1. Management of Catheter-Related Complications: Perspective of an Interventional Radiologist Thomas M. Vesely, M.D. Mallinckrodt Institute of Radiology Washington University School of Medicine Saint Louis, Missouri

2. Catheter-Related Complications Catheter Insertion - malposition - pneumothorax - vascular injury - air embolism - arrhythmias - bleeding - access site thrombosis Catheter Removal - catheter fracture - bleeding - air embolism Catheter Use - infection - air embolism Catheter Duration - dysfunction - thrombosis - fibrin sheath - infection - venous stenosis - catheter fracture

3. Interventional Radiology Evaluation of dysfunctional catheters Treatment of catheter-related complications - infection : catheter exchange - stenosis : angioplasty / stents - thrombosis : thrombolysis Foreign body retrieval

4. Evaluation of Dysfunctional Catheters Inspection - infection - catheter integrity Fluoroscopy - tip position - kinks Contrast injection - thrombus - fibrin sheath catheter tip in pulmonary artery

5. Inspection of Catheter and Skin Exit Site Infected port purulent drainage from tunnel exposed port

6. Catheter Related Venous Thrombosis

7. Inspect Pinch Clamps Hemodialysis catheter Pinch clamps must be periodically moved to avoid causing permanent kinks in tubing kinked tubing

8. Bring patient into angiography suite for fluoroscopy and contrast injection.

9. Angiography Suite fluoroscopy Portable ultrasound unit

10. Evaluation of Dysfunctional Catheters Early problems are usually technical: - catheter kinking - tip malposition Late problems are usually due to: - intraluminal thrombus - pericatheter thrombus - fibrin sheath formation kinked malpositioned

11. Patient referred because of difficulty with removing wire from PICC following the insertion procedure. Fluoroscopy of the entire catheter

12. severely twisted PICC

13. Unusual appearance of PICC within the left arm.

14. Course of PICC suggests left subclavian artery

15. Pulsatile blood flow from PICC insertion site

16. Yikes !!!! Who put in that PICC ?

17. Kinked Catheters kinked lumen kinked tips High resolution fluoroscopy may be necessary to identify subtle kinks in the catheter lumens

18. Use of an extra-stiff guidewire to reduce a kink in a central venous catheter kink extra stiff guidewire kink is reduced

19. Snares Used for intravascular retrieval / manipulation Snare loop at 90° to shaft of guidewire Nitinol - kink resistant Used within snare catheter

20. Catheter Tip Repositioning Use of an Endovascular Snare

21. right chest port catheter looped into right internal jugular vein

22. right femoral vein venous access site attempting to snare the catheter snare is used to pull catheter into position

23. The loop in the catheter has been removed.

24. Foreign Body Retrieval Removal of broken catheter fragments. catheter snapped off

25. Snare inserted from the femoral vein

26. catheter fragment is pulled through the right atrium pulled into the IVC and out of the femoral vein

27. Evaluation of Dysfunctional Catheters Poorly functioning port. Port inserted through the right subclavian vein. Catheter tip in the SVC. “Ballooning” of catheter when injected

28. “Pinch-Off” is due to entrapment of the catheter in the subclavius muscle – costoclavicular ligament complex “ Pinch-Off” Phenomenon A Complication of Subclavian Catheters subclavian vein pinching of vein pinching of vein catheter in vein compressed by ligaments and bones

29. fractured port catheter due to “Pinch-Off” “ Pinch-Off” Phenomenon A Complication of Subclavian Catheters fractured port catheter

30. Injection of X-ray Contrast to Evaluate the Dysfunctional Catheter

31. Evaluation of Dysfunctional Catheters Always aspirate the heparin from the catheter before injecting contrast material. Catheters are routinely “locked” with heparin solution. 1.5 ml per lumen X 5000 u heparin /ml = 7500 units heparin per lumen Hemodialysis catheters :

32. SYRINGE PRESSURE SyringePressureSuction SizeGeneratedGenerated (ml)(atm)(atm) 505.20.98 109.40.90 321.00.67 140.00.50

33. Injecting x-ray contrast through the catheter will provide visualization of the catheter tip and surrounding venous anatomy. injection through venous lumen visualization of right atrium

34. High-Performance Hemodialysis Catheters VaxcelDura-FlowMaxidAsh SplitXpresso Hemostream

35. Injection of venous (distal) lumen of a tunneled hemodialysis catheter

36. Injecting x-ray contrast through the catheter will provide visualization of the catheter tip and surrounding venous anatomy. port catheter thrombus surrounding catheter tip

37. Injection of arterial (proximal) lumen of a tunneled hemodialysis catheter

38. An upper extremity venogram should be performed to evaluate the entire vein in which the catheter is located. left upper extremity venogram right upper extremity venogram

39. Catheter-Induced Venous Stenosis

40. Non-Aspirating Catheter (Port) catheter tip abutting vein Port

41. Patient with a pheresis catheter in the right internal jugular vein which has been in use for several months. BMT resident calls and states that there is now non-erythematous swelling around the catheter tunnel.

