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| Journal of Vascular Access 2004; 5: 39 - 46 |
| Early rupture of subclavian vein catheter: A case report and literature review |
G. Sarzo1, C. Finco1, F. Zustovich2, P. Parise1, S. Savastano1, S. Degregori1, M. Vecchiato1, S. Merigliano1
1Department of Medical and Surgical Sciences, 3rd General Surgery Clinic, Coloproctology Unit “S. Antonio” Hospital, University of Padova, Padova - Italy
2Medical Oncology Unit, Veneto Regional Institute of Oncology, Busonera Hospital, Padova - Italy
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Search Medline for articles by:
 G. Sarzo
C. Finco
F. Zustovich
P. Parise
S. Savastano
S. Degregori
M. Vecchiato
S. Merigliano
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ABSTRACT
Prolonged venous access devices (PVADs) have become indispensable in antiblastic protocols for the treatment of cancer patients, in anti-infection protocols for acquired immunodeficiency syndrome (AIDS) patients and in the management of chronic malabsorption syndromes. Using these catheters carries the risk of several complications, and some are potentially lethal, for example, cardiac embolization of catheter fragments. Rupture is a complication almost exclusive to catheters positioned percutaneously: after using this technique, device malfunction can occur due to catheter kinking after its excessively medial introduction in the subclavian vein. The early recognition of any pinch-off sign (POS) is fundamental in preventing catheter rupture that frequently follows this complication. Other factors can be involved in early rupture, for example, excessive force on a syringe used to clear a catheter that shows early signs of malfunction, or a strength defect in the materials used in the catheter construction. This report describes an early rupture case of an initially correctly positioned catheter and reviews 20 such cases in the recent literature.(The Journal of Vascular Access 2004; 5: 39-46)
Key Words. Prolonged venous access devices, Post-operative complications, Venous access, Chemotherapy, Catheter
INTRODUCTION
The use of totally implantable prolonged venous access devices (PVADs) is expanding, although their main indication remains antiblastic treatment infusion (1, 2). PVAD implantation means connecting a system fitted with a reservoir to a major vessel, such as the superior vena cava, either by puncturing the jugular or subclavian vein or by a surgical cutdown of a peripheral tributary to the central neck veins, such as the cephalic, basilic or axillary vein (3). The greater diffusion of indications for PVAD implantations has been responsible for the onset of specific complications, some of which are severe enough to confirm that the implantation techniques and the use of these systems need to be in the hands of an expert medical team.
Approximately 20 yrs after the first device equipped with a reservoir (port) was implanted (4), initially for oncological purposes and only subsequently extended to applications for controlling chronic hydro-electrolytic balance disorders, for parenteral feeding (5) at home in malabsorption syndromes and for chronic pain treatments, lively debate remains among operators as to the most suitable technique for implanting PVADs and the best type of catheter to use. On the other hand, there are numerous valid reports (albeit mainly retrospective) on the complications relating to PVAD implantation. The complications related with PVAD can be divided into five categories (6), i.e. complications relating to its positioning, to catheter malfunction, to thrombosis of the catheter or of the recipient venous system, to device infection and to an extravasal leakage. Although the method for implanting PVADs is apparently straightforward in expert hands, it is not without perioperative and medium- and long-term post-operative complications, sometimes severe and even fatal, for example, catheter embolization due to its fracture (7) or rupture (8-14).
The pinch-off sign (POS) is an infrequent complication relating to the catheter position, described in 1-5% of patients fitted with a PVAD (1, 7, 15-18). It involves a narrowing of the catheter lumen due to mechanical compression in the catheter passage between the clavicle and the first rib, the costoclavicular passage. A catheter is judged to be incorrectly positioned if it passes through the anteromedial space of the costoclavicular passage and consequently enters the subclavian vein through its medial wall, downstream from the costoclavicular space. This space is narrower than the posterolateral space; and therefore, more susceptible to pinching between the clavicle and the first rib (Fig. 1).
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FIG. 1
Central venous catheters inserted by the subclavian approach pierce the medial vein wall to enter the lumen as the vein passes between the clavicle and the first rib. |
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Conversely, a correctly positioned catheter passes through this space inside the subclavian vein, where there is more space and, consequently, it is protected against costoclavicular pinch-off. This requirement is always fulfilled if the axillary or the cephalic vein is cannulated (Fig. 2).
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FIG. 2
When the catheter enters the axillary vein, it passes between the clavicle and first rib in a more lateral position. |
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This paper reports our experience of a catheter rupture case emerging from a series of 210 PVADs implanted over approximately 3 yrs, along with a review of recent literature concerning this particular complication.
