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Role of Computed Tomographic Angiography in Central Venous Catheter Related Complications in Dialysis Patients


1 Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
*Corresponding author: Konstantinos Spanos, Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece. Tel: +30-6948570321, Fax: +30-2413501739, E-mail: spanos.kon@gmail.com.
Archives of Cardiovascular Imaging. 4(2): e41807 , DOI: 10.5812/acvi.41807
Article Type: Brief Report; Received: Mar 31, 2016; Revised: Apr 15, 2016; Accepted: Apr 30, 2016; epub: May 25, 2016; collection: May 2016

Abstract


Background: The central venous catheter (CVC) is broadly used in medical practice. However, its use constitutes an invasive procedure with morbidity.

Objectives: To assess the role of computed tomographic angiography (CTA) in CVC related complications and the mid-term outcome of dialysis patients after their treatment.

Methods: This is a retrospective analysis of prospectively collected data of dialysis patients treated for CVC-related complications and their monitoring during a midterm follow-up.

Results: From 2012 - 2014, eight patients (mean age 59 ± 1.2 years; 6 males) with CVC related complication were treated. All complication were diagnosed and verified by a CTA (100%). Two patients presented with local hematoma, 3 with major bleeding, 2 with a retained guide-wire, and 1 with a disconnected part of a port-catheter. The direct repair of an arterial or venous wall injury was undertaken in 7 patients, with the simultaneous removal of a retained guide-wire in 2 and the removal of a misplaced CVC in 1 of them. One patient had the endovascular approach with the removal of the disconnected part. No death or major complication occurred during the procedures. During the follow-up (range =12 - 24 mon), no re-intervention, clinical episode of venous thromboembolism, or death was recorded.

Conclusions: Invasive treatment of dialysis patients for CVC related complications is effective and durable during mid-term follow up with no re-intervention, clinical episode of VTE or death. CTA is a reliable mean for the diagnosis of CVC related complications.

Keywords: Computed Tomography Angiography; Central Venous Catheters; Catheterization; Venous Thromboembolism; Injury

1. Background


The 1st case of central venous catheter (CVC) insertion was described by Aubaniac onto battlefield wounded-soldiers (1). Since then, the CVC has been broadly used. Approximately 7 million of such central lines are installed each year in the United States, of which a great proportion is used for renal dialysis patients with the most common sites being the internal jugular, subclavian, and femoral veins (2). The strict application of aseptic precautions, especially when placing the CVC in renal dialysis patients, has effectively reduced the incidence of catheter-related infection; however, the mechanical complications of CVC remain a significant cause of morbidity and mortality (2).


Inadvertent arterial punctures with a small needle (18 G and smaller) during CVC placement range from 4.2% to 9.3% in reported series (3). A small needle puncture appears to be harmless in the vast majority of cases, and most of these small needle arterial punctures are recognized. Still, the failure to recognize arterial punctures has resulted in the subsequent placement of a large-bore catheter, which is usually used in renal dialysis patients, into an artery (range = 0.1% - 1.0% of attempted CVC placements in reported series) (3). CVC insertion has traditionally been performed “blindly” using anatomical landmarks as a guide to vessel anatomy. Nowadays, Doppler ultrasound is employed to assist CVC placement. This method gives an indication of the position of the underlying major vessels without visual imaging. Ultrasound has reduced some of the complications during CVC insertion, but it cannot locate the catheter tip in relation to the heart. Only transesophageal echocardiography can accurately detect a CVC tip in relation to the superior vena cava and the right atrium, although its availability as a bedside tool is limited to major hospitals (4). CVC placement under fluoroscopy is not widely accessible too, but it tends to be the safest way for the catheter insertion, although the computed tomography angiography (CTA) is gaining a more important role in the diagnosis of vascular complicaitons (5).

2. Objectives


The aim of our study was to assess the role of CTA in CVC related complications and the mid-term outcome of dialysis patients after treatment for CVC related complication in relation with re-intervention, clinical venous thromboembolism episode (VTE) or mortality.

