Venous Access In Patients Research Articles

Perviedade e complicações no seguimento de cateteres venosos totalmente implantáveis para quimioterapia

CONTEXTO: A disponibilidade de acesso venoso nos pacientes que recebem cursos prolongados de terapia citotóxica é de grande importância para o sucesso do tratamento. Os cateteres totalmente implantáveis vêm sendo cada vez mais utilizados para a referida terapia, proporcionando melhoria na qualidade de vida dos doentes. OBJETIVO: Avaliar a perviedade e complicações dos cateteres venosos totalmente implantáveis instalados nos pacientes oncológicos. MÉTODOS: Estudo longitudinal retrospectivo com 74 pacientes submetidos a colocação de cateter totalmente implantável de janeiro de 2004 a fevereiro de 2007. RESULTADOS: Foram inseridos cateteres venosos totalmente implantáveis em 74 pacientes com idade média 48,9 anos, predominando o sexo feminino. As neoplasias mais prevalentes foram mama (40,5%), cólon (20,8%) e linfoma (18,9%). Houve predomínio do acesso venoso pela via cervical (74,3%), com utilização da veia jugular interna em 45,9% dos casos. Somente 13,5% dos acessos ocorreram por punção da veia subclávia. A duração média de uso dos cateteres foi de 335,33 dias. Trinta e seis doentes (48,6%) mantiveram-se com o cateter após o término da quimioterapia. Sessenta e sete doentes (90,5%) não apresentaram complicações. Entre as complicações precoces, houve um (1,4%) pneumotórax e um (1,4%) hematoma na loja de implantação. Entre as complicações tardias, ocorreram cinco (6,7%) infecções. Foram retirados 10 (13,5%) cateteres, cinco devido às complicações e cinco por término do tratamento. Houve 11 (14,9%) óbitos de pacientes em decorrência do câncer, com o cateter funcionante. CONCLUSÃO: Os resultados obtidos demonstram baixa taxa de complicações, confirmando a segurança e conveniência do uso dos acessos totalmente implantáveis em paciente em regime de quimioterapia.

Atrial Thrombosis: A near Fatal Complication of a Portacath

Portacaths (Bard Medical Division, Georgia, USA) are routinely used for central venous access in patients with poor peripheral veins who require regular long-term venous access. Complications associated with central venous access devices, including infection and thrombosis, are well described in the literature; however, to our knowledge there have been few case reports of right atrial thrombi and pulmonary emboli related to implanted ports. This paper discusses the case of a patient who developed an atrial thrombosis 4 months after port placement and subsequent pulmonary emboli.

Guidelines for Venous Access in Patients with Chronic Kidney Disease

At the time of hemodialysis vascular access evaluation, many chronic kidney disease patients already have iatrogenic injury to their veins which impedes the surgical construction of an arteriovenous fistula (AVF). Achieving the important goal of a greater prevalence of arteriovenous fistulae in the US hemodialysis population will require identification of those patients prior to reaching end-stage renal disease and an educational and procedural system for preserving their veins.

Comparison of Direct Anti-Fibrotic Therapy with ACE Inhibition on Ventricular Function and Remodelling Following Myocardial Infarction