CASE REPORT
In July 2003, a 58-year-old female suffering from breast cancer underwent surgical cutdown for the positioning of a PVAD to treat relapsing right breast adenocarcinoma. Initial surgical exploration of the left cephalic vein revealed the effects of a prior thrombosis occluding the entire lumen, which prevented cephalic vein use. Given the failure of the surgical approach, a percutaneous cannulation of the left subclavian vein was performed, not without difficulty. The patient was implanted with a ChemoSite® device (Tyco Healthcare, Gosport, UK) with a polyurethane catheter of 2.5 mm outside diameter and 1.3 mm inside diameter. Intraoperative fluoroscopy was used to check the positioning of the catheter tip. At the end of the procedure, a chest X-ray confirmed the correct position of the catheter and revealed no signs of pneumothorax.
In the post-operative period, the patient continued to receive treatment based on a continuous ifosfamide infusion. Already, soon after implantation, the operators managing the port reported difficulty with the lavage and aspiration from the PVAD, constantly having to resort to a forced flushing of the reservoir.
Twenty days after implantation, persistent catheter malfunction led to the suspicion of malpositioning and prompted a chest X-ray, which revealed catheter rupture (Fig. 3) near the middle third of the clavicle, with a corresponding right atrioventricular embolization of the distal fragment.
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FIG. 3
Posterior-anterior chest X-ray of implanted venous access device post-embolization. |
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Consequently, the patient underwent right transfemoral cardiac catheterism to remove the embolized catheter (Fig 4). Ten days later, a new PVAD was installed via surgical cutdown of the right cephalic vein.
LITERATURE REVIEW
We reviewed the literature for articles concerning the specific complication of catheter rupture in patients implanted with a PVAD (Tab. I).
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TABLE I
COMPARISON OF PREVIOUS REPORTS OF CATHETER RUPTURE WITH OUR CASE
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Unfortunately, almost all the articles examined (like our own) were case reports, which made it difficult to extrapolate information to help improve our understanding of the problem. From an initial analysis of 20 cases, including our own, it emerged with some degree of statistical significance that catheter rupture is more common among females (11 vs. 5 in males), it is typically a percutaneous cannulation complication (10 vs. 1 surgical cutdown) and it mainly concerns the subclavian vein rather than the jugular vein (12 vs. 1). Rupture generally occurs 188 days after implantation. Among the cases considered, cannulation of the right subclavian vein was more common than the left, but this is possibly merely a matter of the surgeon’s preference, since operators using the percutaneous technique are known to prefer a right-hand approach due to the lower risk of pleural lesions (because the pleural dome never extends beyond the upper limits of the first rib), the absence of the thoracic duct and the straighter course of the vessels.
The chemotherapeutic regimens revealed no correlation with catheter rupture.
Many authors, considered in this review, reported the rupture as diagnosed almost incidentally due to persistent device malfunction making it difficult to perform aspirations or infusions. Suspecting malpositioning, they performed chest X-rays. The most frequent embolization site was the pulmonary artery, while the rupture site coincided with costoclavicular pinch-off syndrome.
It is also worth noting that a glance at the cases considered in this review, shows that catheter rupture is a complication generally seen in younger patients, whose mean age is lower (44.5 yrs) than that of the adult oncological population. In our opinion, this is possibly due to younger patients being more dynamic than the older, neoplastic patients are.
DISCUSSION
The advent of PVADs immediately supplanted peripheral vein use for this supportive treatment, which led to a progressive exhaustion of the vessels concerned. PVADs have not only reduced patient discomfort, but also facilitated the work of the medical team. Whatever the method used (percutaneous or surgical), implanting PVADs is not without the risk of surgical complications; particularly since the patients concerned are often in already precarious general conditions and generally have already had chemotherapy. Like other colleagues (19, 20), we believe that accessing a central vein via surgical clampdown of the superficial vein carries a lower risk for the patient than percutaneous venipuncture using the Seldinger method and the “catheter through introducer” system, not only because of the pneumothorax risk, but also in terms of hemothorax, arterial hematoma in the neck and mediastinal hematoma. In addition, pinch-off syndrome is avoided because the catheter follows an anatomical route.
