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Technical report: An injection technique for repositioning subclavian catheters
ClinicalRadiology (1991) 44, 197-198
Technical Report: An Injection Technique for Repositioning Subclavian Catheters T. M A H O N and D. L A W R E N C E , SR
Department of Diagnostic Radiology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas, USA Malpositioned central venous catheters need to be repositioned so as to avoid local toxicity from chemotherapeutic and other agents and to prevent venous thrombosis. We describe a simple, safe and effective technique for repositioning silicone central venous catheters, by using a hand injection of sterile saline. It was successful in all nine patients in whom it was attempted, with no complications. Five catheters were single lumen and four were double lumen. We feel that this method should be attempted prior to the use of more invasive techniques. Mahon, T. & Lawrence, D., Sr. (1991). Clinical Radiology 44, 197-198. Technical Report: An Injection Technique for Repositioning Subclavian Catheters
The insertion of central venous catheters is a c o m m o n procedure, particularly in patients requiring chemotherapy, total parenteral nutrition or long term intravenous antibiotics. Occasionally the catheter may be malpositioned, most often into the ipsilateral internal jugular vein. The catheter can be repositioned using a variety of invasive techniques, w e assessed a new minimally invasive method to reposition silicone catheters. METHODS
Ten patients presented between April 9 1990 and June 30 1990 for repositioning of central venous catheters. A limited venogram was performed by injecting 10-20 ml of Angiovist-292 (diatrizoate meglumine and diatrizoate sodium, Berlex Laboratories) through the catheter. In one patient the catheter tip was in a tributary of the internal jugular vein and the patient was excluded from the study. Nine patients were studied, in whom venography demonstrated intraluminal placement of the catheter tip and a patent superior vena cava. Two catheters were inserted via the left subclavian vein. The tip was in the left internal jugular vein in one patient and in the right internal jugular vein in the other patient. The former was a single lumen catheter and the latter a double lumen catheter. Seven central venous catheters were inserted into the right subclavian vein. The tip was in the right internal jugular vein in three patients, the left subclavian vein (Fig. la) in two, the left internal jugular vein in one, and the azygos vein in one patient. The two catheters in the left subclavian vein and one in the right internal jugular vein were 7 gauge double lumen silicone catheters (Cook Inc.). The others were 5 gauge single lumen silicone catheters (Davol Inc.). Following the venogram, the catheter was flushed with a brisk hand injection of 5 ml of normal saline in a 5 ml syringe (Figs la and b). Moderate effort was used over about 1 s. This was done in the erect position in six
Correspondence to: Dr Thomas Mahon, Department of Diagnostic Radiology, New England Deaconess Hospital, Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
patients, and in the supine or semi-erect position in three patients. A repeat venogram was then performed to confirm satisfactory position of the catheter.
RESULTS In all nine cases the catheter was repositioned, with its tip in the superior vena cava or right atrium. In two patients a second injection of saline was necessary. One was a single lumen right subclavian catheter with the tip in the left internal jugular vein, the other was a double lumen left subclavian catheter with the tip in the right internal jugular vein. There was no evidence of any complications, patient discomfort or trauma to the catheters.
DISCUSSION Central vein catheters should be properly sited with their tips in a major central vein. The optimal position, in our opinion, is in the superior vena cava below the azygos vein. This provides m a x i m u m concentration on the first pass of chemotherapy and a high flow rate in order to avoid local toxicity from chemotherapeutic and other agents. The malpositioned catheter m a y initiate venous thrombosis if it is in a minor vein or is in a position that traumatizes the vessel wall. Traditional methods for repositioning central venous catheters are invasive and m a y entail the use of multiple guide wires, tip-deflector wires and balloon catheters (Lois et al., 1987). In our department catheters were often repositioned by using a deflector guide wire which was introduced into the catheter. By using a hand injection of 5 ml of normal saline in a 5 ml syringe we have successfully repositioned the catheter in all nine patients in w h o m it was attempted. The technique is quick and easy to perform, avoids patient discomfort and is minimally invasive. Olcott et al. (1989) describes central venous catheter repositioning using an injection technique in three patients. However, M1 their patients had single lumen
198
CLINICAL RADIOLOGY
(a)
Fig. 1 - (a) Double lumen right subclavian catheter (arrowheads) with tip in left subclavian vein. (b) After a single injection of saline the tip (arrowhead) is in the right atrium.