364 Comparison of Direct Anti-Fibrotic Therapy with ACE Inhibition on Ventricular Function and Remodelling Following Myocardial Infarction Maros Elsik 1,∗, Yuan Zhang2, Bing Wang1, Richard Gilbert 3, Henry Krum1, Darren J. Kelly 2 1DEPM Monash University, Melbourne, Victoria, Australia; 2 Department of Medicine, St Vincent’s Hospital, Melbourne, Victoria, Australia; 3 University of Toronto, Toronto, Canada Introduction: Reactive myocardial fibrosis contributes to adverseventricular remodelingandheart failure.Wecompared FT-011 (FT) (Fibrotech,Melbourne), which has been shown to have antifibrotic properties, to standard therapy and combination therapy to test the hypothesis that preventing reactive fibrosis improves cardiac function. Methods: Sprague Dawley rats underwent ligation of the left anterior descending artery to induce myocardial infarction (MI) (or sham procedure). Twenty-eight days treatment with vehicle (V), FT or Perindopril (P) commenced 1-weekpost surgery. Left ventricular (LV) size and function was assessed with echocardiography (days 2 and 35). Total collagen (TC) content and collagen types I and III (C-I and C-III) were analysed histologically. Results: MIs were of comparable size in all groups. TC was reduced with active treatment—FT: 1.5%, P: 1.54% vs. V: 2.23%, p< 0.05 for all as was C-I and C-III. This was 365 A Single-Hospital Experience with 29 Continuous-Flow Left Ventricular Assist Devices Alasdair Watson1,∗, Paul Jansz2, Emily Granger 2, Alan Farnsworth2, Carmen Axisa2, Eugene Kotlyer 2, Anne Keogh2, Christopher Hayward2, Peter Macdonald1, Phillip Spratt 2 1 Transplant Program, Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; 2 Heart & Lung Transplant Unit, St Vincent’s Hospital, Sydney, NSW, Australia Background: We embarked upon our continuous-flow LVAD program in November 2005. The aim of this study was to report the outcome of all patients receiving such a device. Results: 29 continuous-flow LVADs were implanted at our institution between November 2004 and February 2008. These consisted of 23 Ventrassist and 6Heartware devices, 23 intended as bridge-to-transplantation (17 Ventrassist and 6 Heartware) and 6 as destination. Patients in the “bridge” group consisted of 18 males and 5 females; all 6 “destination” patients weremales. “Destination” patients were significantly older than “bridge” patients (69.7± 1.4 years vs. 48.5± 3.3 years, p= 0.003). Mean ICU stay was 292.3 h for the entire group (range 48.0–968.0), and hospital stay 39.5 days (range 18–108). There were 2 in-hospital deaths in the “bridge” group. associated with reduction of LV size and an improvement inLVfunction (see table).Theheart, bodyand lungweights were also reduced.Correlating collagenandEF (spearman r= 0.66, p< 0.05), confirmed that a reduction of collagen is associated with functional improvement. Group EF% FAC% mLVESDcm LVESA (cm2) LVEDV (cm3) LVESV (cm3) Sham+V 66.50(2.5) 55.17(3.03) 0.51(0.03) 0.50(0.04) 0.55(0.03) 0.18(0.02) MI+V 40.68(3.12)# 29.56(2.13)# 0.79(0.04)# 0.90(0.06)# 0.82(0.07)* 0.50(0.05)** MI+FT 52.85(3.51)* 36.67(2.57)* 0.68(0.03)* 0.72(0.05)* 0.71(0.03) 0.37(0.04) MI+P 52.83(3.9)* 38.78(2.74)* 0.71(0.03)* 0.70(0.06)* 0.67(0.04) 0.33(0.04)* Mean (S.E.M.). EF: ejection fraction; FAC: fractional area change; LVESD: LV end systolic diameter; LVESA: LV end systolic area; LVEDVolume, LVESVolume. *p< 0.05, #p< 0.01, **p< 0.001. MI+V vs. sham. Other groups compared to MI+V. Conclusion: FT-011 reduces pathological deposition of collagen and improves ventricular function post MI. Its effects are comparable to perindopril. FT-011 reduces collagen deposition and ventricular remodelling independent of renin angiotensin aldosterone inhibition. doi:10.1016/j.hlc.2008.05.365 All other patients were discharged home, often to remote rural areas. In the “bridge” group nine patients received a heart transplant after 305.8 days (range 72–794). There was one late death after 751 days. The remaining 11 patients are alive and awaiting transplantation, with mean follow-up 315.2 days (range 10–844). Actuarial survival at 12 months was 91% and at 24 months 73%. In the “destination” group there was 1 late death after 619 days. The remaining 5 patients remain alive and well after a mean of 520.8 days (range 309–654). Conclusion: Continuous-flow LVADs provide an effective meansof circulatory support in selectedpatientswithendstage heart failure, the vast majority of whom are able to be discharged home. doi:10.1016/j.hlc.2008.05.366 366 Experience with Ultrafiltration via Venous Access in Refractory Congestive Heart Failure Christine Bourgault ∗, Jay Baumwol, Peter MacDonald St Vincent Hospital, Sydney, NSW, Australia Background: The treatment of some patients with severe congestive heart failure can be challenging, as they can be resistant to diuretics. Ultrafiltration (UF) is now considered a useful alternative therapy for this group of patients; however it continues to be underutilised. Objective: The aim of this study is to evaluate the efficacy and safety of UF via venous access in patients with refractory heart failure.

