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i 83
Technical .
Simple Technique Venous Catheters P. Recht,1’2
.
,
.
.
‘;r
‘1-
Michael
,
Dana
R. Burke,1
.
-4
for Redirecting Steven
G. Meranze,1
Central venous catheterization by using the infraclavicular subclavian vein approach is a standard method of monitoring central venous pressure, administering hyperalimentation, maintaining venous access when there is a lack of peripheral veins, and administering irritating solutions such as antibiotics or chemotherapeutic agents. Unfortunately, the infraclavicular approach has a significant rate of complication. A frequent problem is malpositioning of the catheter tip, which occurs in 1 i -i 9% of cases [i 2]. Several techniques for redirecting the catheter tip into the superior vena cava have been described [3, 4]. However, in certain circumstances, such as an inadvertent direct internal jugular puncture or a very central subclavian vein puncture, these maneuvers are often unsuccessful, necessitating repuncture of the subclavian vein. In 2i recent cases of direct internal jugular punctures, we have successfully used a Simmons catheter, reshaped with the suture technique [5], to reposition the central line into the superior vena cava, obviating repuncture of the subclavian vein. ,
.
:
Malpositioned
and Constantin
Note .
#{149}
.
‘
Central
Cope1
The catheter is removed over a 0.038-in. (0.97 mm) guidewire. A 5.5-French Simmons 1 catheter (Cook, Bloomington, IN) is then inserted and reshaped within the jugular vein by using the technique described by Cope (Fig. 2) [5]. In this technique (Fig. 3), the free end of a standard 75-cm length of tough braided surgical plastic suture (4.0 Tevdek, Deknatel, Queens Village, NY) is threaded through the tip of the Simmons catheter for approximately 3 cm. The catheter with the preloaded suture is then threaded over the guidewire into the vein. Under fluoroscopic guidance, the guidewire is then retracted until only the floppy tip protrudes from the catheter. The trailing end of the suture is then gently pulled, causing the sidewinder shape to be re-formed. The guidewire is then removed from the catheter, freeing the suture and allowing it to be extracted from the vein. Once re-formed, the Simmons catheter is pulled down into the superior vena cava and exchanged over a guidewire for a central venous catheter (Fig. 4). In all 21 cases, the central venous catheter tip was repositioned successfully in the superior vena cava by using this method. There were no failures, and no morbidity was associated with the procedure.
Discussion Materials
and Methods
Between April 1 987 and December 1 988, 21 patients presented to the angiography/interventional radiology section with central yenous catheters directly inserted into the internal jugular vein. Eleven catheters were in the right internal jugular vein, and 1 0 were in the left internal jugular vein (Fig. 1). All 21 catheters were repositioned by using the following technique.
The shepherd’s crook curve of the Simmons catheter is well suited to redirecting catheters from the internal jugular vein to the superior vena cava. However, the potential difficulty of re-forming the Simmons shape in the internal jugular vein prevented its use for this function. The Simmons catheter can easily, quickly, and safely be reshaped in the internal jugular vein by using the suture technique.
Received January 31 , 1989; accepted after revision May 22, 1989. , Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4034. 2 Present address: Department of Radiology, University Hospitals of Cleveland, 2074 Abington Rd., Cleveland, Recht. AJR 154:183-184,
January
1990 0361-803X/90/1541-0183
© American Roentgen Ray Society
OH 44106. Address reprint requests to M. P.
Downloaded from www.ajronline.org by 109.161.205.156 on 11/15/15 from IP address 109.161.205.156. Copyright ARRS. For personal use only; all rights reserved
Fig. reveals
1.-Injection of central venous catheter direct internal jugular vein puncture.
Fig. 2.-Simmons catheter being reshaped in internal jugular vein by gentie traction on suture (arrow Indicates tip of catheter).
I
2
Fig. 4.-Simmons innominate vein.
Fig. 3.-A,
Simmons
catheter
preloaded
with Tevdek
suture advanced
over guidewire into jugular vein. B, Guidewire withdrawn so that only its floppy tip protrudes from catheter. C and D, Tension applied to suture, causing sidewinder shape to be reformed.
