Comparison of saphenous versus jugular veins for central venous access in children with malignancy

Comparison

of Saphenous Versus Jugular Veins for Central Venous Access in Children With Malignancy By M. Kohli-Kumar, A.J. Rich, A.D.J. Pearson, A.W. Craft, and J. Kernahan

Newcastle upon Tyne, England 0 A retrospective analysis was carried out to compare the performance and complications of central catheters inserted into either the saphenous (27) or jugular (52) veins. The saphenous route may be preferred in certain circumstances including extensive mediastinal pathology, prior neck surgery, previous catheter(s), and cosmetic reasons. There was no difference in complications (local or systemic catheterrelated infections, catheter occlusions, or venous thrombosis). The incidence of catheter removal due to complications was also not different between sites. Hence, the saphenous route can provide an additional portal of vascular access in selected patients. Copyright o 1992 by W. B. Saunders Company INDEX WORDS: Central venous catheters; ters; catheter complications.

saphenous cathe-

S

INCE THEIR introduction, central venous catheters (CVCs) for long-term use have been conventionally inserted via the neck veins.‘,* However, under certain circumstances these veins may be unsuitable so that other sites of venous access have to be sought. A retrospective study was undertaken to compare the performance and complications of CVCs placed in jugular veins with those inserted through saphenous veins. MATERIALS AND METHODS A study was made of the records of all patients attending the paediatric oncology and haematology department, Royal Victoria Infirmary, Newcastle upon Tyne, who had CVCs inserted over an 18-month period. The indications for their use included difficult peripheral venous access, intensive treatment regime, parenteral nutrition, frequent venesection for investigations and administration of blood products, fear of needles, or a combination of several of these. All the catheters were introduced under general anesthesia by a single surgical team. The surgical technique of saphenous access has been described elsewhere.3 The position of the catheter tip was checked fluoroscopically during insertion, the aim being to place it in the right atrium. In very young children the extravascular portion of the CVC was tunnelled subcutaneously to a relatively inaccessible position on the back. When not in continuous use, the catheters were flushed daily (Broviac) or twice weekly (Hickman) with 5 mL of heparin (10 UlmL). The CVC exit site was kept covered with a dry dressing that was changed weekly or more often if indicated. Four types of catheter-related complications were identified and investigated: (1) infection, either superficial infection (included erythema, induration, tenderness, or pus discharge involving the exit wound or the tunnel area or CVC-related systemic infection (included [l] Staphylococcus epidermidis bacteremia, [2] septicemic episodes in patients in absence of neutropenia (absolute neutrophi1 count < 1 x 10Y/mL), and [3] chills, fever, rigors, and systemic manifestations related to catheter flushing or use with or without

Journal ofPediatric Surgery, Vol27, No 5 (May), 1992: pp 609-611

documentation of bacteremia); (2) catheter occlusion; (3) venous thrombosis; and (4) other mechanical problems. For blocked catheters that were not cleared by heparin instillation, 2 mL of urokinase (2,500 UlmL) was instilled over 2 hours.4 If this was unsuccessful, an infusion of urokinase (200 U/kg/h) was started and the catheter was checked for patency every 12 hours. If both of these failed, the catheter was removed. All patients had a minimum follow-up of at least 90 days after CVC insertion. A total of 79 CVCs were inserted in 63 patients (39 boys and 24 girls). Their ages ranged from 7 months to 18 years and their diagnoses are shown in Table 1. Twenty-seven (34%) CVCs were placed through the saphenous veins, whereas the remaining 52 (66%) were introduced via the internal or external jugular veins. The reasons for using the saphenous veins are given in Table 2. Eleven patients (17.4%) required more than one catheter during the course of their treatment as shown in Fig 1. RESULTS