O)
right subclavian catheters only. F u r t h e r m o r e , we p l a c e d the p a t i e n t in the erect p o s i t i o n , when possible, so as to use gravity to aid in r e p o s i t i o n i n g . W e also believe t h a t p e r f o r m i n g an initial v e n o g r a m is essential. This will confirm satisfactory i n t r a l u m i n a l p o s i t i o n i n g o f the c a t h eter, the absence o f t h r o m b u s a n d n o r m a l venous a n a tomy. D u e to the possible risk o f i n t r a v a s c u l a r t r a u m a , the injectiori technique was o n l y us6d with floppy silicone catheters a n d patients with triple l u m e n catheters were excluded f r o m the study. Similarly, n o a t t e m p t was m a d e to r e p o s i t i o n long v e n o u s lines, as the injection technique m a y t r a u m a t i z e these catheters. W e feel t h a t o u r m e t h o d is safe a n d useful for the t r e a t m e n t o f m a l p o s i t i o n e d single o r d o u b l e lumen silicone subclavian catheters. W h i l e it was successful in all
o u r patients, if it fails o t h e r m e t h o d s m a y then be used to r e p o s i t i o n the catheter.
Acknowledgement. The authors wish to thank Patricia Eugene for manuscript preparation.
REFERENCES
Lois, J, Gomes, A & Pusey, E (1987). Nonsurgical repositioning of central venous catheters. Radiology, 165, 329 333. Olcott, E, Gordon, R & Ring, E (1989). The injection technique for repositioning central venous catheters: Technical note. Cardiovascular and Intercentional Radiology, 12, 292 293.
Technical Report: An Injection Technique for Repositioning Subclavian Catheters T. M A H O N and D. L A W R E N C E , SR
Department of Diagnostic Radiology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas, USA Malpositioned central venous catheters need to be repositioned so as to avoid local toxicity from chemotherapeutic and other agents and to prevent venous thrombosis. We describe a simple, safe and effective technique for repositioning silicone central venous catheters, by using a hand injection of sterile saline. It was successful in all nine patients in whom it was attempted, with no complications. Five catheters were single lumen and four were double lumen. We feel that this method should be attempted prior to the use of more invasive techniques. Mahon, T. & Lawrence, D., Sr. (1991). Clinical Radiology 44, 197-198. Technical Report: An Injection Technique for Repositioning Subclavian Catheters
The insertion of central venous catheters is a c o m m o n procedure, particularly in patients requiring chemotherapy, total parenteral nutrition or long term intravenous antibiotics. Occasionally the catheter may be malpositioned, most often into the ipsilateral internal jugular vein. The catheter can be repositioned using a variety of invasive techniques, w e assessed a new minimally invasive method to reposition silicone catheters. METHODS
Ten patients presented between April 9 1990 and June 30 1990 for repositioning of central venous catheters. A limited venogram was performed by injecting 10-20 ml of Angiovist-292 (diatrizoate meglumine and diatrizoate sodium, Berlex Laboratories) through the catheter. In one patient the catheter tip was in a tributary of the internal jugular vein and the patient was excluded from the study. Nine patients were studied, in whom venography demonstrated intraluminal placement of the catheter tip and a patent superior vena cava. Two catheters were inserted via the left subclavian vein. The tip was in the left internal jugular vein in one patient and in the right internal jugular vein in the other patient. The former was a single lumen catheter and the latter a double lumen catheter. Seven central venous catheters were inserted into the right subclavian vein. The tip was in the right internal jugular vein in three patients, the left subclavian vein (Fig. la) in two, the left internal jugular vein in one, and the azygos vein in one patient. The two catheters in the left subclavian vein and one in the right internal jugular vein were 7 gauge double lumen silicone catheters (Cook Inc.). The others were 5 gauge single lumen silicone catheters (Davol Inc.). Following the venogram, the catheter was flushed with a brisk hand injection of 5 ml of normal saline in a 5 ml syringe (Figs la and b). Moderate effort was used over about 1 s. This was done in the erect position in six
Correspondence to: Dr Thomas Mahon, Department of Diagnostic Radiology, New England Deaconess Hospital, Harvard Medical School, 185 Pilgrim Road, Boston, MA 02215, USA
patients, and in the supine or semi-erect position in three patients. A repeat venogram was then performed to confirm satisfactory position of the catheter.
