Fibrin Sleeve Research Articles

The fibroblastic sleeve, the neglected complication of venous access devices: A narrative review.

The presence of a vascular access device (or of any intravascular foreign body) inside the bloodstream is often associated with the formation of a connective tissue sleeve around the catheter (often named-erroneously-"fibrin sleeve"). Such sleeve is usually a physiological phenomenon with little or no clinical relevance, but its pathogenesis is still unclear, so that it is frequently confused with venous thrombosis; also, its relationship with other major catheter-related complications, such as venous thrombosis and bloodstream infection, is uncertain. This narrative review tries to convey in a systematic form the current knowledge about pathogenesis, incidence, clinical manifestations, diagnosis, and management of this phenomenon.

Long-term clinical outcomes of the single-incision technique for implantation of implantable venous access ports via the axillary vein.

To evaluate long-term clinical outcomes and complications of the single-incision technique for implantation of totally implantable venous access ports (TIVAPs) via the axillary vein. A total of 932 TIVAPs were placed in 927 patients between May 2012 and October 2014 using a single-incision technique. Patients included 620 men and 307 women with a mean age of 60.0 years. TIVAPs were placed via the left (n = 475) and right (n = 457) axillary veins after making a single oblique vertical incision and medial side pocket without subcutaneous tunneling. We retrospectively reviewed medical records to evaluate status of the patients and TIVAPs, complications, and reasons for explantation. In patients who still had a TIVAP in place, we calculated the duration of TIVAP use from the cut-off day of November 1, 2015. Clinical follow-up was obtained for a total device service period of 311,069 days with a median indwelling time of 467 days (range: 3-1097 days). A total of 37 (4.0%) complications developed. Early complications (n = 4) were one case each of stenosis of the brachiocephalic vein by tumor growth, thrombosis of axillary vein, intravascular migration, and malfunction depending on patient's position. Late complications (n = 33) were suspected catheter-related blood stream infection (n = 23), local infection of the pocket (n = 4), symptomatic stenosis and thrombosis of central vein (n = 4), malfunction by fibrin sleeve (n = 1), and intravascular migration (n = 1). A single-incision technique for TIVAP implantation via the axillary vein seems to be safe with a low risk of complication.

Dealing with stuck hemodialysis catheter: state of the art and tips for the nephrologist.

The term stuck catheter refers to the condition in which a catheter is not removable from a central vein using standard techniques. Although it is a rare complication, in the last few years it has been reported ever more frequently in hemodialysis due to the widespread use of tunneled catheters. Poor knowledge of the correct procedures and limited experience and training of the specialist in facing this problem are the main reasons for catheter internalization. Stuck catheter is often diagnosed by the nephrologist, who should be competent enough to manage this clinical complication. Among the many options for removing a stuck catheter from the fibrin sleeve, an interventional radiology approach, mainly with endoluminal balloon dilatation, probably provides the best solution. Vascular surgery should be reserved to selected cases in which percutaneous techniques have failed. Nephrologists must play a central role in organizing the treatment of this complication with other specialists in order to avoid making mistakes that may preclude future positive results.

An Unusual Appearance of Fibrin Sheaths after Implantable Cardioverter‐Defibrillator Removal Because of Infective Endocarditis

Mini‐AbstractThe radiological detection of “fibrin sheaths” after removing central catheters is a well‐known delayed complication. “Fibrin sheaths” after implantable cardioverter‐defibrillator (ICD) removal because of infective endocarditis is unusual. We report the case of a 26‐year‐old woman with an ICD who developed infective endocarditis. A transesophageal echocardiography showed an image of “fibrin sleeve” on the superior vena cava (SVC). The patient had no history of SVC central catheter placement. The coexistence of vegetation and “fibrin sheaths” at different moments, as in our case, requires an awareness of this situation for differential diagnosis and treatment.

Early-onset thrombosis of internal jugular vein associated with introducer catheter for heart catheterization in cardiac surgery.

