Tunneled Indwelling Pleural Catheters Research Articles

Surgical management of pleural complications in lymphangioleiomyomatosis

ObjectiveLymphangioleiomyomatosis (LAM) is a rare cystic lung disease occurring primarily in women. Pneumothorax and chylothorax are common pleural complications in LAM. We aim to explore various options in the surgical management of pleural disease in LAM. MethodsA retrospective chart review of all patients at the Center for LAM and Rare Lung Diseases at Columbia University was performed, and date, type, and indication for surgical procedure were collected. All patients with any cystic lung disease seen between January 1, 2000, and March 1, 2023, were included in the database. ResultsThe charts for 326 patients with possible LAM were reviewed, including 213 with confirmed LAM and 113 women with cystic lung disease consistent suspected to be LAM were reviewed. A total of 40.5% underwent surgical procedures at our institution or at referring hospitals. A total of 15.6% of patients underwent surgical lung biopsies. A total of 16.6% had a history of pneumothoraces, of whom 79.6% underwent chemical and/or mechanical pleurodesis, 14.8% required pleurectomy, and 7.4% were discharged with tunneled indwelling pleural catheters. We found that 5.6% of confirmed LAM patients have history of chylothorax, with thoracic duct ligation, thoracic duct embolization, pleurodesis, and pleurodesis with long-term tunneled indwelling pleural catheter placement all used as treatment strategies. ConclusionsHere we demonstrate the significant burden of pleural disease in patients with LAM. It is imperative that thoracic surgeons understand the high incidence of pneumothorax in this patient population. Tunneled indwelling pleural catheters are underutilized but provide long-term options for chylous management with long-term mechanical pleurodesis and a decrease in hospital length of stay.

The Use of Intrapleural Thrombolytic or Fibrinolytic Therapy, or Both, via Indwelling Tunneled Pleural Catheters With or Without Concurrent Anticoagulation Use

Indwelling tunneled pleural catheters are commonly used for recurrent pleural effusion management. Catheter obstruction is not uncommon, often requiring intrapleural medications instillation (i.e., alteplase) to restore flow. The safety profile of intrapleural medications has been previously published, however most studies exclude anticoagulated patients. What is the safety profile of intrapleural alteplase and/or dornase alfa when utilized in indwelling tunneled pleural catheters, including patients that may be undergoing active anticoagulation? Retrospective review of previously placed indwelling tunneled pleural catheters from January 2009 - February 2020 undergoing intrapleural alteplase. Basic demographics, laboratory studies, anticoagulation medication usage, and complications were collected. Descriptive statistics were used to report demographics and outcomes. Univariate Firth's logistic regression analyses were used to identify factors associated with complications, followed by multivariable regression analyses. A total of 94 patients underwent indwelling tunneled pleural catheter placement and intrapleural instillation. The median age of patients was 66.1 (IQR - 57.6-74.9) years. Intrapleural medications were administered 71 times in 30 anticoagulated patients and 172 times in 64 not anticoagulated patients. A total of 20 complications were identified in 18 patients, and one experiencing more than one complication. There were 5 bleeding complications with no significant increased risk with anticoagulation usage (2 anticoagulated, 3 not anticoagulated; p=0.092). Multivariable Firth's logistic regression demonstrated that alteplase dose (p=0.04) and anticoagulation usage (p=0.05) were associated with any complication, but not associated with bleeding complications. We report a relatively low incidence of complications and in particular, bleeding complications in patients receiving intrapleural alteplase for non-draining IPCs. Bleeding episodes occurred in 5/94 (5.3%) patients with no apparent increased risk of bleeding complication, whether receiving anticoagulation or not. Additional study is warranted to identify risk factors for complications, in particular bleeding complications in this patient population.

Retained Granulation Cuff as a Complication of Indwelling Pleural Catheter Removal.