RESULTS In all nine cases the catheter was repositioned, with its tip in the superior vena cava or right atrium. In two patients a second injection of saline was necessary. One was a single lumen right subclavian catheter with the tip in the left internal jugular vein, the other was a double lumen left subclavian catheter with the tip in the right internal jugular vein. There was no evidence of any complications, patient discomfort or trauma to the catheters.
DISCUSSION Central vein catheters should be properly sited with their tips in a major central vein. The optimal position, in our opinion, is in the superior vena cava below the azygos vein. This provides m a x i m u m concentration on the first pass of chemotherapy and a high flow rate in order to avoid local toxicity from chemotherapeutic and other agents. The malpositioned catheter m a y initiate venous thrombosis if it is in a minor vein or is in a position that traumatizes the vessel wall. Traditional methods for repositioning central venous catheters are invasive and m a y entail the use of multiple guide wires, tip-deflector wires and balloon catheters (Lois et al., 1987). In our department catheters were often repositioned by using a deflector guide wire which was introduced into the catheter. By using a hand injection of 5 ml of normal saline in a 5 ml syringe we have successfully repositioned the catheter in all nine patients in w h o m it was attempted. The technique is quick and easy to perform, avoids patient discomfort and is minimally invasive. Olcott et al. (1989) describes central venous catheter repositioning using an injection technique in three patients. However, M1 their patients had single lumen
198
CLINICAL RADIOLOGY
(a)
Fig. 1 - (a) Double lumen right subclavian catheter (arrowheads) with tip in left subclavian vein. (b) After a single injection of saline the tip (arrowhead) is in the right atrium.
O)
right subclavian catheters only. F u r t h e r m o r e , we p l a c e d the p a t i e n t in the erect p o s i t i o n , when possible, so as to use gravity to aid in r e p o s i t i o n i n g . W e also believe t h a t p e r f o r m i n g an initial v e n o g r a m is essential. This will confirm satisfactory i n t r a l u m i n a l p o s i t i o n i n g o f the c a t h eter, the absence o f t h r o m b u s a n d n o r m a l venous a n a tomy. D u e to the possible risk o f i n t r a v a s c u l a r t r a u m a , the injectiori technique was o n l y us6d with floppy silicone catheters a n d patients with triple l u m e n catheters were excluded f r o m the study. Similarly, n o a t t e m p t was m a d e to r e p o s i t i o n long v e n o u s lines, as the injection technique m a y t r a u m a t i z e these catheters. W e feel t h a t o u r m e t h o d is safe a n d useful for the t r e a t m e n t o f m a l p o s i t i o n e d single o r d o u b l e lumen silicone subclavian catheters. W h i l e it was successful in all
o u r patients, if it fails o t h e r m e t h o d s m a y then be used to r e p o s i t i o n the catheter.
Acknowledgement. The authors wish to thank Patricia Eugene for manuscript preparation.
REFERENCES
Lois, J, Gomes, A & Pusey, E (1987). Nonsurgical repositioning of central venous catheters. Radiology, 165, 329 333. Olcott, E, Gordon, R & Ring, E (1989). The injection technique for repositioning central venous catheters: Technical note. Cardiovascular and Intercentional Radiology, 12, 292 293.