In cardiac surgery, Swan-Ganz catheter (SGC) is often necessary and is inserted before the intervention through an introducer catheter. Catheter-related thrombosis (CRT) is a frequent complication of this procedure and often remains subclinical. The aims of this prospective cohort study were to determinate the incidence of CRT after positioning an SGC through an introducer and to identify factors relating to their occurrence. One-hundred and sixteen cardiac surgery patients underwent ultrasound examination of the thoracic-cervical vessels, before and after introducer catheter removal. Data about drugs infused through the introducer catheter were also collected. The incidence of internal jugular vein CRT was 26.7%, corresponding to 70.5 cases per 1,000 catheter days. The incidence of "fibrin sleeve" was 28.4%. All introducer catheter tips lay in the brachiocephalic vein or in the upper third of the superior vena cava. The incidence of CRT was not associated with duration of the placement of the introducer catheter (average 3.9±2 days) or the SGC (average of 2.4±1.7 days). Infusion of total parenteral nutrition and dextran showed a significantly increased risk of thrombosis in both univariate and multivariate analyses. An overly proximal position of the introducer catheter tip was strongly associated with CRT incidence. The presence of an introducer catheter for SGC, even for a short time, is associated with a high incidence of early-onset CRT. This incidence is significantly related to the catheter tip being positioned in the brachiocephalic vein and to its use as a central venous access.

Persistencia intracardíaca de la vaina de fibrina pericatéter en un neonato: informe de un caso

One of the complications related to central venous catheters is the so-called "fibrin sheath or sleeve", the persistence of this structure after central venous catheter removal is uncommon, especially within a cardiac chamber. A neonate with symptoms of infection and portal vein thrombosis with suspected umbilical catheter fragment retained in right atrium was consulted for possible removal by catheterization. Prior to the procedure, the echocardiography findings guided us to the diagnosis of persistent fibrin sheath. The procedure was discontinued and the patient received anticoagulant therapy and antibiotics. In our case, echocardiography was useful in confirming the diagnosis of retained fibrin sheath and rule out the presence of residual central venous catheter after its removal, thereby avoiding an unnecessary and invasive procedure.

A Refinement of Hong's Technique for the Removal of Stuck Dialysis Catheters: An Easy Solution to a Complex Problem

A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety. We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists. All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel. Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus' egg in this previously risky field.

Transesophageal Echocardiographic Image of a Retained Fibrin Sleeve After Removal of a Venous Extracorporeal Membrane Oxygenation Cannula

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) has gained widespread acceptance and success in improving the outcome of patients in cardiogenic shock and/or respiratory failure. Technologic advances in ECMO have decreased overall morbidity and mortality, but the risks of thrombogenic complications and bleeding are still present. The role of echocardiography in the evaluation of thrombus formation on large venous cannulae in the setting of ECMO is poorly described. Transesophageal echocardiographic (TEE) characteristics of a retained fibrin sheath after removal of a right atrial venous cannula are reported.

Endovascular Treatment of Dysfunctional Hemodialysis Catheters

Hemodialysis-catheter dysfunction is a common clinical condition in nephrology. Like other central venous devices, hemodialysis-catheters show a disposition for partial or complete thrombotic obstruction and fibrin sleeve formation. Thrombolytic infusion is recommended as therapy of first choice. Alternative interventional strategies include over-the-wire catheter exchange, mechanical fibrin sleeve stripping with a snare and angioplastic sleeve disruption. Those approaches show extremely variable results with mediocre long-term patency rates. Therefore, catheter-avoiding strategies should be considered in detail and AV-fistula creation preferred.

Retained Fibrin Sleeve: Transesophageal Echocardiographic Observations

The role of echocardiography for the evaluation of thrombus formation on indwelling intracardiac catheters is well established. Considerably less well described, however, are the echocardiographic characteristics of the so-called retained fibrin sheath, a sleeve of fibrin that surrounds the catheter at the point at which it enters the vein that commonly remains adherent to the vessel wall after catheter removal. The authors report the transesophageal echocardiographic findings of a retained fibrin sheath following catheter removal in a patient with end-stage renal disease and infective endocarditis of the aortic valve.

Long-term infusional systems: complications in cancer patients.

Long-term central vein catheters have found clinical application in different fields of medicine and particularly in oncology. In fact, the continuous infusion of some drugs has become the standard treatment in a wide variety of cancers, but central vein catheters are not without risks. The authors report their experience with central vein catheters. From January 1,1998, to December 31, 1999, 98 central vein catheters were placed in neoplastic patients. Seventy-seven (78.6%) Groshong and 16 (16.3%) Port-a-cath catheters were used. The central vein catheters were placed under local anesthesia. Before placement of the central vein catheters, the patients were checked by chest X-ray and neck ultrasonography. The procedure was performed under fluoroscopic control. The central vein catheters were flushed periodically with normal saline solution and sodium heparin. Sterile transparent adhesive dressings were used to occlude the operative site. The median follow-up of patients was 9 catheter months (range, 1-24 months). There were a few early and late clinically evident complications. The early complications were dislodgement in 5 cases (5.1%). The late complications were: fibrin sleeve in 1 case (1.1%), thrombosis in 2 cases (2.1%) and skin infection in 4 cases (4.1%). The low prevalence of major complications related to implants and management of these supports an increased use in oncology.

