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1097
Percutaneous Placement of Hickman Catheters: Comparison Sonographically Techniques
S. Lam#{233}ri& J. M. Post1 Harmine M. Zonderland1 Pieter G. Gemtsen2 Mies C. Kappers-Klunne3 Henri E. Sch#{252}tte1 Johan Pieter
Guided
of
and Blind
We studied the value of sonographically guided puncture of the subclavian vein for placement of indwelling right atrial and permanent subcutaneously tunneled catheters (Hickman) for long-term venous access. The commonly used blind puncture is associated with complications such as pneumothorax, arterial puncture, and hemothorax. The results and complications of 40 sonographically guided punctures and fluoroscopically controlled catheterizations of the subclavian vein (group 1, 31 patients) performed in the radiology department were compared with those of 40 blind percutaneous punctures and fluoroscopically controlled catheterizations (group 2, 29 patients) performed in the operating room The patients were selected consecutively. The groups were comparable in age,
sex,
and
indication
for
catheter
placement;
administration
of chemotherapy
for
hematologic malignancies was the major indication (group 1, 84%; group 2, 83%). All punctures in group I were successful; group 2 had two failures (5%). Puncture-related complications occurred significantly more in group 2 (10%) than in group 1 (0%) (p < .05). These complications were pneumothorax in three cases and hemothorax in one. Complications not related to the puncture technique were prolonged bleeding at the entrance site (groups 1 and 2, two cases each), local infection (group 1, one case), thrombosis (group 1, three cases; group 2, two), catheter sepsis (group 1, 10 cases; group 2, 14), catheter occlusion (group 2, three cases), and catheter migration (groups 1 and 2, two cases each). We conclude that sonographically guided puncture increases the success rate and significantly decreases the puncture-related complications of percutaneous placement of Hickman
catheters.
AJR 155:1097-1099,
Received March sion June 1 , 1990.
26, 1990;
accepted
after
revi-
1 Department of Radiology, University Hospital Dijkzigt, Erasmus University, Dr. Molewaterplein 40, 301 5 GD, Aotterdam, the Netherlands. Address reprint requests to J. S. Lam#{233}ris. 2 Department of Surgery, University Hospital Dijkzigt,
Erasmus
University,
301 5 GD Rotterdam,
the Netherlands. 3 Department of Hematology, University Hospital Dijkzigt, Erasmus University. 301 5 GD Rotterdam, the Netherlands. 0361 -803X/90/1555-1 © American Roentgen
097 Ray Society
November
1990
Catheterization of the subclavian vein is a procedure commonly used to obtain central venous access for hemodialysis and long-term administration of fluids, antibiotics, or chemotherapy. Indwelling right atrial and permanent subcutaneously tunneled catheters such as the Hickman catheter are widely accepted for these purposes [1 ]. Such catheters can be placed by using either the surgical cutdown method or percutaneous puncture of the vein. In general, the percutaneous method is preferred, because it decreases the time and cost of the procedure [2]. Complications of this technique-arterial puncture, hemothorax, nerve injury, and pneumothorax-occur in 1 -7% [2-4]. Of the technical improvements that have been proposed, the use of sonographic and fluoroscopic guidance seems the most logical and the most valuable [5-8]. Demonstrating the target vein and its surrounding anatomic structures could prevent complications and enable easy recognition of malposition. These considerations encouraged us to place the Hickman catheters in the patients in the radiology department, where both sonography and fluoroscopy are available. The results and the complications of 40 procedures in which puncture of the subclavian vein was done under sonographic guidance and catheter placement was controlled by fluoroscopy were compared with those in a control group in
which 40 Hickman catheters were inserted by the surgeon in the operating room by using blind percutaneous puncture and fluoroscopy to control the guidewire and catheter positions.
..-
.:“
Subjects
and
Methods -.,
Group
1 consisted
Downloaded from www.ajronline.org by 113.196.236.104 on 11/10/15 from IP address 113.196.236.104. Copyright ARRS. For personal use only; all rights reserved
were placed subclavian
by the radiologist
vein
a freehand
of 31 patients
was
punctured
approach
skin directly
in whom
40 Hickman
the radiology
in under
guidance.
trolled
The
positions
of
by fluoroscopy.
Group
the
guidewire
through
linear-array
(Aloka Co. , Japan) in which the infraclavicular
.
‘
#{149}.
