Technical Developments and Instrumentation

Functional Restoration of Occluded Central Ve- nous Catheters: New Interventional Techniques1 Mark H. Knelson, MD Edwin R. Hudson, MD Paul V. Suhocki, MD Cynthia 5. Payne, MD D. Skip Sallee, MD Glenn E. Newman, MD

A growing number of interventional radiologists routinely place a variety of central venous access devices to allow administration of chemotherapeutic agents, antibiotics, analgesics, blood products, and hemodialysis (1-10). As the central venous catheter service in the vascular and interventional section a t our institution grew, we began per- forming more "catheter checks" for mal- functioning catheters that were oc- cluded by a fibrin sheath a t the catheter tip. When lytic therapy failed, we found the traditional management scenario of catheter removal and replacement frus- trating for the patient and expensive. As an alternative, two new techniques for restoring the patency of occluded central venous catheters with percuta- neous fibrin-sheath stripping (PFSS) were developed and are presented.

Index terms: Catheters and catheterization, central venous access, 91.1269 Catheters and catheterization, complications, 91.449

JVIR 1995; 6:623427

From the Department of Radiology, Duke Uni- versity Medical Center, Durham, NC. From the 1993 SCVIR annual meeting. Received September 21,1994; revision requested December 2; revision received February 10,1995; accepted February 28. Address reprint requests to M.H.K., Ra- leigh Radiology Associates, Rex Hospital, 4420 Lake Boone Trail, Raleigh, NC 27607.

O SCVIR, 1995

METHODS

Among the 20 patients treated over a 17-month period, 13 Hickman catheters, five Port-a-Cath devices, and two Vas- Cath devices became occluded. Two pa- tients had catheters for hemodialysis, one for a methicillin-resistant Staphylo- coccus infection, and the remainder for treatment of a variety of tumors. In all patients, the procedure was performed after a trial of clearing the catheter with two or three 5,000-IU doses of urokinase failed to restore blood return on aspira- tion.

Wire Technique In 11 patients, the hub of the Hick-

man catheter (Davol, Cranston, RI) was prepared with povidone-iodine and ap- propriately draped to provide a sterile field. At this point, the J tip of a 0.035- inch Rosen wire (Cook, Bloomington, Ind) (five patients) or a 5-mm 0.035-inch tip-deflecting wire (Cook) (six patients) was advanced such that the curved tip just exited the intraluminal portion of the catheter. By rotating the wire in re- peated 360" arcs under fluoroscopic ob-

servation, the very tip of the catheter can be stripped of its fibrin sheath. Care must be exercised with the tip-deflecting wire, as overzealous rotation can result in breakage of the wire's inner core. In our series this occurred twice without further complication, and the wire was removed with gentle traction.

Snare Technique In nine patients, (with two Hickman

catheters, five Port-a-Cath devices [Pharmacia Deltec, S t Paul, Minn], and two Vas-Cath devices [Vas-Cath, On- tario, Canada]) the snare technique was utilized primarily with the Port-a-Cath and Vas-Cath devices and to remove par- ticularly prominent fibrin sheaths in the two Hickman catheters. All snare strip- pings were performed through an 8-F vascular sheath inserted from a right common femoral vein approach. We used a nitinol Goose Neck snare (Microvena, Vadnais Heights, Minn). This snare is available in five diameters; we used the 25-mm loop size. The loop has excellent radiopacity and when deployed is ori- ented a t a right angle to the cable. Stan- dard angiographiclinterventional tech- niques were used to place the 6-F guiding catheter provided with the snare into the right atrium. The snare loop was ad- vanced through the distal tip of the cath- eter, and the distal tip of the malfunc- tioning central venous catheter was en- circled with the snare. The guiding catheter and snare were then advanced as a unit approximately 5 cm before the snare was closed by advancing the cath- eter alone. At this point, mild to moder- ate snare tension is maintained while the snare and guiding catheter are slowly withdrawn through the vascular sheath approximately 5-10 cm. With experience, this maneuver results in some initial stretching and caudal displacement of the tip of the malfunctioning central ve- nous catheter in the right atrium. How- ever, as the intrinsic elastic recoil force of the central venous catheter overcomes the mild to moderate snare tension, the loop of the snare will slowly slide off the

624 Journal of Vascular and Interventional Radiology July-August 1995

Figure 1. (a) After contrast material injection in a dual-lumen Hickman catheter, a large fibrin sheath is visual- ized (arrows). (b) A 0.035-inch tip-deflecting wire with a 5-mm-diameter curve is placed with the tip of the wire just exiting the distal catheter. (c, d) Torque is applied externally, by rotating the wire 360" several times. (e) Re- peated contrast material injection now demonstrates a radiographically normal catheter. Blood was easily aspi- rated from both lumens.

distal tip of the central venous catheter, thereby stripping off the fibrin sheath.

Finally, in both groups of patients contrast material injection with rapid sequence filming was performed to docu- ment the removal of the fibrin sheath and the integrity of the catheter system. Good blood return on aspiration of all ports was also confirmed.