Long-Term Outcome of Permanent Hemodialysis Catheters: A Controlled Study

Aims: Hemodialysis tunneled catheters are widely used nowadays. However, their complications, infection and dysfunction, remain much too frequent. Different types of tunneled silicone hemodialysis catheters are available. We prospectively compared the long-term outcome of the two most popular devices, Permcath cuffed double catheter and TwinCath uncuffed twin catheter, both inserted percutaneously. Methods: From January 1994 to April 1998, 125 tunneled catheters were inserted in the internal jugular vein of 86 chronic hemodialysis patients, 63 TwinCath MedComp^® (TC) and 62 Permcath Quinton^® (PC). They were prospectively followed looking for technical patency, infection and dysfunction rate. Results: TC were used more often for iterative access (52 vs. 25% , p = 0.01) and were inserted more frequently in the left internal jugular vein (59 vs. 16% p < 0.001). Their median technical survival rate was longer (869 vs. 433 days for PC, p < 0.01) with a 1-year patency rate of 80 vs. 53% (p = 0.002). Total catheter extrusion was also slightly less frequent with TC (4.7 vs. 9.6%), but partial extrusion happened more frequently (43 vs. 16%, p = 0.02). No significant difference in infection rate was observed, 0.77 for TC vs. 1.3 local infection/1,000 catheter days; 1.08 vs. 1.30 bacteremia/1,000 catheter days. A persistent catheter thrombosis was observed in 7.9 vs. 20.9% in PC (p = 0.04), the number of dysfunction was 10.5 vs. 24/1,000 days in use (p = 0.0001) and the number of urokinase infusion was 4.4 vs. 12/1,000 days (p = 0.001). PC needed more radiological interventions for dysfunction with endolumenal brushes (4 vs. 0) or fibrin sleeve removal (4 vs. 0). The vena cava thrombosis incidence was not different (2 vs. 3). Conclusion: Although the study was not randomized, TC appears more efficient allowing for a longer patency with a lower dysfunction rate than PC. This was reinforced by less favorable conditions of TC including more left jugular side and more iterative catheters. The cuff does not offer a better bacteriological barrier or protection against extrusion, and the TC seems at a less risk of fibrin sleeves. However, a large randomized study is needed to definitively conclude.

Groshong Catheters: Technical Aspects and Clinical Features

After thousands of Groshong catheter applications over more than twenty years, the cause of blood withdrawal drawbacks is not yet completely understood. This phenomenon - which is not typical of closed-tip catheters since it is also common in open-tip catheters - in the Groshong catheter is attributed to the valve (ball-valve effect). The aim of this work is to understand the relationship between causes and effects in order to provide clinicians with practical solutions. Out of the 16 catheters examined, we observed no clear correlation among electron microscope ultrastructural analysis, valve closing pressure, intraluminal clots and clinical failures after different implantation times up to a maximum of 36 months. The ultrastructural analysis revealed an optimal no-time-related aspect for internal and external surfaces, while the closing pressure in each case was compatible with the efficiency of the working valve (range 22-36 cmH 2 O). We conclude that the blood withdrawal drawbacks cannot be attributed to a single cause and certainly not to the silicone biostability or directly to the valve. Different studies are suggesting that clinical failures can be the re-sult of several different causes such as slime or clots in the internal catheter surfaces and fibrin sleeve in the external catheter surfaces. These are common causes in open-tip catheters and we believe that the presence of valves on the tip of the Groshong may encourage inferences. Our suggestion is to place the tip of the Groshong catheter in atrium one centimetre after the junction with the vena cava. After the implant, it is possible to remove the causes of drawbacks by strong flushing using a 5-ml syringe and/or postural manoeuvres.