‘
the
transducer
subclavian
and
The
We used
in which the needle was inserted
into the plane of a 5- or 7.5-MHz
visualized.
department.
sonographic
:
catheters
catheter
r&
vein was were
con-
2 consisted
of 29 patients in whom 40 in the operating room. The infraclavicular subclavian vein was punctured blindly in a standard fashion from a position 2-3 cm below the middle third of the clavical
Hickman catheters were placed by the surgeon
[9-10]. The positions of the guidewire and catheter were controlled also by fluoroscopy. The procedures were done between January 1 987 and November 1989. Waiting periods for the operating room influenced patient selection during the first few months. Later on, patients were selected consecutively. After September 1988, only sonographically guided procedures
were
Patients
disease, group
and indication 1 there
were
were
sex, age, underlying venous catheter access. In
comparable
for long-term
in
1 5 men and 1 6 women,
in group
2 1 3 men and
16 women. The mean age in group 1 was 44 (range, 16-70); in group 2 it was 49 (range, 20-77). The indications for catheter placement were administration of chemotherapy for hematologic malignancies in 26 patients (84%) in group 1 and 24 patients (83%) in group 2, parenteral nutrition in two patients (7%) in group 1 , administration of antibiotics in one patient (3%) in group 1 and three patients (1 0%) in group 2, and hemodialysis and other miscellaneous indications in two patients (7%) in each group. Platelet transfusion was necessary
before catheter
placement
in 18 patients
with thrombocytopenia
in
both groups. access Local
silicone central venous catheter was used (Gish Biomedical Inc. , Santa Ana, CA). anesthesia and IV sedation were used for both techniques. In
a 14-French double-lumen
the operating room an anesthesiologist was standing by in case failure of the puncture necessitated a cutdown approach. In both groups puncture of the left subclavian vein was preferred, because the longer distance to the superior vena cava facilitates positioning
of the catheter
[1 1] and
prevents
kinking
of the introducer
sheath. When thrombosis was detected sonographically (group 1) or the left vein was catheterized (either group) before placement, the right subclavian vein was punctured. In both groups the puncture site
and subcutaneous
tract for the catheter
were anesthetized
lidocaine,
small
made.
and
two
incisions
were
The
with 1%
subclavian
vein
was punctured with an 1 8-gauge needle. In group 1 the tip of the needle was continuously monitored by sonography (Fig. 1). In both techniques a flexible J wire was introduced through the needle into the vein and the position
Then, a subcutaneous
of the wire was controlled
by fluoroscopy.
tunnel was made. The catheter
was passed
through the tunnel and shortened to its appropriate length. A 14French dilator with peel-away sheath was subsequently introduced over the wire into the subclavian vein. The dilator and the wire were then removed and the catheter was led through the gradually split and withdrawn sheath, leaving the catheter in place. The position of the catheter was again controlled by fluoroscopy. The catheter was immediately flushed with heparin saline. The two incisions
were
closed
and
covered
with
a sterile
dressing.
In both groups patency of the subclavian vein after placement was checked only when clinical signs suggested thrombosis. Sonography was the method of choice in detecting thrombosis. Differences in success
rate and puncture-related
means of a
statistical
test
for difference
complications between
were sample
analyzed proportions.
showing infraclavicular part of left subclavian tip can be seen within vein (arrowheads).
vein.
results and complications are summarized in Table 1. All sonographically guided punctures in group 1 were successful. In two patients, sonographic examination before the procedure showed clinically unsuspected thrombosis of the left subclavian vein; therefore, the right vein was punctured. The
One patient earlier
by
had stenosis
presence
of the subclavian
of an infected
catheter.
vein due to the
This
prevented
cor-
rect positioning of the catheter in the superior vena cava and a malposition was accepted. Unfortunately, thrombosis of the punctured
vein occurred
of thrombosis The
In all procedures,
1.-Sonogram of needle
Results
done.
of both groups
Fig.
Reflection
patients
were treated local
infection
were removed migration
within
2 days.
The two
two patients. subsequently placed under
cases
7 and 59 days after placement.
with
bleeding
prolonged
with several platelet developed
because
at the
transfusions.
on the fourth
of suspected
day.
infection
and malposition of the catheter puncture of the subclavian vein
Blind
other
were diagnosed
In the first patient,
insertion Nine
catheters
and two after
tip. in group
the cutdown
site
In one patient
2 failed
technique
in
was
used; in the second, the catheter was ultimately sonographic guidance. One malpositioned cath-
eter was removed the same day. Pneumothorax occurred in three patients; two needed a chest tube, one was treated conservatively. the contralateral
which
In one of these patients in whom puncture on side was attempted, hemothorax occurred,
was treated
conservatively.