Recurrent pleural effusions can be managed with indwelling tunneled pleural catheters (IPC), with some patients undergoing IPC removal after appropriate palliation has occurred. Little data exists regarding complications related to IPC removal. We report on retained granulation cuffs after successful IPC removal. We identified 122 IPC removals of which 6 (4.9%) were complicated by retained granulation cuff. No additional procedures or need for retrieval were identified over a median follow-up time of 423.5 (IQR-204-1489) days. Clinicians should be aware of this potential complication, but that retained granulation cuffs appear to offer no sequelae and aggressive interventions for retrieval/removal are likely not warranted.

Management of Indwelling Tunneled Pleural Catheters: A Modified Delphi Consensus Statement

The management of recurrent pleural effusions remains a challenging issue for clinicians. Advances in management have led to increased use of indwelling tunneled pleural catheters (IPC) because of their effectiveness and ease of outpatient placement. However, with the increase in IPC placement there have also been increasing reports of complications, including infections. Currently there is minimal guidance in IPC-related management issues after placement. Our objective was to formulate clinical consensus statements related to perioperative and long-term IPC catheter management based on a modified Delphi process from experts in pleural disease management. Expert panel members used a modified Delphi process to reach consensus on common perioperative and long-term management options related to IPC use. Members were identified from multiple countries, specialties, and practice settings. A series of meetings and anonymous online surveys were completed. Responses were used to formulate consensus statements among panel experts, using a modified Delphi process. Consensus was defined a priori as greater than 80%agreement among panel constituents. A total of 25 physicians participated in this project. The following topics were addressed during the process: definition of an IPC infection, management of IPC-related infectious complications, interventions to prevent IPC infections, IPC-related obstruction/malfunction management, assessment of IPC removal, and instructions regarding IPC management by patients and caregivers. Strong consensus was obtained on 36 statements. No consensus was obtained on 29 statements. The management of recurrent pleural disease with IPC remains complex and challenging. This statement offers statements for care in numerous areas related to IPC management based on expert consensus and identifies areas that lack consensus. Further studies related to long-term management of IPC are warranted.

Indwelling Tunneled Pleural Catheters.

"Indwelling Tunneled Pleural Catheters." American Journal of Respiratory and Critical Care Medicine, 200(11), pp. P20–P21

Role of indwelling pleural catheters in hepatic hydrothorax

Role of indwelling pleural catheters in hepatic hydrothorax - IJIRM- Print ISSN No: - 2581-4214 Online ISSN No:- 2581-4222 Article DOI No:- 10.18231/j.ijirm.2019.033, IP Indian Journal of Immunology and Respiratory Medicine-IP Indian J Immunol Respir Med

A comparison between two types of indwelling pleural catheters for management of malignant pleural effusions

Malignant pleural effusion (MPE) is a common cause of quality of life deterioration in patients with advanced cancer. Management options include chemical pleurodesis with a sclerosing agent such as doxycycline or talc powder, surgery, and also the placement of tunneled indwelling pleural catheters (IPCs). Two different IPC types are mostly used in the USA. We conducted a single-center retrospective study with the objective to compare the efficacy and safety profiles of two IPC systems. Patients with a diagnosis of malignancy, who received IPCs by the interventional radiology department of our hospital from January 2013 to March 2015, were identified in the local database and a chart review was performed to record characteristics and outcomes. Patients without a diagnosis of malignancy or with pleural effusions of cardiac origin were excluded from the study. We identified 27 patients with a median age of 59.0 years. Eighty patients received Aspira catheter while nine patients received PleurX catheter, and seven patients achieved spontaneous pleurodesis. The median length of stay (LOS) was 9 days for the Aspira group (AG), as compared to 13 days for the PleurX group (PG) (overall median LOS was 10 days; range, 2-62 days). The rate of catheter-related complications (pain, obstruction, loculations, infection, hemorrhage) was 39% (seven patients) for the AG and 33% (three patients) for the PG (overall ten patients, 37%). In our study, outcomes and safety were similar for patients receiving either type of IPC, Aspira or PleurX.

