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Management of Dysfunctional Catheters and Tubes Inserted by Interventional Radiology Review Article 67 Management of Dysfunctional Catheters and Tubes Inserted by Interventional Radiology Steven Y. Huang, MD1 Bjorn I. Engstrom, MD2 Matthew P. Lungren, MD3 Charles Y. Kim, MD, FSIR4 1 Department of Interventional Radiology, The University of Texas, MD Address for correspondence CharlesY.Kim,MD,FSIR,Divisionof Anderson Cancer Center, Houston, Texas Vascular and Interventional Radiology, Department of Radiology, Duke 2 Division of Interventional Radiology, Consulting Radiologists LTD, University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC Minneapolis, Minnesota 27710 (e-mail: [email protected]). 3 Department of Radiology, Stanford University Medical Center, Palo Alto, California 4 Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina Semin Intervent Radiol 2015;32:67–77 Abstract Minimally invasive percutaneous interventions are often used for enteral nutrition, biliary and urinary diversion, intra-abdominal fluid collection drainage, and central venous access. In most cases, radiologic and endoscopic placement of catheters and tubes has replaced the comparable surgical alternative. As experience with catheters and tubes grows, it becomes increasingly evident that the interventional radiologist needs to be an expert not only on device placement but also on device management. Keywords Tube dysfunction represents the most common complication requiring repeat inter- ► catheter dysfunction vention, which can be distressing for patients and other health care professionals. This ► tube obstruction manuscript addresses the etiologies and solutions to leaking and obstructed feeding ► interventional tubes, percutaneous biliary drains, percutaneous catheter nephrostomies, and drainage radiology catheters, including abscess drains. In addition, we will address the obstructed central ► complications venous catheter. Objectives: Upon completion of this article, the reader will be minimally invasive percutaneous procedures. Without able to discuss how to diagnose and address common issues an organized approach, these complications can lead to encountered with catheters and tubes placed by interven- increased patient morbidity and escalation of medical care tional radiologists. with associated cost. Therefore, the interventional radiol- Accreditation: This activity has been planned and imple- ogist should be familiar with methods to establish the mented in accordance with the Essential Areas and Policies of cause and potential solution(s) to dysfunctional catheters the Accreditation Council for Continuing Medical Education and tubes. In general, common principles hold true across (ACCME) through the joint providership of Tufts University a variety of catheters and tubes, and often similar solu- School of Medicine (TUSM) and Thieme Medical Publishers, tions (such as catheter exchange) are frequently applied. New York. TUSM is accredited by the ACCME to provide However, there are important nuances that are specificto continuing medical education for physicians. particular catheter types that can avoid additional proce- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Credit: Tufts University School of Medicine designates this dures or outright catheter failure. The purpose of this journal-based CME activity for a maximum of 1AMAPRA review article is to describe systematic approaches to Category 1 Credit™. Physicians should claim only the credit common dysfunctional catheters and tubes, including commensurate with the extent of their participation in the percutaneous feeding tubes, percutaneous biliary drain- activity. age (PBD) catheters, percutaneous catheter nephrosto- mies (PCNs), other drainage catheters including abscess Dysfunctional catheters and tubes, which often present drains and chest tubes, and central venous catheters with occlusion or leaking, are commonplace following (CVCs). Issue Theme Iatrogenic Injury; Guest Copyright © 2015 by Thieme Medical DOI http://dx.doi.org/ Editor, Baljendra Kapoor, MD, FSIR Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1549371. New York, NY 10001, USA. ISSN 0739-9529. Tel: +1(212) 584-4662. 