Thrombosis
was seen in
two patients after 30 and 1 03 days. Sepsis was the reason for removing 1 4 catheters (one was occluded also); two catheter migrated and were subsequently removed. The differences in success rates between the two groups
were not statistically related complications, icant difference
significant. however,
in favor
of group
The occurrence of punctureshowed a statistically signif1 (p
1097
Percutaneous Placement of Hickman Catheters: Comparison Sonographically Techniques
S. Lam#{233}ri& J. M. Post1 Harmine M. Zonderland1 Pieter G. Gemtsen2 Mies C. Kappers-Klunne3 Henri E. Sch#{252}tte1 Johan Pieter
Guided
of
and Blind
We studied the value of sonographically guided puncture of the subclavian vein for placement of indwelling right atrial and permanent subcutaneously tunneled catheters (Hickman) for long-term venous access. The commonly used blind puncture is associated with complications such as pneumothorax, arterial puncture, and hemothorax. The results and complications of 40 sonographically guided punctures and fluoroscopically controlled catheterizations of the subclavian vein (group 1, 31 patients) performed in the radiology department were compared with those of 40 blind percutaneous punctures and fluoroscopically controlled catheterizations (group 2, 29 patients) performed in the operating room The patients were selected consecutively. The groups were comparable in age,
sex,
and
indication
for
catheter
placement;
administration
of chemotherapy
for
hematologic malignancies was the major indication (group 1, 84%; group 2, 83%). All punctures in group I were successful; group 2 had two failures (5%). Puncture-related complications occurred significantly more in group 2 (10%) than in group 1 (0%) (p < .05). These complications were pneumothorax in three cases and hemothorax in one. Complications not related to the puncture technique were prolonged bleeding at the entrance site (groups 1 and 2, two cases each), local infection (group 1, one case), thrombosis (group 1, three cases; group 2, two), catheter sepsis (group 1, 10 cases; group 2, 14), catheter occlusion (group 2, three cases), and catheter migration (groups 1 and 2, two cases each). We conclude that sonographically guided puncture increases the success rate and significantly decreases the puncture-related complications of percutaneous placement of Hickman
catheters.
AJR 155:1097-1099,
Received March sion June 1 , 1990.
26, 1990;
accepted
after
revi-
1 Department of Radiology, University Hospital Dijkzigt, Erasmus University, Dr. Molewaterplein 40, 301 5 GD, Aotterdam, the Netherlands. Address reprint requests to J. S. Lam#{233}ris. 2 Department of Surgery, University Hospital Dijkzigt,
Erasmus
University,
301 5 GD Rotterdam,
the Netherlands. 3 Department of Hematology, University Hospital Dijkzigt, Erasmus University. 301 5 GD Rotterdam, the Netherlands. 0361 -803X/90/1555-1 © American Roentgen
097 Ray Society
November
1990
Catheterization of the subclavian vein is a procedure commonly used to obtain central venous access for hemodialysis and long-term administration of fluids, antibiotics, or chemotherapy. Indwelling right atrial and permanent subcutaneously tunneled catheters such as the Hickman catheter are widely accepted for these purposes [1 ]. Such catheters can be placed by using either the surgical cutdown method or percutaneous puncture of the vein. In general, the percutaneous method is preferred, because it decreases the time and cost of the procedure [2]. Complications of this technique-arterial puncture, hemothorax, nerve injury, and pneumothorax-occur in 1 -7% [2-4]. Of the technical improvements that have been proposed, the use of sonographic and fluoroscopic guidance seems the most logical and the most valuable [5-8]. Demonstrating the target vein and its surrounding anatomic structures could prevent complications and enable easy recognition of malposition. These considerations encouraged us to place the Hickman catheters in the patients in the radiology department, where both sonography and fluoroscopy are available. The results and the complications of 40 procedures in which puncture of the subclavian vein was done under sonographic guidance and catheter placement was controlled by fluoroscopy were compared with those in a control group in
which 40 Hickman catheters were inserted by the surgeon in the operating room by using blind percutaneous puncture and fluoroscopy to control the guidewire and catheter positions.
..-
.:“
Subjects
and
Methods -.,
Group
1 consisted
Downloaded from www.ajronline.org by 113.196.236.104 on 11/10/15 from IP address 113.196.236.104. Copyright ARRS. For personal use only; all rights reserved
were placed subclavian
by the radiologist
vein
a freehand
of 31 patients
was
punctured
approach
skin directly
in whom
40 Hickman
the radiology
in under
guidance.
trolled
The
positions
of
by fluoroscopy.
Group
the
guidewire
through
linear-array
(Aloka Co. , Japan) in which the infraclavicular
.
‘
#{149}.