Indwelling tunneled pleural catheters for the management of hepatic hydrothorax.

Hepatic hydrothorax is a complication of end-stage liver disease that may have significant associated morbidity. Sodium restriction and diuretic therapy are the mainstays of treatment, though up to a quarter of patients will become refractory to this and will require a pleural drainage procedure. Thoracentesis, transjugular intrahepatic portosystemic shunt, and chemical pleurodesis all have variable success rates and associated complications in the management of hepatic hydrothorax. Indwelling tunneled pleural catheters (ITPC) have been successfully used to manage recurrent symptomatic malignant pleural effusions, and there is growing interest regarding their use in the management of hepatic hydrothorax. Evidence regarding the use of ITPC for nonmalignant pleural effusions has been limited to retrospective studies and small feasibility trials. A recent meta-analysis regarding the use of IPTC for nonmalignant pleural effusions demonstrated a rate of spontaneous pleurodesis of 51%, whereas a small, prospective study demonstrated spontaneous pleurodesis rates of 33% and an infection rate of 16.7% in 24 patients with ITPC placed for hepatic hydrothorax in patients suitable for liver transplant evaluation. ITPC may be an acceptable treatment option for the management of hepatic hydrothorax which are refractory to conventional medical management. Larger, randomized controlled trials are needed to further evaluate the safety and efficacy of these catheters for the management of nonmalignant pleural effusions.

147: Cost effectiveness of a tunneled indwelling pleural catheter service for malignant pleural effusions secondary to lung cancer and mesothelioma

147: Cost effectiveness of a tunneled indwelling pleural catheter service for malignant pleural effusions secondary to lung cancer and mesothelioma

Tunneled Indwelling Pleural Catheters for Refractory Pleural Effusions after Solid Organ Transplant. A Case-Control Study.

The use of tunneled indwelling pleural catheters for management of refractory pleural effusions continues to increase. Pleural space infections are among the most common and serious complication of the procedure. The risk may be higher in patients receiving immunosuppressive medications. The aim of this study was to assess the risk of infections complicating placement of a tunneled indwelling pleural catheter in patients who have received a solid organ transplant. Electronic medical records were retrospectively reviewed to identify patients with prior solid organ transplant who subsequently underwent placement of a tunneled intrapleural catheter. We selected a matched sample of comparison patients without solid organ transplant who underwent the same procedure during the study period. Detailed chart abstraction was performed to compare baseline clinical information with procedure outcomes in both groups. Nineteen study patients underwent kidney, liver, lung, or heart transplant. Another 55 patients were included in the nontransplant comparison group. Transplant patients were taking a mean of 2.4 (range, 1-4) immunosuppressive medications. In transplant patients, the intrapleural catheter remained in place for a median of 95 days (interquartile range, 58-256 d). Two of the 19 transplant patients (16.9% 90-day Kaplan-Meier estimate) and 4 of the 55 control patients (11.0% weighted 90-day Kaplan-Meier estimate) developed a major infectious complication (not significant). There were no deaths attributed to intrapleural catheter placement in either group. In a series of 19 patients with solid organ transplantation taking daily immunosuppressive medications who underwent placement of a tunneled intrapleural catheter, we report an 11% rate of major infectious complications over the lifetime of the catheter in the transplant group with no significant difference in 90-day estimated risk of complication between transplant and nontransplant comparison group.

Indwelling Tunneled Pleural Catheters for the Management of Hepatic Hydrothorax. A Pilot Study.