3. Methods


A retrospective study of prospectively collected nonrandomized data was undertaken to examine all cases of dialysis patients referred to our department between 2012 and 2014. In all patients, the diagnosis was achieved by CTA. All patients referred for iatrogenic arterial or venous complications and/or misplacement following CVC placement were included, but only those patients that required an intervention to treat the injury site were assessed. The follow-up of each patient was undertaken in the outpatient department. Thus, all patients underwent clinical examinations and evaluations of the ankle brachial index. Additionally, in cases that were indicated, a duplex scan was undertaken. In the present study, research involved the collection of existing data and the diagnostic tests were recorded in such a manner that the subjects could not be identified, either directly or through identifiers linked to the subject. The study protocol was approved by the institutional review board.

4. Results


Eight patients (6 males) at a mean age of 59 ± 1.2 years were referred to our services between 2012 and 2014 (Table 1). The patients’ vascular injury sites and the treatment operations are demonstrated in Table 1. The clinical presentations of 2 of the patients were pain and the edema of the femoro-inguinal crease with a concomitant decrease in hemoglobin after CVC placement and hemodynamic instability. Although a duplex scan was undertaken, it was not diagnostically helpful. Consequently, computed tomographic angiography (CTA) showed a common femoral vein (CFV) injury. The patients were immediately operated on with the open procedure. A concurrent retroperitoneal hematoma was identified in 1 patient (Figures 1 and 2), due to injury to the left external iliac vein (EIV) branches. During the operation, the patients had evacuation of femoro-inguinal hematoma; repair of the CFV, and in the latter one concomitant ligation of the EIV branches. Three of the patients presented with major bleeding and hemodynamic instability, although they had the pull/pressure technique of the CVC (2 of them after unsuccessful CVC placement in the internal jugular vein and 1 in the CFV) and were transferred straight to the operating room. The first 2 had common carotid artery repair with the primary placement of the sutures, while the 3rd one had common femoral artery repair with primary repair. Two patients had the direct repair of a venous injury with the removal of the retained guide-wire. One guide-wire was stuck in the CFV and the other one in the proximal profunda femoral vein.


Table 1.
Patients’ Characteristics

Figure 1.
Retroperitoneal Hematoma After Central Venous Catheter Placement (White Arrow)

Figure 2.
Central Venous Catheter Placement in the Abdome Neverthelss (White Arrow)

The 8th patient had an endovascular removal in the angiosuite of a disconnected part of the superior vena cava port-catheter, used for chemotherapy during the previous 2 years. He was asymptomatic and was diagnosed in an examination after a chest injury with a chest X-ray in which a foreign body was identified. During hospitalization, all patients were on prophylactic low molecular weighted heparin (LMWH) and were discharged with prophylactic LMWH until full mobilization. No death or complication occurred during their hospitalization.


During a follow-up period ranging from 12 to 24 months, no clinical VTE was recorded for all patients, and nor was there any clinical suspicion of VTE. Accordingly, no leg edema or pain was recorded during their examination in the 6th, 12th, 18th, or 24th postoperative month or in the intermediate period of the examinations. However, each patient had a venous duplex scan of their extremities during the 1st examination at the 6th postoperative month: There was no evidence of venous thrombosis. In addition, no chest pain or other clinical signs of pulmonary embolism was recorded in the patients’ recent history. The risk factors are demonstrated in Table 2. All patients were on aspirin (100 mg), and only 1 patient had a concomitant administration of oral anticoagulants (Table 2). None of the patients had referrals to the emergency department during this period. Additionally, during the follow-up period, no re-intervention was required for any patient, while the patients that had an arterial repair did not complain of any signs of newly presented episodes of claudication. Finally, no death episode was recorded during this midterm follow-up period.


