- Email: [email protected]
Migration of a Silastic® central venous catheter into the right jugular vein: report of two cases
Chcal Nurrition (1991) 10: 173-175 0 Longman Group UK Ltd 1991
Migration of a Silastic@ central venous catheter the right jugular vein: report of two cases T. CHIKENJI,
M. MIZUTANI,
M. YOKOYAMA
into
and Y. KITSUKAWA
Department of Surgery, Chiba Municipal Hospital, 827 Yahagi, Chiba 280, Japan (Correspondence”and reprint requests to T.C.)
ABSTRACT-Silastic@ catheters commonly used for total parenteral nutrition have advantages including low rates of infection and thrombosis. However, because of flexibility they produce an unusual problem, catheter tip migration. We present two cases of catheter migration into the right jugular vein. In one case, infusion phlebitis developed which required repositioning over a guidewire, and in a second a spontaneous correction occurred.
Introduction Central venous catheters for the provision of parenteral nutrition were initially made of polyethylene or polyvinyl, and complications such as perforation of the great veins, extrusion, thrombosis and infection were quite common. With the advent of soft and pliable silicone-rubber catheters some of these complications have been eliminated. On the other hand, the more flexible catheters can cause an unusual but often serious problem, catheter tip migration (l-6). This report describes two cases of migration into the right internal jugular veins: one with development of infusion phlebitis requiring repositioning over a guidewire, and the other with a spontaneous correction.
Case reports Case 1: F.I., a 52-year-old male diagnosed as having advanced ulcerative colitis, was admitted to the Chiba Municipal Hospital on June 19 1989. On July 7, a Silastic@ central venous catheter (Silascan@ I.V. Catheter 0 type, Fr 5, Dow Corning Co.. Ashigara Kami Gun, Japan) was placed without difficulty into the superior vena cava via the right subclavian vein. A post-operative chest X-ray confirmed proper placement (Fig. 1). He was ambulatory. After 2 weeks of asymptomatic, uneventful total parenteral nutrition, there occurred a gradual onset of right-sided cervical pain, tenderness and swelling. Local phlebitis was suspected. A chest X-ray film on July 21 revealed the migration of the catheter tip into the right
internal jugular vein (Fig. 2). Using a J-tip guidewire (Hanaco Lead Wire F6J-3T, 0.46mm in diameter. 7Ocm in length, Hanaco Medical Co., Tokyo, Japan), the migrated tip was repositioned (Fig. 3). The symptoms subsequently subsided and a total colectomy was performed on September 19. A follow-up chest X-ray showed no recurrence of the migration. The catheter was removed on November 14. Cuse 2: T.H., a 62-year-old male with a diagnosis of hepatocellular carcinoma. was hospitalised on May 1 1990. On May 7. a Silastic catheter was placed into the right subclavian vein and the tip positioned in the superior vena cava; the postoperative chest X-ray verified correct placement (Fig. 4). Total parenteral nutrition was initiated. He was ambulatory and the catheter functioned well. He underwent an extended right lobectomy with cholecystectomy on May 15. The rate of infusion of the hypertonic solution was reduced by one-half during surgery. A chest X-ray obtained after surgery showed the tip of the catheter had migrated into the right jugular vein (Fig. 5). Because overt signs of phlebitis or venous thrombosis were absent, the reduced rate of infusion was maintained and no attempt at catheter repositioning was made. A chest X-ray was taken every day thereafter and a spontaneous correction was observed on May 21 (Fig. 6). A follow-up chest X-ray indicated no recurrence of the migration until his death 2 months later. He was almost completely confined to bed post-operatively.
174 MIGRATION
OF A SILASTIC-
CENTRAL
VENOUS
CATHETER
Fig. 3. Catheter
tip (arrows)
was repositioned
over a guidewire.
Accidental insertion of a central venous catheter into the internal jugular vein during subclavian venepuncture is a common occurrence. However, migration of the catheter tip is rare once the tip has been positioned in the superior vena cava or right
atrium. Only a few reports have described similar migrations (1, 3-6). It is known that soft, pliable silicone catheters tend to float free in the bloodstream and positional changes can occur (1, 5). Three factors that seem to predispose to catheter migration have been reported: vigorous irrigation of the catheter tip, congestive heart failure with resultant great vein dilatation, and hyperactivity of the patient (4). In our patients, the catheter tip was positioned in the proximal portion of the superior vena cava (7). We suspect that this may be an important factor in the tendency to
Fig. 2. Catheter jugular vein.
Fig. 4. Chest X-ray film shows catheter position.