Hepatic hydrothorax is a complication of cirrhosis in which hydrostatic imbalances result in fluid accumulation within the pleural space. Although uncommon, this may cause significant morbidity, resulting in dyspnea requiring repeated pleural drainage procedures. Liver transplantation is curative, but it is rarely immediately available to qualified patients, presenting the clinical challenge of managing recurrent pleural effusions. Indwelling tunneled pleural catheters (ITPCs) have been used successfully to palliate dyspnea associated with recurrent malignant pleural effusions. This study was performed to evaluate the feasibility of using ITPCs for the management of hepatic hydrothorax. A single-center prospective feasibility study was performed to evaluate the use of ITPCs for the management of recurrent hepatic hydrothorax in patients who were eligible for liver transplant evaluation. Twenty-five ITPCs were placed in 24 patients. The mean number of pleural drainage procedures before ITPC placement was 1.9, with no further pleural drainages required in any patient after ITPC placement. Spontaneous pleurodesis occurred in 8 of 24 patients (33%). All eight catheters were successfully removed without pleural fluid reaccumulation. Mean time to pleurodesis was 131.8 days. Pleural fluid infection occurred in 4 of 24 patients (16.7%), requiring catheter removal in 3 of the 4 patients. ITPCs may be successfully and safely used to control symptoms associated with hepatic hydrothorax. The rate of spontaneous pleurodesis that occurs is similar to that observed with ITPCs placed for malignant pleural effusion, although the infection rate may be higher. Clinical trial registered with www.clinicaltrials.gov (NCT02595567).

Tunneled Indwelling Pleural Catheters (TIPC) for Refractory Pleural Effusions in Patients With Solid Organ Transplant

SESSION TITLE: Interventional Pulmonary SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 25, 2015 at 04:30 PM - 05:30 PM PURPOSE: The use of tunneled indwelling pleural catheters (TIPC) for symptomatic management of refractory pleural effusions continues to rise. Pleural space infections occur in 5% of patients with TIPC for malignant pleural effusions, and this risk is likely higher in patients receiving immunosuppressive therapy which is often considered a relative contraindication to TIPC placement. The use of TIPCs for refractory pleural effusions in solid organ transplant recipients, a population typically maintained on high levels of immunosuppression, has not been reported. METHODS: Electronic records were retrospectively reviewed to identify all patients at our institution with solid organ transplant who subsequently underwent TIPC placement between 1/1/2005 and 12/31/2014. In each patient meeting inclusion criteria, a detailed chart abstraction was performed to identify indication for catheter placement, duration of TIPC, immunosuppressive medication regimen, and TIPC related complications including infection or death. RESULTS: A total of 19 patients were identified, with the following solid organ transplants: kidney (n=12), liver (n=4), heart (n=4), and lung (n=1) with some patients having several organ transplants. TIPC was placed for malignant pleural effusion in 26% (5/19) with the remainder placed for non-malignant indications such as congestive heart failure or hepatic hydrothorax. Patients were taking a mean of 2.4 different immunosuppressive agents at the time of their TIPC placement, and the two most commonly used agents were tacrolimus (n=13) and mycophenolate (n=13). The TIPC remained in place for a median of 95 days (interquartile range 58-241 days). The most common reasons for removal were patient death (n=9) and autopleurodesis (n=8). Two out of the 19 patients developed pleural space infection; both requiring hospitalization. In both cases, the patients were successfully treated with IV and oral antibiotics and did not require thoracic surgical intervention or removal of the TIPC. There were no deaths due to TIPC complication. CONCLUSIONS: In this series of patients with solid organ transplantation who underwent TIPC implantation, we report an 11% rate of major infectious complication with no fatal complications. CLINICAL IMPLICATIONS: Placement of TIPC may be an option for patients with prior solid organ transplant who develop refractory pleural effusions. The benefit to the patient must be weighed against the risk of infection. DISCLOSURE: The following authors have nothing to disclose: Joseph Skalski, Fabien Maldonado No Product/Research Disclosure Information

The Use of Indwelling Tunneled Pleural Catheters for Recurrent Pleural Effusions in Patients With Hematologic Malignancies: A Multicenter Study