Catheter Rupture and Distal Embolisation: A Rare Complication of Central Venous Ports

Central venous access devices placed through a percutaneous subclavian approach may be compressed by neighbouring bony structures, leading to biomaterial fatigue, catheter fracture at the compression site, and possible embolisation of distal fragment into the central veins. The aim of this paper is to review the experience of the authors, including more than 1300 subclavian port placements, carried out during a five-year period, discussing possible causes and therapeutic options of this rare complication. Nine patients out of 1320 (0.68%) experienced this complication during the five-year period of this study. Two patients only showed a retrospective radiologic evidence of the 'pinch-off sign' (e.g. initial compression of the catheter at the costo-clavicular junction). No patients had symptoms from the embolised catheter fragment; the most frequent symptom (8 out of 9 cases) was a painful swelling around the port area during infusion, related to the extravasation of medications or fluids into the subcutaneous tissue. The site of embolised segment varied from azygos vein to right pulmonary artery; however, these findings did not affect the outcome, and all the embolised fragments were successfully retrieved through a transfemoral approach using a radiologic interventional technique. No fatality occurred. The catheter fracture and embolisation of the distal fragment are a well-known complication of subclavian central venous long-term cannulation, whose estimated overall incidence is 0.5-1%. Diagnosis is usually based on the radiologic appearance of the catheter compression (so called 'pinch-off sign'), which is far from being constant; a clinical suspicion can derive from intermittent malfunction, which claims differential diagnosis with the pres-ence of a fibrin sleeve around the tip of the catheter. Once diagnosed, the treatment is always an interventional radiologic approach, which has a very high success rate. When it fails, the possibility to leave the fragment embolised in the central veins, heart or pulmonary arteries, should be considered, being the thoracotomy and open catheter retraction questionable, at present time, in patients who have no symptoms and limited life-expectancy.

Percutaneous fibrin sleeve stripping of failing haemodialysis catheters.

One of the most frequent reasons for failure of haemodialysis lines is catheter blockage caused by fibrin sheath formation. We report our experience of percutaneous fibrin sheath stripping in treating this problem. A consecutive series of failing haemodialysis catheters underwent percutaneous fibrin sheath stripping in an attempt to retrieve and prolong the life of the catheter. Immediate technical success, clinical success, and primary and secondary patency were measured based on clinical follow-up. Sixteen non-functional permanent haemodialysis lines in 15 patients underwent percutaneous fibrin sheath stripping on 21 occasions. Technical success rate was 100%. Catheter flow rates sufficient for initial dialysis were achieved in 12 (75%) lines. Successful percutaneous fibrin sheath stripping produced a mean catheter patency of 126 days (range 6-299 days). Percutaneous fibrin sheath stripping is a simple, repeatable procedure that can usefully extend the life of a failing dialysis line. However, a randomized trial will be needed to evaluate its role compared with catheter replacement.

Composition and formation of the sleeve enveloping a central venous catheter

Purpose:After catheterization, 42% to 100% of central venous catheters are surrounded by a “fibrin sleeve.” This sleeve has been considered the cause of catheter-related infections, withdrawal occlusion, and pulmonary embolism. The reactions between the vein wall and the catheter were studied. Methods: A silicone catheter was placed in the anterior caval vein of 123 rats. After in situ fixation at scheduled intervals, the pathologic changes were studied on semi-serial histologic sections by means of light microscopy, transmission electron microscopy, and scanning electron microscopy (SEM). In 36 rats, the catheter was withdrawn immediately; in 72 rats, it was left in situ up to 6 months; and in 15 rats, the study was performed up to 10 months after withdrawal of a catheter that had remained in situ for 6 months. Results: In the group in which the catheter was withdrawn immediately, mural thrombi disappeared by day 7. In the group in which the catheter remained in situ, thrombi remained around the proximal portion of the catheter. This pericatheter thrombosis (PCT) was invaded by migrating and proliferating smooth muscle cells (SMCs), originating from an injured vein wall, and transformed from day 7 into a tissue composed predominantly of SMCs and collagen and covered by endothelial cells. Later, the number of cells decreased, and the relative amount of collagen increased. Up to 10 months after withdrawal of the catheter, the collapsed sleeve was still present within the vein. Conclusion: The sleeve around a central venous catheter is not a fibrin sleeve, but a stable cellular-collagen tissue covered by endothelium. It is mainly formed by smooth muscle cells migrating from the injured vein wall into the early pericatheter thrombus. (J Vasc Surg 1998;28:260-271.)

Prevention and Treatment of Thrombosis Associated With Long-Term Hemodialysis Catheters.

