Downloaded from www.ajronline.org by 60.49.232.33 on 10/29/15 from IP address 60.49.232.33. Copyright ARRS. For personal use only; all rights reserved
427
Technical
L
.
.
..
.
.
..
The Upper
Inserted James
‘
.
:; .: :
:
,
.‘
Arm Approach
#{149}. ‘
M. Victoria
Marx,1
silicone
catheter
advanced
David
M. Williams,1
into the superior
vena cava from an antecubital vein, usually placed by specially trained nurses. These catheters have been shown to be safe and effective in patients with a wide variety of diseases [1-3]. Limitations to this approach include variable patient tolerance to the presence of a catheter in the antecubital fossa and the inability to place the catheter in patients with thrombosed antecubital veins. We have developed a technique to place
PICCs that relies on fluoroscopic guidance the basilic or brachial vein in the mid portion to overcome
Subjects
these
and
Between
May
and puncture of the upper
of arm
limitations.
Methods 1990
and
March
1991
,
70 patients
.
.
were
referred
of Peripherally
for Protracted
Obtaining and maintaining venous access in patients with a variety of chronic diseases is a constant problem for those involved in the care of these patients. A recently developed option for medium-duration (weeks to months) venous access is the peripherally inserted central catheter (P1CC). This is a
2- to 5-French
:
.
for Placement
Central Catheters
C. Andrews,1
.
to
the interventional radiology service at the University of Michigan Medical Center for placement of 73 indwelling central venous catheters. Three patients had two catheters placed for separate courses of IV therapy. The group included 36 women and 34 men, 17-91 years old. The primary indications for venous access were chemotherapy for malignant tumors (25 cases), long-term antibiotic therapy (47 cases), and long-term IV administration of diuretics (one case).
Received June 6, 1991 ;accepted after revision August 28, 1991. I Department of Radiology, thversity of Michigan Hospitals, 1500 E. Medical
Ian Sproat,1’2
Venous
and Suzette
Access
C. Walker-Andrews#{176}
The patient’s Patients
nondominant arm was used whenever possible. were positioned with the arm abducted and externally roBefore the procedure, a small-bore IV catheter was placed
tated. peripheral to the planned insertion site of the P1CC. This was frequently the most difficult part of the procedure, and in some cases dictated which arm was chosen for P1CC placement. Contrast medium (Omnipaque 240, Winthrop Pharmaceuticals, New
York)
was
injected
via the
peripheral
opacifled vein near the junction of arm, either the brachial or basilic, for the P1CC (Fig. 1). The puncture arm so that the external portion of
the elbow after it was sutured A second
of contrast
bolus
vein was punctured
IV catheter.
3
and taped in place. medium
with a 19-gauge
was injected
1992 0361-803X/92/1582-0427
C American
Roentgen
and the chosen
Seldinger
needle (Inrad, Grand A 0.035 in. (0.97 mm)
traversed by the wire. The dilator was then exchanged for the 5.5French peel-a-way sheath included in the P1CC set. Although the catheter has an endhole, the blunt tip and the high friction of the silicone
catheter
material
make
it difficult
to place
over a guidewire
without the sheath. After the catheter was advanced into position, the sheath was removed, and the wings at the catheter hub sutured
Center
Dr., Box 0020, Ann Arbor, Ml 48109.
Present address: University of Wisconsin Center for Health Sciences, Madison, wi 53792. of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, Fbruary
largest
Rapids, MI) under fluoroscopic guidance. guidewire was advanced into the subclavian vein, and a 5-French dilator was placed to maintain venous access. The P1CC system used was a 5-French silicone catheter (Cook Inc., Bloomington, IN) with a larger, stiffer hub end and pinch clamp (Fig. 2) to allow easy handling by the patient and the patient’s caregivers. The required length of catheter was determined by advancing a guidewire through the dilator to the junction of the superior vena cava and the right atrium, and the catheter was cut to the length
Department
AJR 158:427-429,
The
the middle and upper thirds of the was chosen as the insertion site site was made high enough in the the catheter system did not cross
Address
Andrews. 2
Note
Ray Society
Ml 48109.
reprint
requests
to J.