The Innominate Vein as Alternative Venous Access for Complicated Implantable Cardioverter Defibrillator Revisions

Venous complications of implantable cardioverter defibrillator (ICD) systems may cause significant problems when the need for system revision or upgrades arises. Such revisions require venous access close to the site of the previous ICD implantation. The internal and external jugular vein have disadvantages due to a long subcutaneous course crossing the clavicle and problems with lead extraction if infection occurs. In seven patients with ICD revisions due to lead dysfunction (n = 4) and upgrade to a biventricular device (n = 2) and status after system removal due to infection with new device implantation (n = 1) conventional venous access could not be obtained. Intraoperative contrast venography demonstrated an occluded left subclavian and/or left innominate vein in all patients. In all patients, we gained venous access through puncture of the right innominate vein and tunneled the new lead subcutaneously to the ICD pocket on the left. No intraoperative complications were observed. All patients are followed in our ICD clinic. Mean follow-up is 16 +/- 4 months now. So far, no clinical or lead complications with this access have been observed. We have demonstrated that ICD lead placement through puncture of the right innominate vein is feasible. We propose the innominate vein as an alternative route for establishing venous access in patients requiring ICD revisions or upgrades who suffer from venous obstruction. ICD implanting physicians should acquaint themselves with the technique of right innominate vein puncture to use this vein as a bail-out strategy in patients with complicated venous access.

Saphenous Vein Eversion: A Novel Technique for Hickman® Catheter Insertion

Saphenous eversion Hickman catheter insertion can provide an alternative technique for venous access in patients in whom upper body access is not feasible. The technique is simple and obviates many of the complications of upper body permanent venous access catheter insertion. Further experience is required to assess whether this technique can become one of the standard Hickman insertion techniques.

Electrophysiologic interventions in patients with inferior vena cava filters: Safety and efficacy of the transfemoral approach

The purpose of this study was to evaluate the transfemoral venous approach for electrophysiologic interventions in patients with inferior vena cava filters. Reports have detailed complications associated with obtaining central venous access in patients with inferior vena cava filters. Accordingly, electrophysiologic interventions have been modified or deferred altogether in such patients. Patients requiring interventions with a transfemoral approach who were at least 3 months post filter insertion underwent fluoroscopically guided insertion and withdrawal of electrode catheters with appropriate follow-up. Five patients underwent successful pacing, electrophysiologic study, or radiofrequency ablation using one to three catheters, with no complications attributable to filter placement. Transfemoral electrophysiologic interventions can be safely undertaken across vena cava filters provided appropriate precautions are taken.

Venous Access for Patients with Chronic Kidney Disease

ESTABLISHING and maintaining reliable intravenous access for patients with chronic renal failure or end-stage renal disease presents special considerations unique to this patient population. These patients often present with complicated medical conditions requiring intravenous medical therapies; at the same time, there is a critical need to preserve the peripheral and central veins for future hemodialysis access.

Venous Access for Patients with Chronic Renal Failure or End-Stage Renal Disease: What is the Role for Peripherally Inserted Central Catheters?

Venous Access for Patients with Chronic Renal Failure or End-Stage Renal Disease: What is the Role for Peripherally Inserted Central Catheters?