Table 2.
Patients’ Risk Factors and Their Medical Treatment

5. Discussion


CVC-related vascular complications may occur during placement or sometimes even years later. The corrected placement and functioning of the CVC should always be confirmed (2, 3). When the CVC is placed under ultrasonic or radiological guidance, complications at the access site should be avoided (4). It has been demonstrated previously that duplex scanning is a noninvasive, safe, effective method for the initial evaluation of potential extremity vascular proximity injuries (6). However, after a misplacement, ultrasound may not be a sufficient diagnostic option. That was a problem with which we were faced in some of our cases and as such duplex scan was not diagnostic. We had to perform CTA on most of our patients (although they were on dialysis), which actually guided us with the management of the vascular injury. It has been shown that CTA provides accurate peripheral vascular imaging while additionally it is a noninvasive and immediate available diagnostic mean. Secondary to these advantages, CTA has already supplanted arteriography for the initial radiographic evaluation of peripheral vascular injuries at trauma centers (7). The current study supports CTA as an effective alternative to conventional arteriography in assessing extremity vascular trauma.


The radiologic study of choice for evaluation of traumatic vessel injuries still is conventional arteriography, but it poses the risks of an invasive procedure. It has been suggested that CTA may be an alternative to conventional arteriography or venography for the diagnosis of traumatic vessel injuries (8). Novel techniques have been developed in CTA technology, thus 3D-CTA with multislice CT (MSCT) which is a more recent development may be used to replace the diagnostic angiography in patients with blunt or penetrating extremity injuries. 9 In our study, all the patients with CVC complication were diagnosed by CTA without any delay or secondary angiography.


In clinical practice, if the misplacement of a catheter occurs, the pull/pressure technique is the 1st option. Nevertheless, it is associated with a significant risk of hematoma, major bleeding, false aneurysm formation, airway obstruction, or stroke especially when the site of the vascular trauma cannot be effectively compressed (2, 3). That is in line with 3 of our patients, who presented with major bleeding and hemodynamic instability, although they had the pull/pressure technique of the CVC. In addition, Domino et al. (8) observed that this kind of injury increased mortality and morbidity and led to irreversible complications; thus, the patients had to be treated invasively.


In our study, it is of note that none of the patients had clinical VTE either during postoperative hospitalization or during the follow-up. Nonetheless, a recent study demonstrated that trauma, renal failure, and CVC insertion were significant risk factors for VTE (9). Additionally, it has been shown that the risk of VTE for patients in vascular surgery is significantly higher than that for patients in general surgery (10). It has, therefore, been recommended to emphasize more on short-term risk assessment, adequate prophylaxis, and optimal dosage in order to prevent deep venous thrombosis and embolism disease. Thus, all patients in our study were on prophylactic LMWH until full mobilization at home, and they were taking aspirin (100 mg qd).


Nowadays, in cases of vascular traumas with large-caliber catheters, although open surgical repair remains a treatment option, prompt endovascular treatment seems to be an equally safe approach (2). The endovascular approach was chosen for our last patient, who had the endovascular removal of a disconnected part of the superior vena cava port-catheter, used for chemotherapy, and was discharged on the same day. Because of novel endovascular techniques, the minimally invasive (endovascular) approach tends to be even safer and more efficient for arterial injuries, especially those which are difficult to expose surgically such as the ones below or behind the clavicle (11). Recently, it has been demonstrated that the endovascular management of vascular traumas is feasible with commonly available means, while operative blood loss may be significantly decreased (12).


The potential limitations of our study are its small number of samples included, absence of statistical analysis, and its retrospective nature. Studies on larger scales and with long-term follow-ups should be undertaken to assess with accuracy the outcome after intervention either surgically or endovascularly after CVC-related complications.


5.1. Conclusions

The invasive treatment of dialysis patients for CVC-related complications is effective and durable during a midterm follow-up with no re-intervention, clinical VTE, or death. CTA is an effective imaging modality for diagnosis of CVC related complications.

Footnotes

Authors’ Contribution: Study concept and design: Konstantinos Spanos and Athanasios D Giannoukas; analysis and interpretation of data: Konstantinos Spanos, Christos Karathanos, Christos Karathanos, Athanasios Athanasoulas and Aikaterini Drakou; drafting of the manuscript: Konstantinos Spanos, Christos Karathanos, George Kouvelos; critical revision of the manuscript for important intellectual content: Aikaterini Drakou and Athanasios D Giannoukas; statistical analysis: not applicable.