428
ANDREWS
ET
AL.
February 1992
AJR:158,
Downloaded from www.ajronline.org by 60.49.232.33 on 10/29/15 from IP address 60.49.232.33. Copyright ARRS. For personal use only; all rights reserved
Fig. 1.-Venogram of left upper extremity obtamed before placement of a peripherally inserted central catheter shows that either of the paired brachial veins (long arrow) or the basilic vein (short arrow) can be used for access. In this case, a brachial vein was chosen because of its larger size.
Fig. 2.-Peripherally inserted central catheter. Note wings to allow catheter to be sutured In place and large-diameter external segment
that allows easy handling.
in place with two 4-0 proline sutures. The catheter was then flushed with heparin solution. After the catheter was placed, an occlusive dressing (OpSite, Smith
& Nephew Medical, Massillon, OH) was applied to the insertion site. The dressing was changed every 5 to 7 days. Care was taken to flush the catheter with heparin solution after each use.
after the P1CC placement, collateral vessel thrombosed patients, drawing,
and
it was
that
assumed
around the catheter.
the catheters became occluded after but were easily cleared with urokinase.
the
In two other use for blood
Discussion Results
Catheter placement was successful in all patients. In one patient, placement was unsuccessful in one arm, but the catheter was easily placed in the other, giving a success rate of 99% (73/74 attempts). In the one failure, an initially unsuccessful puncture attempt resulted in spasm of the brachial vein and extravasation of contrast material, which made further attempts at puncture difficult and ultimately unsuc-
cessful. Catheters
a median
were
from 2 days to 14 weeks, with The catheters were used for chemo-
indwelling
of 3 weeks.
therapy, administration of antibiotics, hyperalimentation, administration of diuretics, and transfusion of blood products. Blood sampling could be done reliably, but an exact success rate is unavailable because of limited follow-up for each sampling attempt among outpatients. Acceptance by patients and nursing staff was excellent. Although most of the catheters were placed in hospitalized patients, 27 were intended
for use in outpatients
or after discharge
from the hospital.
Complications requiring removal of the P1CC occurred in four patients. Two catheters (3%) were removed because of infection 14 and 86 days after implantation. In one case, frank
infection was present around other, blood cultures contained
the insertion
site, and in the
Gram-positive organisms, and the catheter was thought to be the source. Symptomatic acute subclavian vein thrombosis developed in one patient 1 4 days after P1CC placement. Arm swelling responded to removal of the catheter and systemic anticoagulation. In another patient who had chronic thrombosis of the subclavian vein, the catheter was advanced into the superior vena cava by way of a collateral vein. The arm swelling worsened 2 days
The conventional options for patients requiring protracted venous access include placement of multiple peripheral IV catheters, placement of a Hickman or Broviac right atrial catheter from the subclavian or internal jugular approach, or placement of a subcutaneous infusion port, also from the subclavian or jugular approach [4, 5]. These devices are intended for access lasting months to years. Peripherally inserted
central
catheters
are
intended
for
patients
who
re-
quire venous access for up to 3-5 months. They retain the advantages of central venous access (the ability to administer hypertonic or sclerosing solutions without damaging periph-
eral veins) without the risk of pneumothorax associated with central venous punctures. The central location of the catheter tip also allows
relative
them
to be left in place
to conventional
peripheral
for extended
IV catheters.