Tunneled Jugular Small-Bore Central Catheters as an Alternative to Peripherally Inserted Central Catheters for Intermediate-term Venous Access in Patients with Hemodialysis and Chronic Renal Insufficiency

In 34 patients with chronic renal insufficiency or failure, 43 small-bore central catheters were placed via the internal or external jugular veins: right internal jugular vein, 28; left internal jugular vein, 14; right external jugular vein, one. Central venous access was achieved in all patients (mean catheter dwell time, 28 days; range, 3-99 days), with two minor complications (arterial puncture and catheter damage during suturing). Tunneled jugular small-bore central catheters are a vein-preserving alternative to peripherally inserted central catheters in this population.

Ultrasound-guided central venous access.

Real-time ultrasound guidance should increase the success rate and lower the complication rate of central venous access in patients with relative contraindications to having the procedure performed. Prospective case series. A community-based tertiary care hospital. Fifty-two patients were studied. Relative risks to central venous catheter insertion included (1) thrombosis or stenosis of central veins, (2) inherent or acquired anticoagulation abnormalities, (3) inability to assume a supine position, (4) hypovolemia, (5) obesity or altered anatomy, and (6) severe respiratory compromise. Real-time ultrasound evaluation of the proposed vein to be cannulated, followed by real-time percutaneous central vein access. Successful cannulation of a central vein. All attempts at central vein cannulation were successful. No bleeding complications occurred. One pneumothorax occurred in an obese patient. Ultrasound-guided central venous access is a helpful technique to gain venous access in difficult cases. Surgeons who perform central venous access procedures should become acquainted with the techniques involved. The techniques should be incorporated into currently developing ultrasound instruction courses for surgeons.

65. Totally implantable venous access in patients with cystic fibrosis (CF)

65. Totally implantable venous access in patients with cystic fibrosis (CF)

Bacterial endocarditis associated with a skin-tunnelled catheter

Skin-tunnelled catheters have become an accepted method for establishing long-term central venous access in patients undergoing treatment for malignancies. They allow administration of continuous infusions of cytotoxic drugs, supplementation of fluids and blood products, total parenteral nutrition and access for the checking of blood tests. It is recognized that there are certain complications associated with their use including the risk of infection both of the exit site and tunnel, as a source of septicaemia, line-associated thrombosis (despite the use of prophylactic low dose warfarin and flushing of the line with heparin) and accidental dislodgement of the line. We report a case of bacterial endocarditis affecting the pulmonary valve shortly after removal of a skin-tunnelled catheter due to line-associated brachiocephalic venous thrombosis.

Transfusion Support for Patients with Sickle Cell Disease.

This small soft-back volume has been written by three authors closely associated with the Comprehensive Sickle Cell Center at Duke University, North Carolina. It is clearly laid out with seven chapters addressing the Pathophysiology of Sickle Cell Disease, Clinical Manifestations, Modes of Transfusion, Indications for Transfusion, Controversies, Immunologic, and non-Immunologic Complications. It presents a useful review targeted for non-experts in the disease and is written in an informal style which can best be portrayed as reader-friendly. Occasional lapses suggest that the authors are not intimately associated with all recent developments as illustrated by the reference on page 1 to the sickle cell gene occurring in ‘parts of southern India’. This seems to refer to the initial description of the gene among primitive tribes in the Nilgiri Hills by Professor Hermann Lehmann in 1952. Over the last 30 years the Anthropological Survey of India and other groups have conducted extensive population surveys indicating the gene to be frequent throughout central India (Orissa, Madhya Pradesh, and Maharastra). Some estimates suggest an average sickle cell trait frequency of 15%, which, bearing in mind the numerator of 300 million, may imply that there are more cases of the disease born in India than in Africa! In chapter 2, on clinical manifestations, there is a potential source of confusion under the phenotypic heading of ‘Hemoglobin S with high fetal hemoglobin’ when it is unclear whether they refer to SS disease with high levels of HbF or the benign syndrome of sickle cell–hereditary persistence of fetal haemoglobin. The authors may wish to revise the table of haematological values in which the mean haemoglobin of Sβ+ thalassaemia is stated as 9.3 g/dl, probably 3 g too low for the −29 and −88 mutations which cause most of the Sβ+ thalassaemia in black populations. Chapter 3 presents clearly the methods and options for transfusion. Chapters 4 and 5 could have been presented together, since the first deals with generally accepted indications and the second with controversial indications. Which chapter the topic falls within will be determined by the perceived risk/benefit ratio of the physician. Generally however, this balance is well maintained and the available data presented objectively, stressing the need for more evidence, and giving clear recommendations when justified. The last two chapters deal with complications, chapter 6 providing a useful review of immunological complications, predominantly red cell alloimmunization, transfusion reactions, and approaches to the prevention of alloimmunization. The last chapter on nonimmunological complications focuses on iron accumulation and transfusion-acquired infections. A surprising omission is the problem of maintaining venous access in patients on chronic transfusion programmes where implantable ports may carry considerable risks of infection and thrombosis. With these minor reservations, this volume provides a balanced summary on the role of transfusion in the management of sickle cell disease, especially for non-experts with small numbers of patients.