Catheter rupture is a severe complication, but it is relatively rare (7-9, 21). It is often correlated with costoclavicular pinch-off (18, 21, 22), but there can also be other physiopathological mechanisms involved. It is common knowledge that a fibrin sleeve (FS) already forms around the catheter in the first hours after implanting the PVAD (23, 24): this is an acellular mesh of fibrin and platelets enveloping the catheter. This reaction is essentially due to endothelial damage and to the venous flow changing from laminar to turbulent. The FS can cause catheter malfunction because it often induces an antireflux valve mechanism, preventing blood collection or treatment infusion. A derivation of the undissolved FS is the coating i.e. a more or less important fibrous-connective tissue sleeve that substantially determines the onset of catheter malfunction both in suction and in infusion. In our opinion, in cases characterized by early catheter malfunction secondary to the formation of an FS, repeated attempts to clear the catheter by applying an excessive force on the syringe plunger can weaken the catheter wall. This situation is more likely to occur in catheters made of weaker material or in the event of manufacturing defects, and it could explain the cases of catheters rupturing shortly after their implantation with no sign of thoracic trauma or POS at the first follow-up X-ray. In three of the cases reviewed, including our own, rupture occurred <1 month (14, 20 and 24 days) after implantation. In an experimental study in 1987, Noyen et al (25) demonstrated that explanted silicone venous catheters were less rupture-resistant than their unused counterparts, suggesting that the fluids and antiblastic agents infused through these catheters alter the strength of the material used in catheter manufacture.
In a brilliant work in 1984, Aitken (18) was the first to describe POS. There is no doubt that costoclavicular pinch-off plays an important part in the rupture of catheters inserted medially and parallel to the subclavian vein in the costoclavicular passage. However, we believe that the trauma induced by POS alone is not sufficient to induce early catheter rupture, with the sole exception of cases with a history of closed chest trauma, as described by Iannelli (9).
The most common clinical signs of catheter rupture observed in the patients considered in this review were pain in the shoulder or chest, cardiac arrhythmia, tumefaction at the reservoir sit, and catheter malfunction.
The catheter should always be removed to prevent tachyarrhythmia or endocardiac thromboembolic phenomena. Klotz (8) suggested never leaving a catheter in situ for >6 months if it showed signs of POS at the first follow-up chest X-ray. Unlike other authors, i.e. Vadlamani et al (26), we believe the catheter should always be removed – providing the patient’s general condition is not so poor that intracardiac catheterism would carry a high risk of morbidity or even death. Fisher and Ferreyro (27) reported a 71% incidence of severe complications and death when no attempt was made to remove ruptured venous catheters. In 1996, Klotz (8) suggested that POS could be prevented by a lateral puncture with respect to the mid-clavicular line, without forcing the patient’s position on the operating table in an attempt to open the costoclavicular angle in the event of it proving difficult to find the subclavian vein percutaneously. In addition, if the catheter shows the typical signs of POS at a follow-up chest X-ray, the patient should repeat the chest X-ray every 4 weeks and the catheter should be removed within 6 months, wherever possible. In 1990, Hinke et al (17) suggested a radiological severity scale to define POS better, where: grade 0 means no sign of compression; grade 1 indicates an abrupt change of direction, but no sign of compression; grade 2 coincides with initial signs of compression and; grade 3 equates to catheter rupture.
We agree with Aitken et al (18) that to avoid rupture due to pinch-off, it is best to avoid inserting the catheters percutaneously via an excessively internal subclavian access, opting instead for a percutaneous cannulation of the internal jugular vein or, better still, a surgical cutdown to the cephalic vein. As Kock reported in 1998 (28), in his vast series of 1500 PVADs, 1237 of them inserted via surgical cutdown to the cephalic vein, there were only two cases of catheter rupture (0.13%); there is no mention in his study of whether these two cases occurred among the 263 percutaneous ports. Unquestionably, the surgical cutdown technique is not as easy to standardize as the percutaneous approach, partly due to technical difficulties involved in finding a peripheral vein (which are patient-specific and influenced by any prior surgery) and partly due to the smaller caliber of these peripheral vessels, which often have more fragile walls and their dimensions can be further reduced by the sequelae of prior phlebitis.
CONCLUSIONS
PVAD rupture is a rare complication that can be fatal for the patient. It almost exclusively affects percutaneous implants cannulating the subclavian vein. Embolized fragments of ruptured catheters should always be removed. In addition, patients with POS require routine radiological follow-up every 4 weeks and their catheters should always be removed within 6 months of implantation. Any early device malfunction unassociated with POS could be related to FS and should be documented by phlebography and treated by attempting to clear the obstruction (29) without resorting to the use of high pressure, which avoids causing vessel wall trauma. If necessary, the device can be replaced, possibly in combination with chronic anticoagulant treatment.
Acknowledgements
We would like to thank “Cecilia per la ricerca” Foundation which made this paper possible www.ceciliaperlaricerca.it
Address for correspondence:
Giacomo Sarzo, MD
Via Facciolati, 71
35127 Padova - Italy
giacomosarzo@hotmail.com info@colon.it
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