periods The
lower
cost, ease of placement, and simplified logistics (placement is usually performed at the bedside) make this an excellent option for medium-duration access. Our choice of the mid arm, or brachial, approach for P1CC placement evolved from our experience with this approach for placement of subcutaneous infusion ports for long-term venous access [6]. We found that even in patients with poor peripheral access, the brachial or basilic vein was patent in the mid portion of the arm. These veins are not easily seen or felt, and thus are not generally subjected to frequent venopuncture. When the initial attempt to cannulate the vein was unsuccessful, extravasation of contrast medium was noted at fluoroscopy. Subsequent attempts to puncture the vein were made more difficult by obscuration of the veins. Venous spasm frequently accompanied these unsuccessful punc-
Downloaded from www.ajronline.org by 60.49.232.33 on 10/29/15 from IP address 60.49.232.33. Copyright ARRS. For personal use only; all rights reserved
AJR:158,
VENOUS
February 1992
ACCESS
VIA
tures. Administration of nitroglycerin, 1 00 zg through the peripheral IV, while compressing the cephalic vein to divert the drug into the brachial and basilic veins, helped to resolve spasm. We have begun to use nitroglycerin in some patients before the initial puncture to prevent vasospasm. The complications we noted are similar in frequency and type to those previously reported. Of 87 P1CC placements, Bottino et al. [1] had three patients with symptomatic acute thrombosis of the subclavian vein and four patients with positive cultures of material from the catheter tip at the time of removal. Although patients’ acceptance was not examined systematically, patients seemed to be satisfied with this approach to P1CC placement. Patients were able to carry on normal activities with the catheters in place, without the impediment
of a catheter
crossing
In our institution, PICCs in patients with adequate complex
fluoroscopic
the elbow.
are currently peripheral
procedure
placed veins,
is reserved
at the bedside and the more for
patients
in
UPPER
ARM
APPROACH
429
whom the bedside procedure fails or for those avoid a catheter placed across the elbow.
who
wish
to
REFERENCES 1 . Bottino
J, McCredie KB, Groschel DHM, Lawson M. Long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer 1979;43:1937-1943 2. Dolcourt JL, Bose CL. Percutaneous insertion of Silastic central venous catheters in newborn infants. Pediatrics 1982;70:484-486 3. Dietrich JKA, Lobas JG. Use of a single Sllastic IV catheter for cystic fibrosis pulmonary exacerbations. Pediatr Pu!monol 1988;4: 181-184 4. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 1973;1 36: 602-606
5. Neiderhuber JE, Ensminger WD, Gyves JW, et al. A totally implanted injection port system for blood sampling and chemotherapy administration. JAMA 1984;251 :287-288 6. Andrews JC, Walker-Andrews SC, Ensminger WD. Long-term central venous
access
results. Radiology
with a peripherally placed 1990;176:45-47
subcutaneous
infusion
port: initial
427
Technical
L
.
.
..
.
.
..
The Upper
Inserted James
‘
.
:; .: :
:
,
.‘
Arm Approach
#{149}. ‘
M. Victoria
Marx,1
silicone
catheter
advanced
David
M. Williams,1
into the superior
vena cava from an antecubital vein, usually placed by specially trained nurses. These catheters have been shown to be safe and effective in patients with a wide variety of diseases [1-3]. Limitations to this approach include variable patient tolerance to the presence of a catheter in the antecubital fossa and the inability to place the catheter in patients with thrombosed antecubital veins. We have developed a technique to place
PICCs that relies on fluoroscopic guidance the basilic or brachial vein in the mid portion to overcome
Subjects
these
and
Between
May
and puncture of the upper
of arm
limitations.
Methods 1990
and
March
1991
,
70 patients
.
.
were
referred
of Peripherally
for Protracted
Obtaining and maintaining venous access in patients with a variety of chronic diseases is a constant problem for those involved in the care of these patients. A recently developed option for medium-duration (weeks to months) venous access is the peripherally inserted central catheter (P1CC). This is a
2- to 5-French
:
.
for Placement
Central Catheters
C. Andrews,1
.
to
the interventional radiology service at the University of Michigan Medical Center for placement of 73 indwelling central venous catheters. Three patients had two catheters placed for separate courses of IV therapy. The group included 36 women and 34 men, 17-91 years old. The primary indications for venous access were chemotherapy for malignant tumors (25 cases), long-term antibiotic therapy (47 cases), and long-term IV administration of diuretics (one case).