Surgical technique and biomaterials for totally implanted port catheter systems

The surgeon is frequently requested to perform a long term venous access in patients with chronic medical illness. In recent years the indications for placement of permanent catheter in central veins have expanded considerably. Particularly in cancer patients, permanent catheters are today employed for chemotherapy, home parenteral nutrition or hormone and pain-related drug administration. Various technical strategies can be adopted for a simple clinical requirement, but each one of these is distinguished by dissimilar opportunities and failures; in like manner, several biomaterials and models of permanent port are now available, and each one of these is characterized by different properties. In our opinion, it is necessary to define the gold standard for permanent vascular device placement, making an effort to adapt the best surgical placement strategy and biomaterial to the characteristics of the patient and his/her disease.

Peripheral Infusion Ports for Central Venous Access in Patients with Gynecologic Malignancies

During treatment for gynecologic malignancies, many patients require frequent or prolonged intravenous access. Implantable permanent venous access devices are useful in assuring adequate access and improving quality of life. A new technique for central venous access by peripheral placement of a subcutaneous infusion port was evaluated in 18 women undergoing treatment for gynecologic malignancies. Patients were followed prospectively with a mean follow-up of 105 days. Six catheters required removal because of complications, including 1 patient with a catheter site infection and 5 patients (26%) with catheter-related thrombosis. Although the rate of immediate insertion-related complications was low, the incidence of deep venous thrombosis was markedly increased over that reported with other central venous access devices.

Long-term central venous access in patients with sickle cell disease. Incidence of thrombotic and infectious complications.

Central venous access devices (CVAD) have been used with increasing frequency in recent years among pediatric patients. We retrospectively reviewed our experience in 25 children and young adults with sickle cell disease (SCD) over a 4 1/2 year period in an attempt to define occurrence rates of perioperative complications, thrombosis requiring catheter removal, and infectious episodes. The setting was a university-associated tertiary children's hospital. Patients were 25 children and young adults (ages 8 months to 23 years) with SCD who required CVAD placement between February 1987 and April 1992. A total of 31 catheters (totally implantable ports and partially implanted catheters) were placed for 17,444 patient catheter days. Rates of significant perioperative complications, thrombotic events requiring catheter removal, and infectious episodes were recorded. No perioperative complications were noted. Five episodes of catheter occlusion requiring replacement occurred in two patients (0.29 per 1,000 catheter patient days, involving 8% of patients and 16% of catheters). Fifteen episodes of catheter-associated bacteremia occurred in eight patients (0.86 per 1,000 catheter patient days involving 32% of patients and 26% of catheters). Three catheters required removal because of infection unresponsive to antibiotic therapy. The occurrence of thrombosis requiring catheter removal and infection in our population of patients with SCD was comparable to that reported in patients with malignant disease, cystic fibrosis and acquired immune deficiency syndrome. CVAD represents an effective, reliable, and reasonably safe means of establishing and maintaining venous access for a selective group of children and young adults with SCD who have limited peripheral venous access and require intravenous therapies.