Damage to the vein wall by the suture while reshaping the catheter is unlikely because very little tension needs to be developed. Another potential problem occurs-when the suture slips and fails to reshape the catheter; this can be remedied by making a small knot on the end of the suture to improve the friction fit. In our earlier cases, several techniques, such as buckling soft-tip guidewires, use of torqueable guidewires or cobra catheters, or turning the end of the catheter with a tipdeflecting wire, were tried unsuccessfully before we used the suture technique with the Simmons catheter. Because the other techniques require that the catheter be withdrawn almost to the puncture site before redirection is attempted, loss
catheter
being
used
to redirect
the guidewire
Into left
of access as well as procedure failure is not infrequent, particularly in cases of direct jugular puncture. Also, torqueable wires and deflecting wires are relatively rigid, with more potential for vascular damage than floppy-tipped wires. Once we became convinced of the efficacy of the suture technique, we used it primarily in cases of direct internal jugular or central subclavian punctures, resulting in significant decreases in time and equipment expenditure.
REFERENCES
1 . van Berge Henegouwen DP, Marinkovic D, Lam D, Brummelkamp WH. Roentgenological monitoring of the position of subclavian catheters introduced by the infraclavicular approach. Diagn Imag Clin Med 1980;49: 320-325 2. Deitel M, McIntyre JA. Radiographic confirmation of site of central venous pressure catheters. Can J Surg 1971;14:42-51 3. Hawkins IF Jr, Paige AM. Redirection of malpositioned central venous catheters. AJR 1983;140:393-394 4. Carrasco CH, Richli WR, Chamsangavej C, Wallace S. Technical note: repositioning misplaced central venous catheters. Cardiovasc Intervent Radiol 1987; 10:234-236 5. Cope C. Suture technique to reshape J Intervent Radiol 1986;1 :63-64
the
“sidewinder”
catheter
curve.
i 83
Technical .
Simple Technique Venous Catheters P. Recht,1’2
.
,
.
.
‘;r
‘1-
Michael
,
Dana
R. Burke,1
.
-4
for Redirecting Steven
G. Meranze,1
Central venous catheterization by using the infraclavicular subclavian vein approach is a standard method of monitoring central venous pressure, administering hyperalimentation, maintaining venous access when there is a lack of peripheral veins, and administering irritating solutions such as antibiotics or chemotherapeutic agents. Unfortunately, the infraclavicular approach has a significant rate of complication. A frequent problem is malpositioning of the catheter tip, which occurs in 1 i -i 9% of cases [i 2]. Several techniques for redirecting the catheter tip into the superior vena cava have been described [3, 4]. However, in certain circumstances, such as an inadvertent direct internal jugular puncture or a very central subclavian vein puncture, these maneuvers are often unsuccessful, necessitating repuncture of the subclavian vein. In 2i recent cases of direct internal jugular punctures, we have successfully used a Simmons catheter, reshaped with the suture technique [5], to reposition the central line into the superior vena cava, obviating repuncture of the subclavian vein. ,
.
:
Malpositioned
and Constantin
Note .
#{149}
.
‘
Central
Cope1
The catheter is removed over a 0.038-in. (0.97 mm) guidewire. A 5.5-French Simmons 1 catheter (Cook, Bloomington, IN) is then inserted and reshaped within the jugular vein by using the technique described by Cope (Fig. 2) [5]. In this technique (Fig. 3), the free end of a standard 75-cm length of tough braided surgical plastic suture (4.0 Tevdek, Deknatel, Queens Village, NY) is threaded through the tip of the Simmons catheter for approximately 3 cm. The catheter with the preloaded suture is then threaded over the guidewire into the vein. Under fluoroscopic guidance, the guidewire is then retracted until only the floppy tip protrudes from the catheter. The trailing end of the suture is then gently pulled, causing the sidewinder shape to be re-formed. The guidewire is then removed from the catheter, freeing the suture and allowing it to be extracted from the vein. Once re-formed, the Simmons catheter is pulled down into the superior vena cava and exchanged over a guidewire for a central venous catheter (Fig. 4). In all 21 cases, the central venous catheter tip was repositioned successfully in the superior vena cava by using this method. There were no failures, and no morbidity was associated with the procedure.
