Central Venous Catheters: a Closer Look at the Subclavian Vein Approach

CASE REPORT

Central Venous Catheters: A Closer Look at the Subclavian Vein Approach

KEVIN SUN, MD; GREGORY M. SOARES, MD

KEYWORDS: Central venous catheter, Subclavian Figure 1. AP chest under fluoroscopy showing a chemotherapy port placed in the vein, internal jugular vein subclavian vein illustrating the “pinch off” sign. Fracture occurred at the location of the clavicle and first rib.

INTRODUCTION Central venous catheters (CVCs) are commonly used and have a range of outpatient and inpatient indications. A subclavian vein approach has tradi- tionally been used for placement of these catheters; however, this method exposes the patient to the high risk of subclavian stenosis as well as an increased risk for catheter fracture. In this report, we describe a patient with a chemotherapy port placed in the subclavian vein that underwent spon- taneous fracture. We therefore advocate for the use of an internal jugular approach for CVCs.

CASE REPORT A 62-year-old man with a history of Kaposi’s sar- coma was referred to interventional radiology for a percutaneous chemotherapy port study. The percutaneous port was originally placed through the Figure 2. Digital subtraction angiography showing extravasation of left subclavian vein for adjuvant chemotherapy. contrast revealing the catheter fracture. Port malfunction was first noticed during a routine follow-up appointment with the patient’s hematol- ogy oncologist. Blood return was sluggish and there was a noticeable soft lump at the upper sternum after flushing. A Port study was performed under fluoroscopic guidance. The initial AP view of the chest (Figure 1) revealed luminal narrowing and “pinch off” sign at the intersection of the clavicle and first rib. Digital subtraction acquisition with contrast confirmed the location of the fracture Fig( - ure 2). Contrast extravasation was documented at the location of the soft swelling. (Figure 3). The device was removed in the interventional radiology suite. Gentle traction was used to remove the catheter, given the known damage and possible risk for embolization of the catheter tip. Upon removal, parallel 1cm long longitudinal fractures were identified at the fluoroscopically identified point of extravasation (Figure 4).

RIMJ ARCHIVES | MAY ISSUE WEBPAGE | RIMS MAY 2018 RHODE ISLAND MEDICAL JOURNAL 31 CASE REPORT

Figure 3. Extravasation of contrast into the subcutaneous tissue. Figure 4. Extent of the catheter fracture after removal.

DISCUSSION object in a narrow vessel lumen at the restricted anatomic Various factors leading to catheter fracture have been rec- space between the first rib and clavicle. Utilization of larger ognized. It has been well established that catheters placed caliber vessels such as the internal jugular vein for catheter in the subclavian vein are exposed to high mechanical fric- placement has been shown to minimize this complication, tion from the clavicle and first rib. 1 Compressive forces can with reported stenosis rates as low as 3%.8 cause transient obstruction. Over time, repetitive stress on Though the subclavian vein has been the preferred site the catheter causes structural degradation leading to frac- for many proceduralists, given the evidence of complica- ture. Previously reported incidences for catheter fracture tions with long-term use, many have advocated for the have ranged from .1–1.3%.2,3 internal jugular vein as the first-line approach. 1,9,10 It is well Occult fracture may first be noticed with difficulty admin- documented that an internal jugular approach with image istering or aspirating fluid through the line. More serious guidance provides a safe and reliable method for long-term symptoms may present as extravascular administration of central venous catheters. The course of the internal jugular medications through the fractured line or embolization of vein is free of anatomic features that may cause compression the catheter tip. or catheter damage. It has a large caliber and high flow to Early diagnosis of catheter fracture is key to manage- reduce the risk for thrombosis. Other risks such as infection ment. Chest x-ray can provide the earliest radiographic evi- are comparable to the subclavian approach, while pneumo- dence for possible catheter fracture with a positive “pinch thorax risk is diminished. 11 Finally, complications such as off” sign. Patients with a positive “pinch off” sign have an brachial plexus injuries and thoracic duct injuries are unique estimated 40% risk for catheter fracture and such catheters to a subclavian catheter and are also avoided. should be removed and replaced using another vessel.4 If fracture is suspected and complete transection has occurred, the patient should undergo emergent percutaneous retrieval CONCLUSION by interventional radiology, which has been shown to be a Central venous catheter placement through the subclavian highly successful and safe procedure.5 vein has a high rate of vein stenosis and increased risk for Catheter fractures are a rare event. Stenosis is a more com- catheter fracture. Catheter fracture is less common, but may mon and insidious complication of subclavian venous cath- lead to dangerous complications such as extravascular extrav- eter placement. Venous stenosis in the setting of subclavian asation of medication or embolization. Subclavian stenosis catheters has a reported incidence of 32–50%, typically seen can severely limit venous access which becomes problem- with catheters used for greater than 2 weeks of duration.6,7 atic for patients requiring long-term parenteral therapy. The The mechanism for stenosis is catheter-induced throm- Internal Jugular approach with imaging guidance minimizes bosis and intimal fibrosis due to the presence of a foreign risk and provides a proven, safe and reliable alternative.