Neutral head position for placement of internal jugular vein catheters.

A new approach to the internal jugular vein is described which keeps the head and neck in the neutral position and uses bony and cartilaginous landmarks for guidelines. Venous puncture is made along an axial line drawn superiorly from the lateral edge of the bony depression caused by the insertion of the sternocleidomastoid muscle on the superior edge of the clavicle. This line, at the level of the cricoid cartilage, lies directly over the internal jugular vein. In 55 patients initially studied, the mean (SEM) number of puncture attempts to locate the vein was 1.4 (0.2) per patient, with an overall success rate of 98%. In 84%, the internal jugular vein was located exactly where predicted, the others were just lateral to the point. The complication rate (all short-term) was 3.6%. Subsequently the internal jugular vein was cannulated successfully using the developed technique in 20 consecutive trauma patients with suspected cervical instability. An average of 1.2 (0.2) (range 1-3) attempts were made per patient to locate the vein and there were no complications. We propose this technique as a safe and reliable method of gaining central venous access in patients with possible cervical spine injury following trauma.

An audit of hickman catheter use in patients with solid tumours

The purpose of this study was to analyse the use and relative complication rates of Hickman lines inserted by angiographic and surgical routes in patients with solid tumours. Sixty-one patients (median age 55 years; range 21–81) with solid tumours had 71 Hickman catheters inserted. Fifty-three patients had 58 catheters inserted angiographically and eight patients had 13 catheters inserted surgically. Indications were as follows: for administration of infusional chemotherapy (48 patients), poor venous access (nine patients), needle phobia (four patients). The catheters remained in situ for 7981 days (median 105; range 10–750). Immediate complications occurred only in angiographically placed catheters (ten pneumothoraces, one tachydysrhyth-mia). Pneumothorax was associated with poor nutritional status but not with age, side of insertion or catheter gauge. The median body mass indices (BMIs) were 19.65 kg/m 2 and 22.8 kg/m 2 in those with and without pneumothorax respectively ( P = 0.0045). Five of six patients with BMI <19 kg/m 2 developed a pneumothorax, compared with five of 52 with BMI >19 kg/m 2 ( P = 0.0003). The overall sepsis rate was 2.38 per 1000 catheter days. Systemic sepsis was significantly increased for surgically inserted lines (3.94 versus 0.60 per 1000 catheter days; P = 0.001), although there was no significant difference in superficial sepsis (2.36 versus 1.04 per 1000 catheter days; P = 0.22). We conclude that Hickman catheters provide safe, long-term venous access in patients with solid tumours. Angiographic insertion carries a greater risk of acute complications in patients of poor nutritional status but a significantly lower risk of late systemic infective complications. Angiographic insertion is our method of choice, but the subclavian route should be avoided in cachexic patients because of the risk of pneumothorax.

Chronic venous access in patients with cancer. Selective use of the saphenous vein.

Dependable chronic venous access is an important aspect of supportive care for patients requiring chemotherapy or other long-term therapy because it enables such patients to be treated on an outpatient basis. The authors studied 56 patients with cancer requiring chronic venous access who had an infusion catheter placed into the inferior vena cava (IVC) through open saphenous venotomy, most commonly because superior vena cava (SVC) occlusion, severe chest wall infection, or chest wall malignancy precluded standard subclavian or jugular cannulation. The 56 catheters were in place for 12-550 days. The overall complication rate was 0.30 complications per 100 catheter-days. Thirty-six patients (64%) had no complications. Among the remaining 20 patients, 8 (14.3%) had a local infection, 2 (3.6%) had systemic bacteremia, and 10 had lower extremity edema, including 9 patients (16.1%) in whom the IVC was thrombosed. Twelve of the 20 complications were treated successfully without catheter removal. Thus, in 86% (48 of 56) of patients, the catheter was effective for as long as infusion therapy was required. Venous cannulation through the saphenous vein is a useful method of achieving and maintaining chronic venous access in patients in whom the subclavian or jugular veins are unavailable.