Fig. 1. Chest X-ray film shows catheter vena cava.
tip (arrows)
in superior
Discussion
tip (arrows)
was migrated
into right internal
tip (arrows)
in correct
obesity are susceptible to catheter dislodgement (8). Therefore. care should be taken in selection of catheter exit sites and subcutaneous placements. Vazquez and Brodski (5) suggested that repositioning of the catheter tip should not be attempted, because the migrated tip usually corrects itself spontaneously. Catheter migration corrected in local spontaneously in Case 2, but resulted phlebitis in Case 1. Infusion of hypertonic solutions into the internal jugular vein has been reported to cause cerebral venous thrombosis and subsequent development of infarct of the brain (9). Occasional monitoring of the tip, therefore, seems required and the catheter should be repositioned when migration occurs. Safe and rapid repositioning of the catheter can he accomplished over a guidewire. Fig. 5. Chest X-ray film taken after surgery (arrows) in right internal jugular vein.
shows catheter
tip
References
Fig. 6. Spontaneous red 6 days later.
correction
of catheter
tip (arrows)
occur-
migrate. It is also just possible that at insertion the catheter tip was folded back, which would not be recognised without a lateral or oblique view, although this seems unlikely. There is a report showing that patients with highly mobile subcutaneous tissue secondary to pendulous breasts or
Submirsion date: 1 October
1. Mullen J L. Oleaga .I. Ring E J 1977 Catheter migration during home hyperalimentation. Journal of the American Medical Association 238: 1946-1947 2. Bottino J. McCredie K B, Groschel D H M. Lawson M 1979 Long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer 43: 1937-1943 3. Fleming C R, Witzke D .I, Beart R W Jr 1980 Catheterrelated complications in patients receiving home parenteral nutrition. Annals of Surgery 192: 593-599 4. Ouriel K. Brennan J K, Desch C et al 1983 Migration of a permanent central venous catheter. Journal of Parenteral and Enteral Nutrition 7: 41&411 5. Vazyuez R M. Brodski E G 1985 Primary and secondary malposition of silicone central venous catheters. Acta Anaesthesiologica Scandinavica Suppl 8 1: 22.-75 with the 6. Wagman L D, Neifeld J P 1986 Experience Hickman catheter: unusual complications and suggestions for their prevention. Journal of Parentcral and Enteral Nutrition 10: 31 l-315 Pithie A. Soutar J S. Pennington C R 19X8 Catheter tip position in central vein thrombosis. Journal of Parenteral and Enteral Nutrition 12: 613-614 Moorman D W, Horattas M C. Wright D et al 1987 Hickman catheter dislodgement d&to pendulous breasts. Journal of Parenteral and Enteral Nutrition 11: 502-503 Souter R G, Mitchell A 1982 Spreading cortical venous thrombosis due to infusion of hyperosmolar solution into the internal jugular vein. British Medical Journal 2X5: 935-936
1990; Accepted after revision: 15 February
1991
Migration of a Silastic@ central venous catheter the right jugular vein: report of two cases T. CHIKENJI,
M. MIZUTANI,
M. YOKOYAMA
into
and Y. KITSUKAWA
Department of Surgery, Chiba Municipal Hospital, 827 Yahagi, Chiba 280, Japan (Correspondence”and reprint requests to T.C.)
ABSTRACT-Silastic@ catheters commonly used for total parenteral nutrition have advantages including low rates of infection and thrombosis. However, because of flexibility they produce an unusual problem, catheter tip migration. We present two cases of catheter migration into the right jugular vein. In one case, infusion phlebitis developed which required repositioning over a guidewire, and in a second a spontaneous correction occurred.
Introduction Central venous catheters for the provision of parenteral nutrition were initially made of polyethylene or polyvinyl, and complications such as perforation of the great veins, extrusion, thrombosis and infection were quite common. With the advent of soft and pliable silicone-rubber catheters some of these complications have been eliminated. On the other hand, the more flexible catheters can cause an unusual but often serious problem, catheter tip migration (l-6). This report describes two cases of migration into the right internal jugular veins: one with development of infusion phlebitis requiring repositioning over a guidewire, and the other with a spontaneous correction.
Case reports Case 1: F.I., a 52-year-old male diagnosed as having advanced ulcerative colitis, was admitted to the Chiba Municipal Hospital on June 19 1989. On July 7, a Silastic@ central venous catheter (Silascan@ I.V. Catheter 0 type, Fr 5, Dow Corning Co.. Ashigara Kami Gun, Japan) was placed without difficulty into the superior vena cava via the right subclavian vein. A post-operative chest X-ray confirmed proper placement (Fig. 1). He was ambulatory. After 2 weeks of asymptomatic, uneventful total parenteral nutrition, there occurred a gradual onset of right-sided cervical pain, tenderness and swelling. Local phlebitis was suspected. A chest X-ray film on July 21 revealed the migration of the catheter tip into the right
internal jugular vein (Fig. 2). Using a J-tip guidewire (Hanaco Lead Wire F6J-3T, 0.46mm in diameter. 7Ocm in length, Hanaco Medical Co., Tokyo, Japan), the migrated tip was repositioned (Fig. 3). The symptoms subsequently subsided and a total colectomy was performed on September 19. A follow-up chest X-ray showed no recurrence of the migration. The catheter was removed on November 14. Cuse 2: T.H., a 62-year-old male with a diagnosis of hepatocellular carcinoma. was hospitalised on May 1 1990. On May 7. a Silastic catheter was placed into the right subclavian vein and the tip positioned in the superior vena cava; the postoperative chest X-ray verified correct placement (Fig. 4). Total parenteral nutrition was initiated. He was ambulatory and the catheter functioned well. He underwent an extended right lobectomy with cholecystectomy on May 15. The rate of infusion of the hypertonic solution was reduced by one-half during surgery. A chest X-ray obtained after surgery showed the tip of the catheter had migrated into the right jugular vein (Fig. 5). Because overt signs of phlebitis or venous thrombosis were absent, the reduced rate of infusion was maintained and no attempt at catheter repositioning was made. A chest X-ray was taken every day thereafter and a spontaneous correction was observed on May 21 (Fig. 6). A follow-up chest X-ray indicated no recurrence of the migration until his death 2 months later. He was almost completely confined to bed post-operatively.