The study period covered 13,917 catheter days. The saphenous catheters were functional for a mean of 172 days (range, 4 to 386 days). Jugular catheters lasted 178.7 days (range, 2 to 422 days). One hundred twelve febrile episodes were recorded, 69 of which were attributable to specific foci of infection other than the CVC (Table 3). On 37 occasions, the catheter was incriminated as the cause of systemic symptoms (10 in patients with saphenous catheters and 27 in patients with jugular catheters). There were 0.21 episodes per 100 patient days of catheter sepsis in saphenous CVC and 0.29 episodes per 100 patient days in jugular CVC. Various organisms were isolated during these periods (Table 4); however, on 9 occasions, despite extensive search, no organism was identified. Exit wound infections occurred in six patients; two in those with saphenous CVC and four with jugular access, an identical rate of 0.043 infections per 100 patient days. Eight of 27 (29.6%) saphenous CVCs and 13 of 52

From the Departments of Child Health and Surgery, University of Newcastie upon Tyne, Newcastle upon Tvne, England. Date accepted: November 13, 1990. M.K.K. was supported by the Leukaemia Research Fund. Address reprint requests to A. W. Craft, MD, Department of Child Health, The Medical School, Framlington Place, Newcastle upon Tyne NE2 4HH, England. Copyright o 1992 by W.B. Saunders Company 0022-3468/92/2705-0019$03.0010

609

KOHLI-KUMAR ET AL

610

Table 1. Diagnosis No. of Patients

Diagnosis Acute lymphoblastic leukemia

20

Neuroblastoma

10

0

Saphenous

q

Jugular

catheter

catheter

5

Rhabdomyosarcoma Primitive neuroectodermal

tumor

Non-Hodgkin’s lymphoma

4 3

Acute myeloid leukemia

3

Ewing’s sarcoma

3

First

2

Osteogenic sarcoma Others

13

Total

63

Sequence Fig 1. tions.

(25%) jugular CVCs became blocked at least once during the observation period and required urokinase treatment. There was only one episode of asymptomatic caval thrombosis in a 14-year-old boy with a right-sided saphenous catheter. His platelet count was 384 x 109/L and had been normal for several weeks before. His catheter was discovered to be nonfunctional on a routine hospital visit. An x-ray contrast study was performed that showed thrombosis in the inferior vena cava. As he had finished chemotherapy the catheter was removed. There have been no adverse sequelae. Eighteen CVCs were working at the end of the study period; 13 patients had died with their catheters still in situ. Seventeen CVCs were removed electively at the completion of treatment. Six CVCs developed mechanical faults (crack, extrusion of tip) and were taken out. Twelve catheters slipped or were pulled out accidentally. Infection necessitated the premature removal of 7 CVCs (2 saphenous and 5 jugular). Five blocked CVCs did not respond to urokinase and were hence nonfunctional (3 saphenous and 2 jugular) (Table 5). DISCUSSION

CVCs providing long-term vascular access have made it possible to administer intensive chemotherapy regimens including bone marrow transplantation. They also facilitate intensive supportive therapy with blood products, parenteral nutrition, and antibiotics. Often a single catheter suffices during the entire treatment period. The jugular veins have been the preferred portal of entry for the CVC by most

Unmaneuverable

neck veins

Third

Fourth

Fifth

of insertion

Distribution of catheter type in first and subsequent inser-

surgeons. However, many factors may make this site difficult or unsuitable to use. Gross mediastinal disease including enlarged lymph nodes make this route potentially hazardous. Previous neck surgery, local infection, or prior use of these veins for CVCs limit their use. Obesity and anatomical variations of these veins may also pose a problem.5 In young children these veins may be so small as to prevent the use of even the smallest catheter. Adolescent patients may prefer their CVC to be in an area that can be easily concealed under their clothing. With the everimproving survival of these patients, scarring and the final cosmetic appearance also have to be considered. In an attempt to overcome these problems, use of other veins has been reported. Subclavian, azygos, hypogastric,6 and inferior epigastric’ veins have been used for central venous cannulation but their use has not gained popularity. The use of the long saphenous vein8 has been avoided in the belief that its use may lead to an increase in the incidence of infection and caval thrombosis, although there is no evidence to support this. Furthermore there may be surgical advantages to be gained in using this route.3 In the present series there were no significant differences in the complication rate between saphenous or jugular routes. One fifth (16/79) of the patients required more than one catheter. Ten of these were sited via the saphenous vein. More than two thirds (72.2%) of the first insertions were in the neck veins, reflecting the familiarity of the surgeons with this conventional route. Catheter life and function in these two sites were similar and compare well with other reports.9 The use