RIMJ ARCHIVES | MAY ISSUE WEBPAGE | RIMS MAY 2018 RHODE ISLAND MEDICAL JOURNAL 32 CASE REPORT

References Authors 1. Mirza B, Vanek VW, Kupensky DT. Pinch-off syndrome: case Kevin Sun, MD, Department of Internal Medicine, Roger Williams report and collective review of the literature. Am Surg. 2004 Medical Center, Providence, RI. Jul;70(7):635-44. Gregory M. Soares, MD, Associate Professor of Diagnostic & 2. Wu CY, Fu JY, Feng PH, Kao TC, Yu SY, Li HJ, Ko PJ, Hsieh Interventional Radiology, Warren Alpert Medical School of HC. Catheter fracture of intravenous ports and its management. World J Surg. 2011 Nov;35(11):2403-10. Brown University; Rhode Island Medical Imaging. 3. Amr Mahmoud Abdel Samad, Yosra Abdelzaher Ibrahim. Com- Correspondence plications of Port A Cath implantation: A single institution ex- perience, In The Egyptian Journal of Radiology and Nuclear Med- [email protected] icine, Volume 46, Issue 4, 2015, Pages 907-911, ISSN 0378-603X 4. Fazeny-Dörner B, Wenzel C, Berzlanovich A, Sunder-Plassmann G, Greinix H, Marosi C, Muhm M. Central venous catheter pinch-off and fracture: recognition, prevention and management. Bone Marrow Transplant. 2003 May;31(10):927-30. Review. 5. Dinkel HP, Muhm M, Exadaktylos AK, Hoppe H, Triller J Emer- gency percutaneous retrieval of a silicone port catheter fragment in pinch-off syndrome by means of an Amplatz gooseneck snare. Emerg Radiol. 2002 Sep;9(3):165-8. 6. Beenen L, van Leusen R, Deenik B, Bosch FH. The incidence of subclavian vein stenosis using silicone catheters for hemodialysis. Artif Organs. 1994 Apr;18(4):289-92. 7. Vanherweghem JL. Thrombosis and stenosis of central venous access in hemodialysis]. Nephrologie. 1994;15(2):117-21. 8. Surratt RS, Picus D, Hicks ME, Darcy MD, Kleinhoffer M, Jen- drisak M. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. AJR Am J Roentgenol. 1991 Mar;156(3):623-5. 9. Andris DA, Krzywda EA, Schulte W, Ausman R, Quebbeman EJ. Pinch-off syndrome: a rare etiology for central venous catheter occlusion. JPEN J Parenter Enteral Nutr. 1994 Nov- Dec;18(6):531-3. 10. Cho, Jin-Beom et al. “Pinch-off Syndrome.” Journal of the Kore- an Surgical Society 85.3 (2013): 139–144. PMC. Web. 2 Dec. 2017. 11. Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulen- ti D, Haidich AB. Cumulative Evidence of Randomized Con- trolled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis. Crit Care Med. 2017 Apr;45(4):e437-e448.

RIMJ ARCHIVES | MAY ISSUE WEBPAGE | RIMS MAY 2018 RHODE ISLAND MEDICAL JOURNAL 33