‘
the
transducer
subclavian
and
The
We used
in which the needle was inserted
into the plane of a 5- or 7.5-MHz
visualized.
department.
sonographic
:
catheters
catheter
r&
vein was were
con-
2 consisted
of 29 patients in whom 40 in the operating room. The infraclavicular subclavian vein was punctured blindly in a standard fashion from a position 2-3 cm below the middle third of the clavical
Hickman catheters were placed by the surgeon
[9-10]. The positions of the guidewire and catheter were controlled also by fluoroscopy. The procedures were done between January 1 987 and November 1989. Waiting periods for the operating room influenced patient selection during the first few months. Later on, patients were selected consecutively. After September 1988, only sonographically guided procedures
were
Patients
disease, group
and indication 1 there
were
were
sex, age, underlying venous catheter access. In
comparable
for long-term
in
1 5 men and 1 6 women,
in group
2 1 3 men and
16 women. The mean age in group 1 was 44 (range, 16-70); in group 2 it was 49 (range, 20-77). The indications for catheter placement were administration of chemotherapy for hematologic malignancies in 26 patients (84%) in group 1 and 24 patients (83%) in group 2, parenteral nutrition in two patients (7%) in group 1 , administration of antibiotics in one patient (3%) in group 1 and three patients (1 0%) in group 2, and hemodialysis and other miscellaneous indications in two patients (7%) in each group. Platelet transfusion was necessary
before catheter
placement
in 18 patients
with thrombocytopenia
in
both groups. access Local
silicone central venous catheter was used (Gish Biomedical Inc. , Santa Ana, CA). anesthesia and IV sedation were used for both techniques. In
a 14-French double-lumen
the operating room an anesthesiologist was standing by in case failure of the puncture necessitated a cutdown approach. In both groups puncture of the left subclavian vein was preferred, because the longer distance to the superior vena cava facilitates positioning
of the catheter
[1 1] and
prevents
kinking
of the introducer
sheath. When thrombosis was detected sonographically (group 1) or the left vein was catheterized (either group) before placement, the right subclavian vein was punctured. In both groups the puncture site
and subcutaneous
tract for the catheter
were anesthetized
lidocaine,
small
made.
and
two
incisions
were
The
with 1%
subclavian
vein
was punctured with an 1 8-gauge needle. In group 1 the tip of the needle was continuously monitored by sonography (Fig. 1). In both techniques a flexible J wire was introduced through the needle into the vein and the position
Then, a subcutaneous
of the wire was controlled
by fluoroscopy.
tunnel was made. The catheter
was passed
through the tunnel and shortened to its appropriate length. A 14French dilator with peel-away sheath was subsequently introduced over the wire into the subclavian vein. The dilator and the wire were then removed and the catheter was led through the gradually split and withdrawn sheath, leaving the catheter in place. The position of the catheter was again controlled by fluoroscopy. The catheter was immediately flushed with heparin saline. The two incisions
were
closed
and
covered
with
a sterile
dressing.
In both groups patency of the subclavian vein after placement was checked only when clinical signs suggested thrombosis. Sonography was the method of choice in detecting thrombosis. Differences in success
rate and puncture-related
means of a
statistical
test
for difference
complications between
were sample
analyzed proportions.
showing infraclavicular part of left subclavian tip can be seen within vein (arrowheads).
vein.
results and complications are summarized in Table 1. All sonographically guided punctures in group 1 were successful. In two patients, sonographic examination before the procedure showed clinically unsuspected thrombosis of the left subclavian vein; therefore, the right vein was punctured. The
One patient earlier
by
had stenosis
presence
of the subclavian
of an infected
catheter.
vein due to the
This
prevented
cor-
rect positioning of the catheter in the superior vena cava and a malposition was accepted. Unfortunately, thrombosis of the punctured
vein occurred
of thrombosis The
In all procedures,
1.-Sonogram of needle
Results
done.
of both groups
Fig.
Reflection
patients
were treated local
infection
were removed migration
within
2 days.
The two
two patients. subsequently placed under
cases
7 and 59 days after placement.
with
bleeding
prolonged
with several platelet developed
because
at the
transfusions.
on the fourth
of suspected
day.
infection
and malposition of the catheter puncture of the subclavian vein
Blind
other
were diagnosed
In the first patient,
insertion Nine
catheters
and two after
tip. in group
the cutdown
site
In one patient
2 failed
technique
in
was
used; in the second, the catheter was ultimately sonographic guidance. One malpositioned cath-
eter was removed the same day. Pneumothorax occurred in three patients; two needed a chest tube, one was treated conservatively. the contralateral
which
In one of these patients in whom puncture on side was attempted, hemothorax occurred,
was treated
conservatively.
Thrombosis
was seen in
two patients after 30 and 1 03 days. Sepsis was the reason for removing 1 4 catheters (one was occluded also); two catheter migrated and were subsequently removed. The differences in success rates between the two groups
were not statistically related complications, icant difference
significant. however,
in favor
of group
The occurrence of punctureshowed a statistically signif1 (p