Received June 6, 1991 ;accepted after revision August 28, 1991. I Department of Radiology, thversity of Michigan Hospitals, 1500 E. Medical
Ian Sproat,1’2
Venous
and Suzette
Access
C. Walker-Andrews#{176}
The patient’s Patients
nondominant arm was used whenever possible. were positioned with the arm abducted and externally roBefore the procedure, a small-bore IV catheter was placed
tated. peripheral to the planned insertion site of the P1CC. This was frequently the most difficult part of the procedure, and in some cases dictated which arm was chosen for P1CC placement. Contrast medium (Omnipaque 240, Winthrop Pharmaceuticals, New
York)
was
injected
via the
peripheral
opacifled vein near the junction of arm, either the brachial or basilic, for the P1CC (Fig. 1). The puncture arm so that the external portion of
the elbow after it was sutured A second
of contrast
bolus
vein was punctured
IV catheter.
3
and taped in place. medium
with a 19-gauge
was injected
1992 0361-803X/92/1582-0427
C American
Roentgen
and the chosen
Seldinger
needle (Inrad, Grand A 0.035 in. (0.97 mm)
traversed by the wire. The dilator was then exchanged for the 5.5French peel-a-way sheath included in the P1CC set. Although the catheter has an endhole, the blunt tip and the high friction of the silicone
catheter
material
make
it difficult
to place
over a guidewire
without the sheath. After the catheter was advanced into position, the sheath was removed, and the wings at the catheter hub sutured
Center
Dr., Box 0020, Ann Arbor, Ml 48109.
Present address: University of Wisconsin Center for Health Sciences, Madison, wi 53792. of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, Fbruary
largest
Rapids, MI) under fluoroscopic guidance. guidewire was advanced into the subclavian vein, and a 5-French dilator was placed to maintain venous access. The P1CC system used was a 5-French silicone catheter (Cook Inc., Bloomington, IN) with a larger, stiffer hub end and pinch clamp (Fig. 2) to allow easy handling by the patient and the patient’s caregivers. The required length of catheter was determined by advancing a guidewire through the dilator to the junction of the superior vena cava and the right atrium, and the catheter was cut to the length
Department
AJR 158:427-429,
The
the middle and upper thirds of the was chosen as the insertion site site was made high enough in the the catheter system did not cross
Address
Andrews. 2
Note
Ray Society
Ml 48109.
reprint
requests
to J.
428
ANDREWS
ET
AL.
February 1992
AJR:158,
Downloaded from www.ajronline.org by 60.49.232.33 on 10/29/15 from IP address 60.49.232.33. Copyright ARRS. For personal use only; all rights reserved
Fig. 1.-Venogram of left upper extremity obtamed before placement of a peripherally inserted central catheter shows that either of the paired brachial veins (long arrow) or the basilic vein (short arrow) can be used for access. In this case, a brachial vein was chosen because of its larger size.
Fig. 2.-Peripherally inserted central catheter. Note wings to allow catheter to be sutured In place and large-diameter external segment
that allows easy handling.
in place with two 4-0 proline sutures. The catheter was then flushed with heparin solution. After the catheter was placed, an occlusive dressing (OpSite, Smith
& Nephew Medical, Massillon, OH) was applied to the insertion site. The dressing was changed every 5 to 7 days. Care was taken to flush the catheter with heparin solution after each use.
after the P1CC placement, collateral vessel thrombosed patients, drawing,
and
it was
that
assumed
around the catheter.
the catheters became occluded after but were easily cleared with urokinase.
the
In two other use for blood
Discussion Results
Catheter placement was successful in all patients. In one patient, placement was unsuccessful in one arm, but the catheter was easily placed in the other, giving a success rate of 99% (73/74 attempts). In the one failure, an initially unsuccessful puncture attempt resulted in spasm of the brachial vein and extravasation of contrast material, which made further attempts at puncture difficult and ultimately unsuc-
cessful. Catheters
a median
were
from 2 days to 14 weeks, with The catheters were used for chemo-
indwelling
of 3 weeks.
therapy, administration of antibiotics, hyperalimentation, administration of diuretics, and transfusion of blood products. Blood sampling could be done reliably, but an exact success rate is unavailable because of limited follow-up for each sampling attempt among outpatients. Acceptance by patients and nursing staff was excellent. Although most of the catheters were placed in hospitalized patients, 27 were intended
for use in outpatients
or after discharge
from the hospital.