Malignant pleural effusion is a common complication of advanced malignancies. Indwelling tunneled pleural catheter (IPC) placement provides effective palliation but can be associated with complications, including infection. In particular, hematologic malignancy and the associated immunosuppressive treatment regimens may increase infectious complications. This study aimed to review outcomes in patients with hematologic malignancy undergoing IPC placement. A retrospective multicenter study of IPCs placed in patients with hematologic malignancy from January 2009 to December 2013 was performed. Inclusion criteria were recurrent, symptomatic pleural effusion and an underlying diagnosis of hematologic malignancy. Records were reviewed for patient demographics, operative reports, and pathology, cytology, and microbiology reports. Ninety-one patients (mean ± SD age, 65.4 ± 15.4 years) were identified from eight institutions. The mean × SD in situ dwell time of all catheters was 89.9 ± 127.1 days (total, 8,160 catheter-days). Seven infectious complications were identified, all of the pleural space. All patients were admitted to the hospital for treatment, with four requiring additional pleural procedures. Two patients died of septic shock related to pleural infection. We present, to our knowledge, the largest study examining clinical outcomes related to IPC placement in patients with hematologic malignancy. An overall 7.7% infection risk and 2.2% mortality were identified, similar to previously reported studies, despite the significant immunosuppression and pancytopenia often present in this population. IPC placement appears to remain a reasonable clinical option for patients with recurrent pleural effusions related to hematologic malignancy.

Adjunct strategies to enhance the efficacy of indwelling pleural catheters

Malignant pleural effusion remains a distressing and unfortunately common occurrence. Pleural palliation should be focused on relieving dyspnea with as few procedures as possible. The introduction of the indwelling tunneled pleural catheter has been shown to fulfill these goals; however, it is not without limitations. The ability to potentially combine the results of a long-term pleurodesis procedure without the need for a prolonged hospitalization remains an attractive option. While no large-scale trials have been completed nor is there widespread acceptance, the introduction of “rapid” or “accelerated” pleurodesis procedures, often using tunneled indwelling pleural catheters, have the potential to significantly change the current paradigm of malignant pleural effusion management. This article reviews the current data available for “rapid” and “accelerated” pleurodesis protocols and their outcomes.

Management of recurrent malignant pleural effusions with a tunneled indwelling pleural catheter

Management of recurrent malignant pleural effusions with a tunneled indwelling pleural catheter

The Role for Tunneled Indwelling Pleural Catheters in Patients With Persistent Benign Chylothorax

BackgroundUtilization of tunneled indwelling pleural catheters (TIPCs) for persistent pleural effusions is increasingly more common; however, the presence of chylothorax is generally considered a contraindication for utilization of a TIPC due to concerns regarding potential nutritional, immunologic and hemodynamic complications. Therefore, in this study, a cohort of patients with persistent benign chylothorax managed with TIPCs is described. MethodsA retrospective analysis of patients with persistent benign chylothorax managed with a TIPC at the study center between January 1, 2008, and March 1, 2012, was completed. Extracted data included patient characteristics, chylothorax etiologies, prior interventions, outcomes and complications. ResultsEleven patients (14 hemithoraces) had persistent benign chylothorax treated with placement of a TIPC during the inclusion time frame. Etiology of the chylothorax was nontraumatic in 8 of the 11 patients, with the remaining 3 secondary to thoracic surgery. Pleurodesis was achieved in 9 of the 14 hemithoraces, with a median time to pleurodesis of 176 days. All procedures were well tolerated, and no immediate periprocedural complications were reported. One serious complication was encountered in the form of a postoperative pulmonary embolism after replacement of an occluded TIPC, resulting in the patient’s death. Two patients had transient occlusions of their TIPCs successfully treated with intracatheter thrombolytic therapy. No significant adverse nutritional, hemodynamic or immunologic outcomes were reported during follow-up for any included patient. ConclusionsUtilization of a TIPC for the management of persistent benign chylothorax should be considered early because pleurodesis may be frequently and safely achieved in this patient population.

