Pasteur
Rasuli,
MD,
FRCP(C)
Spontaneous Long-term
D. Ian Hammond,
MD,
#{149}
FRCP(C)
Intrajugular Central Venous
Ian R. Peterkin,
MD
#{149}
Migration Access
of Catheters’
Two patients with long-term central venous access catheters introduced via the right subclavian vein demonstrated catheter migration into the right internal jugular vein several months after satisfactory catheter placement. One patient developed internal jugular vein thrombosis,
direct
which
infusion
was
treated
of urokinase
catheter removal. the catheter was
In the other repositioned
an intravascular
snare
introduced first patient,
suggested
which
the
catheter
which
the mechanism had
a clue for early migration.
Index term: complications
Radiology
loop,
patient, by using
was
via the femoral vein. In the an interim chest radio-
graph provided catheter
with
before
Catheters
and
migrated
detection
by and
of
catheterization,
Figures
1, 2. Case
catheter placement
1.
(1) Chest
shows satisfactory reveals migration
radiograph
position of the
in the catheter
obtained
after
surgical
placement
of
15 month
after
1992; 182:822-824
central venous access cathare in wide use for chemotherapy and parenteral nutrition in patients with cancer and other debilitating ONG-TERM
eters
diseases.
They
are
surgically
inserted
and fixed in the soft tissues of the chest wall to prevent infection and accidental disbodgment. Therefore, removal and reinsertion of such catheters is more complex than with standard central yenous catheters, which can be easily exchanged over a guide wire. Complications associated with these catheters include infection, thrombosis, venous perforation, catheter breakage, catheter dislodgment
From the Department of Radiology, University of Ottawa Faculty of Medicine and Ottawa General Hospital, 501 Smyth, Ottawa, Ont, Canada K1H 8L6. Received September 13, 1991; accepted October 10. Address reprint requests to P.R. ( RSNA, 1992
822
2 months
SVC. (2) Chest radiograph obtained tip up into the right jugular vein.
and
fallout,
subintimal
catheter entrapment, and catheter tip migration to neighboring veins after satisfactory initial placement (1,2). Dislodgment signifies displacement of the entire catheter, including the fixed tunneled portion, and usually requires removal of the catheter, since reinsertion may cause infection. A migrated catheter tip, however, may be repositioned safely. Lois et al (1), describing techniques for repositioning central venous catheters, used the term migration in a broad sense to include subintimal entrapment and partial disbodgment as well as true migration, which we would define as displacement of the tip of an undislodged catheter from a documented satisfactory position in the su-
perior vena cava (SVC) into a neighboring vein. Because of indiscriminate use of the term migration, the incidence of true migration is probably not known, but it seems to be a rare event.
CASE
REPORTS
Case 1.-A 42-year-old woman with metastatic breast cancer underwent surgical placement of a Port-a-cath (Pharmacia, Piscataway, NJ) via the right subclavian vein in February 1990. (The Port-a-cath is a long-term central ye-
nous access catheter that differs from the Hickman and Broviac catheters [Bard, Murray Hill, NJ] in that it is connected to an infusion sac that is placed subcutaneously in the chest wall.) Satisfactory placement of the catheter tip in the SVC was documented on a postop-
erative
chest
radiograph 1). In May
catheter mitted
radiograph
and
on a chest
obtained 2 months later (Fig 1991, almost 15 months after
placement, the patient was adto the hospital with a 3-day his-
tory of progressive pain and swelling the right side of her neck, beginning several hours after her catheter had
been
flushed
by a home
chest radiograph admission revealed
catheter
tip from
internal
jugular
care
nurse.
on
A
obtained on the day migration of the
the SVC into vein,
with
the
the right tip point-
of
ing
cranially
patient could physical cial
(Fig
2).
By
had such severe not sleep or bend examination,
edema
and
a 4-cm
time, the pain that she her neck. On she had mild fathis
erythematous,
tender mass in the right submandibular region. No chemotherapeutic agents had been administered through the catheter for the previous 12 months. A right upper limb venogram revealed thrombosis of the right innominate vein and presumptive evidence of right internal
jugular
vein
puted tomography neck confirmed internal jugular extended to the
thrombosis.