174 MIGRATION
OF A SILASTIC-
CENTRAL
VENOUS
CATHETER
Fig. 3. Catheter
tip (arrows)
was repositioned
over a guidewire.
Accidental insertion of a central venous catheter into the internal jugular vein during subclavian venepuncture is a common occurrence. However, migration of the catheter tip is rare once the tip has been positioned in the superior vena cava or right
atrium. Only a few reports have described similar migrations (1, 3-6). It is known that soft, pliable silicone catheters tend to float free in the bloodstream and positional changes can occur (1, 5). Three factors that seem to predispose to catheter migration have been reported: vigorous irrigation of the catheter tip, congestive heart failure with resultant great vein dilatation, and hyperactivity of the patient (4). In our patients, the catheter tip was positioned in the proximal portion of the superior vena cava (7). We suspect that this may be an important factor in the tendency to
Fig. 2. Catheter jugular vein.
Fig. 4. Chest X-ray film shows catheter position.
Fig. 1. Chest X-ray film shows catheter vena cava.
tip (arrows)
in superior
Discussion
tip (arrows)
was migrated
into right internal
tip (arrows)
in correct
obesity are susceptible to catheter dislodgement (8). Therefore. care should be taken in selection of catheter exit sites and subcutaneous placements. Vazquez and Brodski (5) suggested that repositioning of the catheter tip should not be attempted, because the migrated tip usually corrects itself spontaneously. Catheter migration corrected in local spontaneously in Case 2, but resulted phlebitis in Case 1. Infusion of hypertonic solutions into the internal jugular vein has been reported to cause cerebral venous thrombosis and subsequent development of infarct of the brain (9). Occasional monitoring of the tip, therefore, seems required and the catheter should be repositioned when migration occurs. Safe and rapid repositioning of the catheter can he accomplished over a guidewire. Fig. 5. Chest X-ray film taken after surgery (arrows) in right internal jugular vein.
shows catheter
tip
References
Fig. 6. Spontaneous red 6 days later.
correction
of catheter
tip (arrows)
occur-
migrate. It is also just possible that at insertion the catheter tip was folded back, which would not be recognised without a lateral or oblique view, although this seems unlikely. There is a report showing that patients with highly mobile subcutaneous tissue secondary to pendulous breasts or
Submirsion date: 1 October
1. Mullen J L. Oleaga .I. Ring E J 1977 Catheter migration during home hyperalimentation. Journal of the American Medical Association 238: 1946-1947 2. Bottino J. McCredie K B, Groschel D H M. Lawson M 1979 Long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer 43: 1937-1943 3. Fleming C R, Witzke D .I, Beart R W Jr 1980 Catheterrelated complications in patients receiving home parenteral nutrition. Annals of Surgery 192: 593-599 4. Ouriel K. Brennan J K, Desch C et al 1983 Migration of a permanent central venous catheter. Journal of Parenteral and Enteral Nutrition 7: 41&411 5. Vazyuez R M. Brodski E G 1985 Primary and secondary malposition of silicone central venous catheters. Acta Anaesthesiologica Scandinavica Suppl 8 1: 22.-75 with the 6. Wagman L D, Neifeld J P 1986 Experience Hickman catheter: unusual complications and suggestions for their prevention. Journal of Parentcral and Enteral Nutrition 10: 31 l-315 Pithie A. Soutar J S. Pennington C R 19X8 Catheter tip position in central vein thrombosis. Journal of Parenteral and Enteral Nutrition 12: 613-614 Moorman D W, Horattas M C. Wright D et al 1987 Hickman catheter dislodgement d&to pendulous breasts. Journal of Parenteral and Enteral Nutrition 11: 502-503 Souter R G, Mitchell A 1982 Spreading cortical venous thrombosis due to infusion of hyperosmolar solution into the internal jugular vein. British Medical Journal 2X5: 935-936
1990; Accepted after revision: 15 February
1991