Table 2. Indications for the Insertion of Saphenous Catheters Previous neck catheter(s)

Second

Table 3. Infective Episodes

10

CVC (27)

Saphenous

2

Mediastinal pathology

1

Systemic

Cosmetic reasons

4

Exit wound and tunnel infections

Surgeon’s choice

10

Total

27

22

JugularCVC (52) 47

2

4

Catheter sepsis

10

27

Total

34

78

SAPHENOUS

611

v JUGULAR CVC

Table 4. Organisms Isolated During CVC-Related

Table 5. Complications and Course

Systemic Infection

Saphenous CVC Jugular CVC

Saphenous CVC (27)

Jugular CVC (52)

S epidermidis

2

11

Pseudomonas

0

2

Total no. of catheter days

Diphtheroids

1

3

Mean no. of catheter days

Enterococci

2

3

Catheter-related

Klebsiella

0

1

Streptococci

1

1

days) Superficial

Proteus

0

1

Systemic catheter-related

Sterile

4

5

Febrile neutropenic

10

27

Total

27

52

4,644

9,295

172

178

0.043

0.043

No. of catheters

Occlusion

sepsis (per 100 catheter

infections

requiring

sepsis

episodes urokinase

0.21

0.29

0.47

0.50

0.17

0.13

(per 100

catheter days) Premature removal due to

of saphenous veins for the introduction of CVCs was not associated with a greater incidence of local or systemic infection, as might be anticipated by the close proximity of this site to the groin and perineum. As in other series,10-12catheter-related infections do occur but the rate in this series is not unusual. Thrombosis of the inferior vena cava was documented on one occasion but was uncomplicated. Major venous thrombosis in patients with CVCs introduced through the neck veins is well documented.13-l5 This study has shown no evidence of an increased risk of complications with the use of the saphenous

Infection Accidental

dislodgement

Blockage Mechanical

5 9

3 1

Thrombosis Total

2 3

failure

2 -

2

4

11 (40.7%)

20 (38.4%)

veins and, thus, there is an additional site of vascular access in patients with specific problems and indications. ACKNOWLEDGMENT The authors acknowledge the help given by Sue Vecsey in data compilation.

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catheterization through the saphenous vein. Surg Gynecol Obstet 154:87-88,1982 9. King DR, Komer M, Hoffman J, et al: Broviac catheter sepsis: The natural history of an iatrogenic infection. J Pediatr Surg 20:728-733,1985 10. Cameron GS: Central venous catheters for children with malignant disease; surgical issues. J Pediatr Surg 22:702-704, 1987 11. Krog MPM, Ekbom A, Nystrom-Rosander C, et al: Central venous catheters in acute blood malignancies. Cancer 59:13581361, 1987 12. Wurzel CL, Halom K, Feldman JG, et al: Infection rates of Broviac-Hickman catheters and implantable venous devices. Am J Dis Child 142:536-540, 1988 13. Stricker PD, Manoharan A, Hanel KC: Major venous thrombosis in patients with indwelling venous access catheters. Med J Aust 144:601-603, 1986 14. Topiel MS, Bryan RT, Kessler CM, et al: Case report: Treatment of silastic catheter-induced central vein septic thrombophlebitis. Am J Med Sci 291:425-428,1986 15. Ryan JA, Abel RM, Abbott WM, et al: Catheter complications in total parenteral nutrition. N Engl J Med 290:757-761, 1974