Corn-
(CT) of the head and the presence of right vein thrombosis, which base of the skull but did
not involve
the intracranial
veins
(Fig
placed,
3).
Urokinase (Abbokinase; Abbott Laboratories, North Chicago, Ill) was infused through the catheter into the thrombus as a 250,000-U bolus followed by continuous infusion at a rate of 250,000 U/h for 6 hours. With this treatment, the swelling and pain improved overnight,
and the catheter was surgically removed the following day without any complications. charged 2 days
The patient later.
In retrospect, tamed 3 months
a chest before
shown spontaneous ter into the right
where was
it looped directed
was
dis-
radiograph admission
obhad
ascent of the catheinternal jugular vein,
on itself caudally
so that
toward
prostate
cancer
chest
radiograph
the
right
did a second months after which
time
the period
Figure
3. Case 1. CT scan of the neck catheter within the thrombosed lumen right internal jugular vein (arrow).
internal
underwent
surgi-
confirmed
jugular
via
satis-
vein,
as
chest radiograph taken catheter placement, at we
that
were
consulted.
the catheter
the
catheter
were
unsuccessful.
was
pulled
leased
down
(Figs
into
the
SVC
and
re-
5, 6).
DISCUSSION
factory position of the catheter tip in the SVC. Two months later, a chest radiograph revealed spontaneous migration of the tip of the catheter from the SVC into
through
The following day, after a venogram showed that there was no thrombus in the right internal jugular vein, the tip of the catheter was easily snared via a transfemoral approach with a 6-F, 35mm-wide gooseneck Amplatz snare (Microvena, Vadnais Heights, Minn). With the snare loop open to a diameter of approximately 1 cm, the catheter tip
in-
cal placement of a Hickman catheter the right subclavian vein. A postprocedural
agents
the tip the
nominate vein. This appearance had been misinterpreted radiographically as a partially withdrawn jugular venous line (Fig 4), and no action had been taken at the time. Case 2.-A 71-year-old man with metastatic
no chernotherapeutic
were infused. Attempts to reposition the catheter tip by means of direct introduction of different guide wires
During
was dis-
4
The English literature contains several reports of central venous catheters malpositioned
and
discusses
at the
time
of insertion
the therapeutic
implica-
tions (3). Mirro et al (2) reported cases of catheter migration-all ing removal-associated with
term
central
venous
access
three requir359 long-
devices
in
children. In addition, Lois et al (1) descnbed the intenventional techniques they used in attempting to reposition central venous catheters whose tips had
migrated into the internal jugular vein in two patients. They were able to reposition a left subclavian catheter whose tip had
ment
moved
into
of the night
the
most
internal
caudal
jugular
seg-
vein
in one patient (on two separate occasions) but were unsuccessful in a second
shows of the
Figure
4. Case 1. Interim chest radiograph obtained 12 months after placement demonstrates looping of the shaft of the catheter in the right internal jugular vein, with the tip directed caudally. This appearance was misinterpreted as a partially dislodged jugular line.
Volume
182
Number
#{149}
3
5 6. Figures 5, 6. Case 2. (5) Spot radiograph shows platinum-tipped the right internal jugular vein alongside the migrated segment graph shows catheter snared with gooseneck snare and pulled
snare of the down
catheter
positioned
catheter. (6) Spot to the SVC.
Radiology
in
radio-
823
#{149}
patient whose catheter had migrated 10 cm up into the internal jugular vein. In each instance, a subclavian rather than femoral approach was used for catheter manipulation. Our experience confirms the potential for catheter migration and the risk of subsequent venous thrombosis. Because these catheters for a relatively
should when
are meant long time,
to be in place their position
be monitored at least bimonthly they are not in use and more fre-
quently
when
they
are
being
used
for
infusion of chemotherapeutic administration of hyperosmolar
agents or solu-
tions,
nutrition
such
as total
parenteral
and blood products. The for the tip of the catheter which
is a large
vessel
ideal
location
is in the SVC, with high flow
of catheter migration before the development of venous thrombosis enables intenventional reposition(3).