References


  • 1. Aubaniac R. [Subclavian intravenous injection; advantages and technic]. Presse Med. 1952;60(68):1456. [PubMed]
  • 2. Guilbert MC, Elkouri S, Bracco D, Corriveau MM, Beaudoin N, Dubois MJ, et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg. 2008;48(4):918-25. [DOI] [PubMed]
  • 3. Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment. J Cardiothorac Vasc Anesth. 2014;28(2):358-68. [DOI] [PubMed]
  • 4. Atkinson P, Boyle A, Robinson S, Campbell-Hewson G. Should ultrasound guidance be used for central venous catheterisation in the emergency department? Emerg Med J. 2005;22(3):158-64. [DOI] [PubMed]
  • 5. Thomopoulos T, Meyer J, Staszewicz W, Bagetakos I, Scheffler M, Lomessy A, et al. Routine chest X-ray is not mandatory after fluoroscopy-guided totally implantable venous access device insertion. Ann Vasc Surg. 2014;28(2):345-50. [DOI] [PubMed]
  • 6. Fry WR, Smith RS, Sayers DV, Henderson VJ, Morabito DJ, Tsoi EK, et al. The success of duplex ultrasonographic scanning in diagnosis of extremity vascular proximity trauma. Arch Surg. 1993;128(12):1368-72. [PubMed]
  • 7. Peng PD, Spain DA, Tataria M, Hellinger JC, Rubin GD, Brundage SI. CT angiography effectively evaluates extremity vascular trauma. Am Surg. 2008;74(2):103-7. [PubMed]
  • 8. Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW. Injuries and liability related to central vascular catheters: a closed claims analysis. Anesthesiology. 2004;100(6):1411-8. [PubMed]
  • 9. Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access. 2012;13(2):231-8. [DOI] [PubMed]
  • 10. Mommertz G, Sigala F, Glowka TR, Sigalas P, Langer S, Koeppel T, et al. Differences of venous thromboembolic risks in vascular general and trauma surgery patients. J Cardiovasc Surg (Torino). 2007;48(6):727-33. [PubMed]
  • 11. DuBose JJ, Rajani R, Gilani R, Arthurs ZA, Morrison JJ, Clouse WD, et al. Endovascular management of axillo-subclavian arterial injury: a review of published experience. Injury. 2012;43(11):1785-92. [DOI] [PubMed]
  • 12. Scott AR, Gilani R, Tapia NM. Endovascular management of traumatic peripheral arterial injuries. J Surg Res. 2015;(15):00523. [DOI]

Table 1.

Patients’ Characteristics

Pt. Age Sex Vessel With Injury Treatment
1 62 M LCFA LCFA repair hematoma evacuation
2 60 M RICA RCIA repair hematoma evacuation
3 74 M RCFA RCFA repair hematoma evacuation
4 82 M LCFA LCFA repair hematoma evacuation
5 50 M Retained guide-wire RCFA Removal of the guide-wire RCFA repair
6 66 F Retroperitoneal hematoma LEIV injury LEIV branches ligation LEIV repair
7 28 F Retained guide-wire LFV Removal of the guide-wire LFV repair
8 60 M Disconnected part of the cava port-superior vena cava catheter asymptomatic Endovascular removal
Abbreviations: M, male; F, female; LCFA, left common femoral artery; RICA, right internal carotid artery; RCFA, right common femoral artery; LEIV, left external iliac vein; LFV, left femoral vein.

Table 2.

Patients’ Risk Factors and Their Medical Treatment

Risk Factor Medications
CRD 5.2 ± 1.8 y Antiplatelet 8/8 (100)
DM 5/8 (62.5) Statin 6/8 (75)
CAD 4/8 (50) Anticoagulants 1/8 (12.5)
HT 7/8 (87.5)
HL 6/8 (75)
Abbreviations: CRD, chronic renal disease; DM, diabetes mellitus; CAD, coronary artery disease; HT, hypertension; HL, hyperlipidemia.

Figure 1.

Retroperitoneal Hematoma After Central Venous Catheter Placement (White Arrow)

Figure 2.

Central Venous Catheter Placement in the Abdome Neverthelss (White Arrow)