Soft, cuffed, central vein hemodialysis catheters are used in about 20% of chronic hemodialysis patients in the United States, because long-term arteriovenous blood access cannot be maintained in an aging patient population with a large proportion of diabetics. The most frequent complication of these catheters is thrombosis. The treatment of catheter-related thrombosis is difficult and expensive; thus the emphasis should be on prevention. The preferred material for a long-term catheter is silicone rubber, since it is the least thombogenic. Anticoagulation should be more vigorous during "catheter dialysis" than during "fistula dialysis." Heparin is the least expensive and most convenient anticoagulant, suitable for over 99% of chronic dialysis patients. The dose of heparin for sufficient anticoagulation depends on many factors, varies widely, and should be established for each patient based on activated clotting time (ACT). ACT should be kept over 270 sec throughout dialysis. Recently we introduced a method of locking catheter lumina with a predetermined amount of heparin; this heparin is not discarded before the next dialysis, but serves as a loading dose. This saves a number of connections/ disconnections and decreases dialysis-associated blood losses. To prevent catheter thrombosis, over 60% of patients require warfarin in sufficient doses to keep the international normalized ratio (INR) between 1.5 and 2.5. The most common catheter-related thrombus is a periluminal fibrin sleeve. Locking the catheter with urokinase to dissolve the clot is of little value, because the bulk of the thrombus is outside the catheter. We have found a high-dose (250 000 U or more) intradialytic urokinase infusion through the venous chamber to be a very efficient and convenient method for dissolving clots. Cumulative success of up to three infusions is over 99%. This obviates the need of catheter stripping or replacement, which is more cumbersome and expensive.

Central Venous Dialysis Catheter Dysfunction

Central venous catheter dysfunction is a limiting factor in regard to renal replacement therapy efficiency and can thus influence patient morbidity. Early catheter dysfunction is frequently due to mechanical problems such as inadequate positioning, kinking, or constriction, but early fibrin deposition can develop soon after insertion. Delayed dysfunction usually results from thrombus formation, either within the lumen, around the catheter ("fibrin sleeve"), or in the host vein. Catheter dysfunction is suspected clinically or documented by simple imaging studies. It is usually evident and manifested by failure to aspirate blood from the lumen(s), inadequate blood flow and/or high resistance pressures during hemodialysis. However, a more subtle dysfunction may lead to a high recirculation of dialyzed blood and be overlooked if dialysis adequacy is not monitored regularly. Local instillation of a fibrinolytic agent is usually successful in restoring catheter patency. Central venous dialysis catheters present intrinsic limitations consequent to their composition and design, whereas extrinsic limitations result from site of insertion, blood properties and anatomic particularities of a given individual. These characteristics largely determine overall catheter performances. Performance parameters to consider include maximal consistently achievable blood flow rate, resistance to blood flow indicated by arterial and venous pressures during hemodialysis, and blood recirculation rate. Catheter longevity is an important consideration for cuffed catheters implanted for long-term use. The tolerated blood recirculation within central venous dialysis catheters should be below 10% to 15%, and is ideally between 3% to 7% in most clinical settings. Several recent studies confirm that short femoral catheters recirculate significantly more than is desirable. Well functioning and nonreversed internal jugular and subclavian venous catheters have, in general, recirculation rates less than 5%. With regard to various performance criteria, the TwinCath (Medcomp, Harleysville, PA) appears particularly advantageous. In any case, a good catheter maintenance program is of critical importance for the prevention and the early detection of catheter dysfunction.

An endoluminal brush to detect the infected central venous catheter in situ: a pilot study.

Catheter related sepsis is a potentially life threatening infection caused by an indwelling intravenous catheter, with the same organism cultured from peripheral blood and from the removed catheter. If such sepsis is suspected the catheter is usually removed, although subsequent bacterial culture shows most catheters to be sterile.1 2 We evaluated a new brush (Endoluminal, FAS Medical, London) for detecting infection in the lumen of a central venous catheter. The brush has nylon bristles wound tightly around the distal end of a stainless steel wire and slides along the lumen of the catheter to its distal (inner) end. It is then removed for culture. The technique is based on the principle that bacteria collect on the fibrin sleeve on the catheter's inner surface; fibrin thus becomes enmeshed in the brush's bristles. We studied …

Les thromboses veineuses sur cathéter central en cancérologie

Central venous catheters have considerably improved the comfort and safety of chemotherapy in cancer patients. However complications as thrombosis could occur and their incidence vary from 3.7 to 42% in oncology. Catheter placement induces modifications of vascular system with formation of a fibrin sleeve and/or a mural thrombus. Thrombosis origin is linked with catheter itself, its position and the biomaterial used. Hypercoagulable state in cancer results from the perturbation of blood flow, the composition of blood itself and the vessel wall, and increases the iatrogenic effects of indwelling catheters. Finally chemotherapy used in the treatment of cancer has been associated with an increased incidence of thromboembolic events, suggesting the proposal of an antithrombotic prophylaxis in cancer patients receiving chemotherapeutic agents through indwelling catheter.