Detection
Spontaneous
migration
of these
(Dow Corning, Midland, may be related to their
Silastic catheters
ent flexibility,
which
allows
displaced when there are changes in venous pressure may occur with coughing
them
soft Mich) inher-
to be
sudden and flow, as or cardiac ar-
rhythmia. The cephalad looping of the catheter into the internal jugular vein in our first patient suggests that catheter migration up into the internal jugular vein is not an instantaneous event. It begins with herniation of a short segment of the shaft of the catheter into the internal jugular vein. Because the hub end of the catheter is fixed, further herniation will result in progressive cranial migration of the catheter tip. On a chest radiograph, a catheter that has partially migrated may serted directly
be mistaken for one ininto the jugular vein be-
approached either by passing a guide wire directly through the catheter (1) or by introducing a snare ioop through the femorab vein, as in our second patient.
cause the portion of the catheter that is in the subclavian vein may be thought to be on the surface of the patient’s body. Careful review of previous chest radiographs and communication with the attending physician can prevent
With
such
ing.
A Hickman
lion
catheter
a Port-a-cath, because
the
documented phy,
the
catheter
with
port
catheter
in pulmonary thrombosis
and
late that
of the
ogy
cathe-
tissues. In eiof thromboshould
first
ultrasound,
be
venogra-
of penicatheter manipulation
thrommay
result
emboli or permanent of the jugular, subclavian,
innominate
veins.
Vigorous
local
treatment with streptokinase or urokinase has been successfully employed to avoid this complication (4-6); therefore,
transcatheter
infusion
of a fibrinolytic
agent before surgical or radiologic vention should be considered.
inter-
Radiology
#{149}
plays
It is reasonable
the patient’s a role
to specu-
venous
in migration,
tients that activities such ing that require extreme
of preventing
duced
as weight Valsalva
liftma-
we
believe
thrombosis,
complication
than
the development that would lie in the prevent catheter mithat
catheter-in-
a more migration,
common would
then lead to more extensive thrombosis of the SVC extending below the azygos vein insertion, eliminating this venous channel, which is an important bypass route in patients with SVC thrombosis. Periodic monitoring of catheter position with chest radiography can enable detection of migration early and allow for interventional repositioning before thrombosis develops. Radiologists must be vigilant in ensuring that the position of these catheters is correct. U References 1.
2.
3.
in that
neuvers may lead to catheter migration. Manufacturers might wish to investigate the possibility of wire-braiding the proximal half of the Hickman catheter and adding a wide curvature to fit the right subclavian-innominate venous as means
gration,
morphol-
migration is more likely to occur if the jugular vein is of large caliber or if it forms an obtuse angle with the subclavian vein. Our first patient related the onset of her symptoms to the flushing of her catheter, and this action may also influence catheter migration. It might be prudent to caution physically active pa-
angle
824
an error.
via a femoral
or CT.
In the presence bosis,
intenven-
only
ter is in the subcutaneous ther situation, the absence sis around
be
radiologic
can be attempted
approach,
can
migration. Although of longer catheters right atrium might
4.
5.
LoisJF, Gomes AS, Pusey E. Nonsurgical repositioning of central venous catheters. Radiology 1987; 165:329-333. Mirro J, Rao BN, Kumar M, et al. A cornparison of placement techniques and complications of externalized catheters and implantable port use in children with cancer. Pediatr Surg 1990; 25:120-124. Walker TG, Geller SG, Waltrnan AC, Malt RA, Athanasoulis CA. A simple technique for redirection of malpositioned Broviac or Hickman catheters. Surg Gynecol Obstet 1988; 167:247-249. Rubenstein M, Creger WP. Successful streptokinase therapy for catheter-induced subclavian thrombosis. Arch Intern Med 1980; 140:1370-1371. Matthews JA, Blake HA, Hall DJ. latrogenic superior vena cava syndrome treated with streptokinase. Radiol Oncol 1987; 26: 119-122.
6.
Fraschini
Carrasco
G, Jadeja J, Lawson M, Holmes HC, Wallace S. Local infusion
urokinase for lysis of thrombosis associated with permanent central venous catheters cancer patients. J Clin Oncol 1987; 5:672678.