RESULTS

Ten Hickman catheters were success- fully treated with use of the wire tech- nique of PFSS. The single failure in- volved a surgically placed dual-lumen Hickman catheter that, in addition to having a fibrin sheath, had been placed short from a left subclavian vein ap- proach with the tip of the catheter ori- ented directly into the lateral wall of the superior vena cava (SVC). It was hoped that the stripping procedure would also reposition the catheter tip in the SVC. The fibrin sheath was successfully re- moved and the catheter tip slightly repo- sitioned. However, adequate blood re- turn only lasted 1 day, as the reposi- tioned tip was not stable and returned to a sidewalled orientation.

The snare technique of PFSS was successful in all nine patients in whom it was used. Thus, overall technical suc- cess was achieved in 19 of 20 patients (95%). In all of these 19 patients the presenting symptoms of inability to as- pirate blood, difficulty in flushing, or pain with catheter flushing resolved. Catheters were subsequently functional for a total of 2,377 days (range, 8-521 days; mean, 125 days) during the 1-18-

month follow-up period. In 11 cases, catheters were fully functional until re- moval or unrelated patient death. In the remaining eight patients, the catheters continue to function with a mean dura- tion of 150 days. All patients were ques- tioned immediately after the procedure and 1-3 days thereafter for evidence of pulmonary (signs of pulmonary embolus such as shortness of breath or chest pain) or infectious complications. No

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Figure 2. (a) Contrast material injection in a single-lumen chest port documents a fibrin sheath. (b) Initial at- tempts a t PFSS with use of a snare were unsuccessful. A Mikaelsson catheter (solid arrow) is used to hook the midportion of the catheter (open arrow). Note the catheter tip adherent to the SVC. (c) Withdrawal of the Mikaels- son at the groin frees the catheter tip from the SVC (Fig 2 continues).

complications were noted clinically. The average procedure time for PFSS was 20-30 minutes per case.

DISCUSSION

The complications related to tunneled central venous catheters are numerous and include infections, hemorrhage, pneumothorax, and thrombosis (1,2,8,11,12). The most common form of thrombosis involving central venous catheters is a fibrin sleeve (more re- cently referred to as a fibrin sheath), which was first described in the French literature by Motin et a1 in 1964 (13). In a study of 55 subclavian central venous catheters, Hoshal et a1 documented microembolization due to fibrin-sleeve breakage during catheter removal with cine fluoroscopic observation (14). In a more recent study of 25 patients with

sleeve thrombus who underwent cath- eter removal, respiratory symptoms were noted in three patients. These pa- tients subsequently underwent pulmo- nary scintigraphy, with findings compat- ible with pulmonary embolism (15). Thus, while percutaneous sheath strip- ping can result in a pulmonary embolus, so can catheter removal. With the PFSS technique, a functioning catheter will probably remain.

I t should be stressed that we per- formed PFSS only when more conserva- tive lytic therapy failed. Low-dose strep- tokinase therapy consisting of infusion via a pump of 3,000 U per lumen per hour for 12-24 hours has been shown to effectively restore lumen patency in 87% of catheters occluded by a fibrin sheath (16). Urokinase flush with a typical pro- tocol of 10,000 U repeated up to three times in a 4-hour period has been re- cently described by Mauro et al (17).

While Hawkins et a1 described using a 0.025-inch straight guide wire with si- multaneous aspiration via a Tuohy-Borst Y valve to remove thrombotic intralumi- nal occlusion, to our knowledge, this is the first report of PFSS (18).

As our experience with these two techniques has grown, we have found the wire technique effective for the ma- jority of tunneled catheters (Fig 1). It has the advantages of being less invasive and requiring less equipment expendi- tures. The snare technique is applicable to a vast array of central venous access devices including tunneled catheters, he- modialysis catheters, and various port devices. In our hands, PFSS with the snare technique has never failed in a properly positioned catheter regardless of the size of the fibrin sheath. Finally, when the catheter tip becomes adherent to the wall of the SVC by a well-formed fibrin sheath, it is often effective to com-

626 Journal of Vascular and Interventional Radiology July-August 1995

d. e. f. Figure 2 (continued). (d) A 25-mm Microvena snare is tightened several centimeters proximal from the tip of the malfunctioning catheter. (e) With retraction of the tightened snare PFSS is achieved. Note the slight stretching of the catheter as tension is applied. (0 The catheter is radiographically normal and fully functional after PFSS.

bine a number of techniques (Fig 2). If an external hub is available, a tip-deflec- tor wire will often pull the tip away and allow subsequent PFSS with either the wire or the snare technique. If this ma- neuver is unsuccessful or in the case of ports, a hook-shaped catheter such as a Simmons I1 or a Mikaelsson catheter can be used to hook the midportion of the malfunctioning catheter in the bra- chiocephalic vein, after which with- drawal a t the groin will free the tip of the central venous catheter and allow subsequent PFSS.

In conclusion, we have found that the PFSS techniques described herein have shown enough promise to warrant fur- ther evaluation. These techniques in our institutions have largely replaced the more costly previous practice of catheter removal and replacement.

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Radiologic placement of Hickman cath-

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11. Malatinsky J , Faybik M, Same1 M, Majek M. Surgical, infectious and thromboembolic complications of central venous catheterization. Resuscitation 1983; 10:271-281.

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phlebography after prolonged central ve- 17. Mauro MA, Jaques PF. Radiologic nous catheterization. Ann Surg 1981; placement of long-term central venous 194:779-783. catheters: a review. JVIR 1993; 4:127-

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