Home-management of malignant pleural effusion with an indwelling pleural catheter: Ten years experience

BackgroundMore than one half of patients with cancer have a malignant pleural effusion (MPE) at some time during their life span. Recurrent malignant pleural effusions impair respiratory functions and worsen the quality of life. Once a patient develops MPE, only fluid drainage relieves pulmonary compression and dyspnea. Optimal treatment is however, still controversial. In patients not suitable for pleurodesis, or with recurrent MPE after pleurodesis, or with trapped lung, the outpatient intermittent drainage through a subcutaneous tunneled indwelling pleural catheter (IPC) is a possible choice. MethodsIn ten years, we treated 90 patients by outpatient insertion of IPC. Eligibility for IPC required previous thoracentesis with histological confirmation of malignancy and chest roentgenogram evidence of effusion. All patients treated were made aware of their malignancy and positive cytology in the pleural effusion. ResultsMean survival was 197 days (range 23–296 days). Median time of draining interval was 7.0 days with maximum amount of effusion drained off being 1000 ml. Pleurodesis occurred in 37 (41.1%) patients with a mean time of pleurodesis of 51 days (range 34–78 days). No major complication was recorded. ConclusionsThe IPC is a useful device in the management of recurrent MPE. Treatment can be entirely accomplished at home and the complication rate is low.

Use of Tunneled Indwelling Pleural Catheters for Palliation of Nonmalignant Pleural Effusions

PURPOSE: The use of tunneled indwelling pleural catheters (TIPCs) in non-malignant disease has not been systematically investigated. We characterize our experience with the use of TIPCs in non-malignant pleural effusions.

Use of Indwelling Tunneled Pleural Catheters for the Management of Hepatic Hydrothorax

PURPOSE: Hepatic Hydrothorax (HH) occurs in 5-10% of cirrhotic patients and remains a significant clinical challenge. Despite medical therapy with diuretics, many patients experience intractable, debilitating dyspnea and respiratory compromise. Trans-jugular intrahepatic porto-systemic shunt (TIPS), while a valuable treatment for HH, is not always effective and liver transplantation may not be available to many patients. Indwelling tunneled pleural catheters (ITPC) have been successfully used to control dyspnea in patients with malignant pleural effusions.

Efficacy and Safety of Tunneled Pleural Catheters in Adults with Malignant Pleural Effusions: A Systematic Review

BackgroundMalignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE.ObjectiveTo systematically review published data on the efficacy and safety of the TIPC for treatment of MPE.DesignWe searched the MEDLINE, EMBASE, and ISI Web of Science databases to identify studies published through October 2009 that reported outcomes in adult patients with MPE treated with a TIPC. Data were aggregated using summary statistics when outcomes were described in the same way among multiple primary studies.Main MeasuresSymptomatic improvement and complications associated with use of the TIPC.Key ResultsNineteen studies with a total of 1,370 patients met criteria for inclusion in the review. Only one randomized study directly compared the TIPC with the current gold standard treatment, pleurodesis. All other studies were case series. Symptomatic improvement was reported in 628/657 patients (95.6%). Quality of life measurements were infrequently reported. Spontaneous pleurodesis occurred in 430/943 patients (45.6%). Serious complications were rare and included empyema in 33/1168 patients (2.8%), pneumothorax requiring a chest tube in 3/51 (5.9%), and unspecified pneumothorax in 17/439 (3.9%). Minor complications included cellulitis in 32/935 (3.4%), obstruction/clogging in 33/895 (3.7%) and unspecified malfunction of the catheter in 11/121 (9.1%). The use of the TIPC was without complication in 517/591 patients (87.5%).ConclusionsBased on low-quality evidence in the form of case series, the TIPC may improve symptoms for patients with MPE and does not appear to be associated with major complications. Prospective randomized studies comparing the TIPC to pleurodesis are needed before the TIPC can be definitively recommended as a first-line treatment of MPE.