FA, of in
catheter
March
1992
Rasuli,
MD,
FRCP(C)
Spontaneous Long-term
D. Ian Hammond,
MD,
#{149}
FRCP(C)
Intrajugular Central Venous
Ian R. Peterkin,
MD
#{149}
Migration Access
of Catheters’
Two patients with long-term central venous access catheters introduced via the right subclavian vein demonstrated catheter migration into the right internal jugular vein several months after satisfactory catheter placement. One patient developed internal jugular vein thrombosis,
direct
which
infusion
was
treated
of urokinase
catheter removal. the catheter was
In the other repositioned
an intravascular
snare
introduced first patient,
suggested
which
the
catheter
which
the mechanism had
a clue for early migration.
Index term: complications
Radiology
loop,
patient, by using
was
via the femoral vein. In the an interim chest radio-
graph provided catheter
with
before
Catheters
and
migrated
detection
by and
of
catheterization,
Figures
1, 2. Case
catheter placement
1.
(1) Chest
shows satisfactory reveals migration
radiograph
position of the
in the catheter
obtained
after
surgical
placement
of
15 month
after
1992; 182:822-824
central venous access cathare in wide use for chemotherapy and parenteral nutrition in patients with cancer and other debilitating ONG-TERM
eters
diseases.
They
are
surgically
inserted
and fixed in the soft tissues of the chest wall to prevent infection and accidental disbodgment. Therefore, removal and reinsertion of such catheters is more complex than with standard central yenous catheters, which can be easily exchanged over a guide wire. Complications associated with these catheters include infection, thrombosis, venous perforation, catheter breakage, catheter dislodgment
From the Department of Radiology, University of Ottawa Faculty of Medicine and Ottawa General Hospital, 501 Smyth, Ottawa, Ont, Canada K1H 8L6. Received September 13, 1991; accepted October 10. Address reprint requests to P.R. ( RSNA, 1992
822
2 months
SVC. (2) Chest radiograph obtained tip up into the right jugular vein.
and
fallout,
subintimal
catheter entrapment, and catheter tip migration to neighboring veins after satisfactory initial placement (1,2). Dislodgment signifies displacement of the entire catheter, including the fixed tunneled portion, and usually requires removal of the catheter, since reinsertion may cause infection. A migrated catheter tip, however, may be repositioned safely. Lois et al (1), describing techniques for repositioning central venous catheters, used the term migration in a broad sense to include subintimal entrapment and partial disbodgment as well as true migration, which we would define as displacement of the tip of an undislodged catheter from a documented satisfactory position in the su-
perior vena cava (SVC) into a neighboring vein. Because of indiscriminate use of the term migration, the incidence of true migration is probably not known, but it seems to be a rare event.
CASE
REPORTS
Case 1.-A 42-year-old woman with metastatic breast cancer underwent surgical placement of a Port-a-cath (Pharmacia, Piscataway, NJ) via the right subclavian vein in February 1990. (The Port-a-cath is a long-term central ye-
nous access catheter that differs from the Hickman and Broviac catheters [Bard, Murray Hill, NJ] in that it is connected to an infusion sac that is placed subcutaneously in the chest wall.) Satisfactory placement of the catheter tip in the SVC was documented on a postop-
erative
chest
radiograph 1). In May
catheter mitted
radiograph
and
on a chest
obtained 2 months later (Fig 1991, almost 15 months after
placement, the patient was adto the hospital with a 3-day his-
tory of progressive pain and swelling the right side of her neck, beginning several hours after her catheter had
been
flushed
by a home
chest radiograph admission revealed
catheter
tip from
internal
jugular
care
nurse.
on
A
obtained on the day migration of the
the SVC into vein,
with
the
the right tip point-
of
ing
cranially
patient could physical cial
(Fig
2).
By
had such severe not sleep or bend examination,
edema
and
a 4-cm
time, the pain that she her neck. On she had mild fathis
erythematous,
tender mass in the right submandibular region. No chemotherapeutic agents had been administered through the catheter for the previous 12 months. A right upper limb venogram revealed thrombosis of the right innominate vein and presumptive evidence of right internal
jugular
vein
puted tomography neck confirmed internal jugular extended to the
thrombosis.