68 Management of Dysfunctional Catheters and Tubes Huang et al. Percutaneous Enteral Feeding Catheters encapsulating the tube circumferentially along its length. As the tract continues to mature over time, tract contraction Percutaneous enteric catheters can be placed by open or results in sealing around the tube with cessation of leakage laparoscopic surgical, endoscopic, or radiologic techni- under normal circumstance. However, as this process re- – ques.1 3 Percutaneous radiologic placement of gastrostomy quires normal healing mechanisms, patients with malnutri- tubes (G-tubes), gastrojejunostomy tubes (GJ-tubes), and tion, malignancy, or systemic inflammatory states may not jejunostomy tubes (J-tubes) is safe and well tolerated.4,5 have normal healing, and thus expected tract maturation and However, catheter revision for occlusion or tip malposition sealing may not occur—and in some cases, the tract may is not an uncommon event, occurring in up to 13% of G-tubes.5 enlarge. Unfortunately, patients with malnutrition, malig- This section discusses common problems of enteric catheters, nancy, and other systemic pathologies are those who often specifically pericatheter leakage, catheter obstruction, dis- need percutaneous enteral feeding access. lodgement, malposition, and catheter-related pain, along Another cause of pericatheter leakage is excessive gastric with potential management options. pressurization related to gastroparesis, ileus, or obstruction, which can force gastric or enteric fluid through the tract Pericatheter Leakage around the tube. Another potential etiology for leakage Pericatheter leakage is a relatively common issue encoun- around the tube is a fistula from the gastric lumen to the tered with percutaneous G-tubes, GJ-tubes, and J-tubes.6,7 A tract. In the case of GJ-tubes, leakage of tube feeds around the small amount of leakage around the tube is common and not catheter may be a sign that the jejunal limb has retracted into unexpected and may require up to two to three dressing the stomach as cause for pressurization. An abdominal radio- changes per day. A greater degree of leakage is often prob- graph can be useful for ascertaining whether this has oc- lematic due to skin breakdown, as well as other consider- curred (►Fig. 1). Since GJ-tubes are typically inserted in lieu ations such as the demand of frequent bandage changes and of G-tubes due to a contraindication to gastric feeding, this soiled clothing/bedding. Feeding tube–related leakage can be catheter malposition should be promptly addressed. J-tubes difficult to control and results in chronic management issues have been shown to have a higher rate of pericatheter for the patient. leakage.4 This may be related to the thinner jejunal wall There are several potential reasons for pericatheter leak- when compared with stomach wall or lesser luminal capacity age. Probably the most common reason is a tract that is not that may be more prone to the effects of ileus or dysmotility. well sealed around the tube. Initially after percutaneous feeding tube insertion, the degree of sealing of the gastric Buried Bumper Syndrome wall or bowel around the tube is variable, usually with little to Buried bumper syndrome is characterized by erosion of the no associated leakage. Over the subsequent days and weeks internal retention bumper or balloon into the stomach or after insertion, a foreign-body reaction to the tube occurs, bowel wall. Essentially all percutaneous enteral feeding tubes consisting of acute and chronic inflammatory processes.8 can manifest with buried bumper syndrome, although this After an initial inflammatory response, granulation tissue, entity is by far most often described with endoscopically consisting of fibroblasts and angioblasts in a matrix of colla- inserted G-tubes. Excessive or chronic pressure exerted upon gen, begins to form around the foreign body (i.e., the catheter the gastric wall and abdominal wall in between the internal or tube), resulting in physiologic exclusion of the foreign body bumper or balloon and the external retention disc can induce by means of fibrous capsule formation at the interface. This ischemia of the intervening structures with breakdown of tract formation results in a sleeve of fibrous tissue tissues. The reported incidence is as high as 21.8% of cases,9,10 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Fig. 1 GJ-tube malposition. A 68-year-old man with gastroparesis presenting with bloating during tube feeds into the jejunal port with pericatheter leakage of tube feeds. (a) Initial scout radiograph demonstrates the tube to be coiled over the left upper quadrant in an abnormal configuration (arrow). (b) The GJ-tube was exchanged for a new one, in appropriate position as confirmed by contrast injection into the jejunal port (arrow). Seminars in Interventional Radiology Vol. 32 No. 2/2015 Management of Dysfunctional Catheters and Tubes Huang et al. 69 and typically first presents between 3 and 6 months post- To solve the problem of pericatheter leakage, some inter- insertion.11 This clinical finding ranges from simple ulcera- ventionalists may attempt to place a larger diameter gastro- tion underneath the internal bolster, to an enlarging hole stomy tube with the thought of minimizing space around the around the
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