Complications requiring removal of the P1CC occurred in four patients. Two catheters (3%) were removed because of infection 14 and 86 days after implantation. In one case, frank
infection was present around other, blood cultures contained
the insertion
site, and in the
Gram-positive organisms, and the catheter was thought to be the source. Symptomatic acute subclavian vein thrombosis developed in one patient 1 4 days after P1CC placement. Arm swelling responded to removal of the catheter and systemic anticoagulation. In another patient who had chronic thrombosis of the subclavian vein, the catheter was advanced into the superior vena cava by way of a collateral vein. The arm swelling worsened 2 days
The conventional options for patients requiring protracted venous access include placement of multiple peripheral IV catheters, placement of a Hickman or Broviac right atrial catheter from the subclavian or internal jugular approach, or placement of a subcutaneous infusion port, also from the subclavian or jugular approach [4, 5]. These devices are intended for access lasting months to years. Peripherally inserted
central
catheters
are
intended
for
patients
who
re-
quire venous access for up to 3-5 months. They retain the advantages of central venous access (the ability to administer hypertonic or sclerosing solutions without damaging periph-
eral veins) without the risk of pneumothorax associated with central venous punctures. The central location of the catheter tip also allows
relative
them
to be left in place
to conventional
peripheral
for extended
IV catheters.
periods The
lower
cost, ease of placement, and simplified logistics (placement is usually performed at the bedside) make this an excellent option for medium-duration access. Our choice of the mid arm, or brachial, approach for P1CC placement evolved from our experience with this approach for placement of subcutaneous infusion ports for long-term venous access [6]. We found that even in patients with poor peripheral access, the brachial or basilic vein was patent in the mid portion of the arm. These veins are not easily seen or felt, and thus are not generally subjected to frequent venopuncture. When the initial attempt to cannulate the vein was unsuccessful, extravasation of contrast medium was noted at fluoroscopy. Subsequent attempts to puncture the vein were made more difficult by obscuration of the veins. Venous spasm frequently accompanied these unsuccessful punc-
Downloaded from www.ajronline.org by 60.49.232.33 on 10/29/15 from IP address 60.49.232.33. Copyright ARRS. For personal use only; all rights reserved
AJR:158,
VENOUS
February 1992
ACCESS
VIA
tures. Administration of nitroglycerin, 1 00 zg through the peripheral IV, while compressing the cephalic vein to divert the drug into the brachial and basilic veins, helped to resolve spasm. We have begun to use nitroglycerin in some patients before the initial puncture to prevent vasospasm. The complications we noted are similar in frequency and type to those previously reported. Of 87 P1CC placements, Bottino et al. [1] had three patients with symptomatic acute thrombosis of the subclavian vein and four patients with positive cultures of material from the catheter tip at the time of removal. Although patients’ acceptance was not examined systematically, patients seemed to be satisfied with this approach to P1CC placement. Patients were able to carry on normal activities with the catheters in place, without the impediment
of a catheter
crossing
In our institution, PICCs in patients with adequate complex
fluoroscopic
the elbow.
are currently peripheral
procedure
placed veins,
is reserved
at the bedside and the more for
patients
in
UPPER
ARM
APPROACH
429
whom the bedside procedure fails or for those avoid a catheter placed across the elbow.
who
wish
to
REFERENCES 1 . Bottino
J, McCredie KB, Groschel DHM, Lawson M. Long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer 1979;43:1937-1943 2. Dolcourt JL, Bose CL. Percutaneous insertion of Silastic central venous catheters in newborn infants. Pediatrics 1982;70:484-486 3. Dietrich JKA, Lobas JG. Use of a single Sllastic IV catheter for cystic fibrosis pulmonary exacerbations. Pediatr Pu!monol 1988;4: 181-184 4. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 1973;1 36: 602-606
5. Neiderhuber JE, Ensminger WD, Gyves JW, et al. A totally implanted injection port system for blood sampling and chemotherapy administration. JAMA 1984;251 :287-288 6. Andrews JC, Walker-Andrews SC, Ensminger WD. Long-term central venous
access
results. Radiology
with a peripherally placed 1990;176:45-47
subcutaneous
infusion
port: initial