Corn-
(CT) of the head and the presence of right vein thrombosis, which base of the skull but did
not involve
the intracranial
veins
(Fig
placed,
3).
Urokinase (Abbokinase; Abbott Laboratories, North Chicago, Ill) was infused through the catheter into the thrombus as a 250,000-U bolus followed by continuous infusion at a rate of 250,000 U/h for 6 hours. With this treatment, the swelling and pain improved overnight,
and the catheter was surgically removed the following day without any complications. charged 2 days
The patient later.
In retrospect, tamed 3 months
a chest before
shown spontaneous ter into the right
where was
it looped directed
was
dis-
radiograph admission
obhad
ascent of the catheinternal jugular vein,
on itself caudally
so that
toward
prostate
cancer
chest
radiograph
the
right
did a second months after which
time
the period
Figure
3. Case 1. CT scan of the neck catheter within the thrombosed lumen right internal jugular vein (arrow).
internal
underwent
surgi-
confirmed
jugular
via
satis-
vein,
as
chest radiograph taken catheter placement, at we
that
were
consulted.
the catheter
the
catheter
were
unsuccessful.
was
pulled
leased
down
(Figs
into
the
SVC
and
re-
5, 6).
DISCUSSION
factory position of the catheter tip in the SVC. Two months later, a chest radiograph revealed spontaneous migration of the tip of the catheter from the SVC into
through
The following day, after a venogram showed that there was no thrombus in the right internal jugular vein, the tip of the catheter was easily snared via a transfemoral approach with a 6-F, 35mm-wide gooseneck Amplatz snare (Microvena, Vadnais Heights, Minn). With the snare loop open to a diameter of approximately 1 cm, the catheter tip
in-
cal placement of a Hickman catheter the right subclavian vein. A postprocedural
agents
the tip the
nominate vein. This appearance had been misinterpreted radiographically as a partially withdrawn jugular venous line (Fig 4), and no action had been taken at the time. Case 2.-A 71-year-old man with metastatic
no chernotherapeutic
were infused. Attempts to reposition the catheter tip by means of direct introduction of different guide wires
During
was dis-
4
The English literature contains several reports of central venous catheters malpositioned
and
discusses
at the
time
of insertion
the therapeutic
implica-
tions (3). Mirro et al (2) reported cases of catheter migration-all ing removal-associated with
term
central
venous
access
three requir359 long-
devices
in
children. In addition, Lois et al (1) descnbed the intenventional techniques they used in attempting to reposition central venous catheters whose tips had
migrated into the internal jugular vein in two patients. They were able to reposition a left subclavian catheter whose tip had
ment
moved
into
of the night
the
most
internal
caudal
jugular
seg-
vein
in one patient (on two separate occasions) but were unsuccessful in a second
shows of the
Figure
4. Case 1. Interim chest radiograph obtained 12 months after placement demonstrates looping of the shaft of the catheter in the right internal jugular vein, with the tip directed caudally. This appearance was misinterpreted as a partially dislodged jugular line.
Volume
182
Number
#{149}
3
5 6. Figures 5, 6. Case 2. (5) Spot radiograph shows platinum-tipped the right internal jugular vein alongside the migrated segment graph shows catheter snared with gooseneck snare and pulled
snare of the down
catheter
positioned
catheter. (6) Spot to the SVC.
Radiology
in
radio-
823
#{149}
patient whose catheter had migrated 10 cm up into the internal jugular vein. In each instance, a subclavian rather than femoral approach was used for catheter manipulation. Our experience confirms the potential for catheter migration and the risk of subsequent venous thrombosis. Because these catheters for a relatively
should when
are meant long time,
to be in place their position
be monitored at least bimonthly they are not in use and more fre-
quently
when
they
are
being
used
for
infusion of chemotherapeutic administration of hyperosmolar
agents or solu-
tions,
nutrition
such
as total
parenteral
and blood products. The for the tip of the catheter which
is a large
vessel
ideal
location
is in the SVC, with high flow
of catheter migration before the development of venous thrombosis enables intenventional reposition(3).