42. Contrast injected through the catheter demonstrates prompt leakage from one lumen. leakage of contrast

43. Obstruction of Central Venous Catheters vein catheter tip thrombus

44. Catheter Obstruction Thrombotic Mechanical Catheter is kinked Catheter malposition Drug precipitation Pinch-off syndrome kink

45. Etiology of Catheter Malfunction Events Mechanical Thrombus Crain (’96) 44 4 40 Suhocki (’96) 42 4 38 Rockall (’97) 31 7 24 Trerotola (’97) 63 23 40

46. Types of Thrombotic Occlusion Intraluminal thrombus Thrombus or fibrin tail Fibrin Sheath vein catheter

47. Intraluminal Thrombus

48. Thrombolytic Agents Injecting CathFlo into occluded catheter lumen

49. Low doses of thrombolytic agents used for catheter clearance are very safe and do not produce a systemic effect. 1 The INR and PTT remain unchanged when using 2 – 4mg tPA or 10,000 units of urokinase. 1 Atkinson JB et al. J Parenter Enteral Nutr 1990; 14:310-311. Thrombolytic Agents

50. Use of Thrombolytic Agents for Treatment of Occluded Catheters Results of the COOL 1 Trial COOL = The Cardiovascular Thrombolytic to Open Occluded Lines Efficacy Trial J Vasc Int Radiol 2001; 12: 951 - 955 Tissue plasminogen activator (Alteplase) 2 mg in 2 ml for 2 hours 75 patients received tPA 74 % success with 2 nd dose 90 % success 74 patients received placebo 17 % success

51. High-Performance Hemodialysis Catheters VaxcelDura-FlowMaxidAsh SplitXpresso Hemostream

52. Multisidehole Hemodialysis Catheters Heparin (or TPA) will exit catheter through proximal side holes. Drug will not fill tip of catheter. thrombus occluding tip of catheter contrast exits through proximal side holes

53. Examples of Intraluminal Thrombus

54. Endoluminal Brushes - useful for multi-sidehole catheters

55. Occluded Hemodialysis Catheter occluded tip After brushing catheter tip widely patent

56. Fibrin Tail Fibrin tail intraluminal thrombus

57. Thrombus at Catheter Tip Hickman catheter catheter tip thrombus catheter tip thrombus

58. Examples of fibrin sheaths obtained during removal of hemodialysis catheters Fibrin Sheaths thin fibrin sheath thick rind of fibrin

59. Ultrasound of Fibrin Sheath “Dual” fibrin sheaths extending from subcutaneous tissue into jugular vein Fibrin Sheath fibrin sheath fibrin sheath extends from jugular vein into subcutaneous tissue jugular vein

60. Residual fibrin sheath following removal of catheter

61. Catheter Dysfunction Due to Fibrin Sheath Fibrin sheath envelopes the tip of the catheter Injected drug will flow inside of fibrin sheath. May be difficult to inject. Aspiration will suck fibrin sheath against catheter tip.

62. Treatment of Fibrin Sheath or Pericatheter Thrombus Stripping with endovascular snare Exchange catheter + disruption of fibrin sheath Infusion of thrombolytic drug

63. Endovascular Snare Fibrin Sheath Stripping

64. PTA of Fibrin Sheath Fibrin sheath 12mm x 4cm Post-PTA Intraluminal debris Replace catheter

65. Angioplasty of Catheter-Induced Stenoses

66. High Pressure Angioplasty Balloons Rated burst pressure : 20 atm (4 – 8 mm)

67. Angioplasty of Central Venous Stenoses

68. Using catheter to direct guidewire through occlusion Short segment occlusion of left subclavian vein

69. positioning balloon inflating balloon

70. Post-angioplasty 12mm persistent narrowing and irregularity of the stenosis

71. Fluoroscopic imageDigital subtraction image occlusion of right brachiocephalic vein Recanalization of Occluded Veins

72. advanced guidewire across occlusion occluded venous segment

73. Angioplasty of stenosis Created channel in vein Insert catheter

74. Endovascular Stents

75. Wallstent (Boston Scientific) S.M.A.R.T. stent (Cordis / J & J) - stainless steel - self-expanding - nitinol - self-expanding Luminexx Bard Peripheral Vascular - nitinol - self-expanding

76. 12mm x 4cm Post-PTA : 12mm 12mm x 40mm SMART stent

77. Mural Thrombus thrombus surrounding catheter Thrombus extends from the catheter to the wall of the adjacent vein.

78. Mural Thrombus catheter thrombus catheter thrombus

79. Venous Thrombolysis Multisidehole Infusion Catheter Pulse-spray thrombolysis

80. Central Venous Occlusion

81. Thrombolysis Endovascular Recanalization Angioplasty

82. Endovascular Recanalization

83. www.vascularaccessdoc.com Tom Vesely, M.D. veselyt@wustl.edu