Discussion Materials
and Methods
Between April 1 987 and December 1 988, 21 patients presented to the angiography/interventional radiology section with central yenous catheters directly inserted into the internal jugular vein. Eleven catheters were in the right internal jugular vein, and 1 0 were in the left internal jugular vein (Fig. 1). All 21 catheters were repositioned by using the following technique.
The shepherd’s crook curve of the Simmons catheter is well suited to redirecting catheters from the internal jugular vein to the superior vena cava. However, the potential difficulty of re-forming the Simmons shape in the internal jugular vein prevented its use for this function. The Simmons catheter can easily, quickly, and safely be reshaped in the internal jugular vein by using the suture technique.
Received January 31 , 1989; accepted after revision May 22, 1989. , Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4034. 2 Present address: Department of Radiology, University Hospitals of Cleveland, 2074 Abington Rd., Cleveland, Recht. AJR 154:183-184,
January
1990 0361-803X/90/1541-0183
© American Roentgen Ray Society
OH 44106. Address reprint requests to M. P.
Downloaded from www.ajronline.org by 109.161.205.156 on 11/15/15 from IP address 109.161.205.156. Copyright ARRS. For personal use only; all rights reserved
Fig. reveals
1.-Injection of central venous catheter direct internal jugular vein puncture.
Fig. 2.-Simmons catheter being reshaped in internal jugular vein by gentie traction on suture (arrow Indicates tip of catheter).
I
2
Fig. 4.-Simmons innominate vein.
Fig. 3.-A,
Simmons
catheter
preloaded
with Tevdek
suture advanced
over guidewire into jugular vein. B, Guidewire withdrawn so that only its floppy tip protrudes from catheter. C and D, Tension applied to suture, causing sidewinder shape to be reformed.
Damage to the vein wall by the suture while reshaping the catheter is unlikely because very little tension needs to be developed. Another potential problem occurs-when the suture slips and fails to reshape the catheter; this can be remedied by making a small knot on the end of the suture to improve the friction fit. In our earlier cases, several techniques, such as buckling soft-tip guidewires, use of torqueable guidewires or cobra catheters, or turning the end of the catheter with a tipdeflecting wire, were tried unsuccessfully before we used the suture technique with the Simmons catheter. Because the other techniques require that the catheter be withdrawn almost to the puncture site before redirection is attempted, loss
catheter
being
used
to redirect
the guidewire
Into left
of access as well as procedure failure is not infrequent, particularly in cases of direct jugular puncture. Also, torqueable wires and deflecting wires are relatively rigid, with more potential for vascular damage than floppy-tipped wires. Once we became convinced of the efficacy of the suture technique, we used it primarily in cases of direct internal jugular or central subclavian punctures, resulting in significant decreases in time and equipment expenditure.
REFERENCES
1 . van Berge Henegouwen DP, Marinkovic D, Lam D, Brummelkamp WH. Roentgenological monitoring of the position of subclavian catheters introduced by the infraclavicular approach. Diagn Imag Clin Med 1980;49: 320-325 2. Deitel M, McIntyre JA. Radiographic confirmation of site of central venous pressure catheters. Can J Surg 1971;14:42-51 3. Hawkins IF Jr, Paige AM. Redirection of malpositioned central venous catheters. AJR 1983;140:393-394 4. Carrasco CH, Richli WR, Chamsangavej C, Wallace S. Technical note: repositioning misplaced central venous catheters. Cardiovasc Intervent Radiol 1987; 10:234-236 5. Cope C. Suture technique to reshape J Intervent Radiol 1986;1 :63-64
the
“sidewinder”
catheter
curve.