Detection
Spontaneous
migration
of these
(Dow Corning, Midland, may be related to their
Silastic catheters
ent flexibility,
which
allows
displaced when there are changes in venous pressure may occur with coughing
them
soft Mich) inher-
to be
sudden and flow, as or cardiac ar-
rhythmia. The cephalad looping of the catheter into the internal jugular vein in our first patient suggests that catheter migration up into the internal jugular vein is not an instantaneous event. It begins with herniation of a short segment of the shaft of the catheter into the internal jugular vein. Because the hub end of the catheter is fixed, further herniation will result in progressive cranial migration of the catheter tip. On a chest radiograph, a catheter that has partially migrated may serted directly
be mistaken for one ininto the jugular vein be-
approached either by passing a guide wire directly through the catheter (1) or by introducing a snare ioop through the femorab vein, as in our second patient.
cause the portion of the catheter that is in the subclavian vein may be thought to be on the surface of the patient’s body. Careful review of previous chest radiographs and communication with the attending physician can prevent
With
such
ing.
A Hickman
lion
catheter
a Port-a-cath, because
the
documented phy,
the
catheter
with
port
catheter
in pulmonary thrombosis
and
late that
of the
ogy
cathe-
tissues. In eiof thromboshould
first
ultrasound,
be
venogra-
of penicatheter manipulation
thrommay
result
emboli or permanent of the jugular, subclavian,
innominate
veins.
Vigorous
local
treatment with streptokinase or urokinase has been successfully employed to avoid this complication (4-6); therefore,
transcatheter
infusion
of a fibrinolytic
agent before surgical or radiologic vention should be considered.
inter-
Radiology
#{149}
plays
It is reasonable
the patient’s a role
to specu-
venous
in migration,
tients that activities such ing that require extreme
of preventing
duced
as weight Valsalva
liftma-
we
believe
thrombosis,
complication
than
the development that would lie in the prevent catheter mithat
catheter-in-
a more migration,
common would
then lead to more extensive thrombosis of the SVC extending below the azygos vein insertion, eliminating this venous channel, which is an important bypass route in patients with SVC thrombosis. Periodic monitoring of catheter position with chest radiography can enable detection of migration early and allow for interventional repositioning before thrombosis develops. Radiologists must be vigilant in ensuring that the position of these catheters is correct. U References 1.
2.
3.
in that
neuvers may lead to catheter migration. Manufacturers might wish to investigate the possibility of wire-braiding the proximal half of the Hickman catheter and adding a wide curvature to fit the right subclavian-innominate venous as means
gration,
morphol-
migration is more likely to occur if the jugular vein is of large caliber or if it forms an obtuse angle with the subclavian vein. Our first patient related the onset of her symptoms to the flushing of her catheter, and this action may also influence catheter migration. It might be prudent to caution physically active pa-
angle
824
an error.
via a femoral
or CT.
In the presence bosis,
intenven-
only
ter is in the subcutaneous ther situation, the absence sis around
be
radiologic
can be attempted
approach,
can
migration. Although of longer catheters right atrium might
4.
5.
LoisJF, Gomes AS, Pusey E. Nonsurgical repositioning of central venous catheters. Radiology 1987; 165:329-333. Mirro J, Rao BN, Kumar M, et al. A cornparison of placement techniques and complications of externalized catheters and implantable port use in children with cancer. Pediatr Surg 1990; 25:120-124. Walker TG, Geller SG, Waltrnan AC, Malt RA, Athanasoulis CA. A simple technique for redirection of malpositioned Broviac or Hickman catheters. Surg Gynecol Obstet 1988; 167:247-249. Rubenstein M, Creger WP. Successful streptokinase therapy for catheter-induced subclavian thrombosis. Arch Intern Med 1980; 140:1370-1371. Matthews JA, Blake HA, Hall DJ. latrogenic superior vena cava syndrome treated with streptokinase. Radiol Oncol 1987; 26: 119-122.
6.
Fraschini
Carrasco
G, Jadeja J, Lawson M, Holmes HC, Wallace S. Local infusion
urokinase for lysis of thrombosis associated with permanent central venous catheters cancer patients. J Clin Oncol 1987; 5:672678.
FA, of in
catheter
March
1992
