire was removed. Contrast was injected through the introducer
MG. 0. The catheter cava
appropriately repositioned
into the superior vena
using the described injection technique.
to document
patency of the superior vena cava. The wire rethreaded through the introducer, and a 3.0-French Silastic catheter was installed with the tip residing in the ipsilateral internal jugular vein. Using the described technique, the tip of the catheter was flipped into the
was
superior vena cava without difficulty. DISCUSSION
Many methods have been used to reposition aberrantly silicone central venous catheters. Walker et all’ described the use of a pigtail catheter, which is introduced through a separate femoral venipuncture. The catheter tip is engaged by the pigtail and is pulled down into a correct position. The disadvantages of this technique include the necessity for a separate femoral venipuncture. In pediatric patients, this may necessitate general anesthesia. In addition, the malpositioned catheter might be subjected to a potential increased risk of infection when touched by a second catheter introduced through the groin. Finally, concern must be raised about the possibility of inducing arrhythmias from the catheter passing through the heart from the inferior vena cava to the superior vena cava. Lois et al&dquo; have described the use of standard interventional radiologic materials introduced through the catheter itself to manipulate the catheter tip into the correct position. Using J-, tip-deflector, and floppy wires as well as an occasional balloon catheter, these authors were successful in repositioning 88S~ of malpositioned catheters. Most catheters in this study had migrated into
placed
FIG. 2. Image from a video recording demonstrates the tip of the catheter malpositioned within the left subclavian vein.
a
subintimal
position only. whereas only 3 of 15 catheters
476
malpositioned into the internal jugular vein. The disadvantages of these techniques include the necessary skill of an interventional radiologist to reposition the catheter successfully. In addition, the soft catheter may be at risk for perforation during attempts to thread wires or stiff balloon catheters. It may be impossible to thread a wire through a catheter that has been inserted via a neck site because of the acute angle the catheter must take to enter the vessel. Finally, catheter sizes frequently used for children (2.7, 3.0, 4.2, and 5 French) may be too
SUMMARY
were
small to allow passage of a useful wire. Other approaches in managing malpositioned catheters include complete removal of the catheter and placement of a new catheter. However, this would not be ideal for the pediatric patient with limited sites for central venous access. Vazquez and Brodski8 advocate observation only with the expectation of spontaneous correction of the malposition. We do not share this experience and because many catheters that have migrated to an aberrant position usually manifest themselves with symptoms of catheter malfunction, pain from local phlebitis, or swelling of an extremity from venous thrombosis, we feel strongly that the catheter should be repositioned. It should be emphasized that this technique should only be applied with the soft, silicone catheters (Hickman, Broviac). We would not advocate this method for repositioning the stiffer catheters composed of polyvinyl chloride, polyethylene, or polyurethane. Finally, this method should only be used for catheters whose tip is still within the lumen of the blood vessel. If any question exists as to the exact location of the malpositioned catheter tip, injection of a small amount of contrast material through the catheter under fluoroscopy should provide the answer.
A simple, noninvasive, and safe method has been described to reposition the tip of malpositioned silicone central venous catheters. It is easy to perform using a saline-filled syringe and fluoroscopy, thus avoiding additional central venipuncture, instrumentation, possible damage to the catheter with wires or balloons, or catheter replacement. The technique is effective and without significant complications. REFERENCES 1.
Connolly CK: Spreading cortical venous thrombosis due to infusion of hyperosmolar solution into the internal jugular vein. Br Med J 285:935-936, 1982 DJ, Holden RW: Aberrant locations and complications in
2. Conces
initial placement of subclavian vein catheters. Arch Surg 119:293-
295, 1984 RD, Mitchell R, Lavine M: Aberrant locations of central venous catheters. Lancet 1:711-715, 1981
3. Dunbar
4. Finch MT:
Subclavian-mammary
vein catheterization. JAMA
125:1001-1002, 1976 5.
Quigley RG, Petty C, Tobin G: Unusual placement of a central venous catheter via the internal jugular vein. Anesth Analg 53:478,
1974 6. Smith
7. 8.
9.
10.
11.
DC, Pop PM: Malposition of a total parenteral nutrition catheter in the accessory hemiazygous vein. JPEN 7:289-292, 1983 Mitchell SE, Clark RA: Complications of central venous catheterization. Am J Roentgenol 133:467-476, 1979 Vazquez RM, Brodski EG: Primary and secondary malposition of silicone central venous catheters. Acta Anaesth Scand S81:22-25, 1985 Olcott EW, Gordon RL, Ring EJ: The injection technique for repositioning central venous catheters: Technical note. Cardiovasc Intervent Radiol 12:292-293, 1989 Walker TG, Geller SC, Waltman AC, et al: A simple technique for redirection of malpositioned Broviac or Hickman catheters. Surg Gynecol Obstet 167:246-248, 1988 Lois JF, Gomes AS, Pusey E: Nonsurgical repositioning of central venous catheters. Radiology 165:329-333, 1987
