Current Concepts in Vascular Therapies 2011 Mid-Atlantic Conference PICCs, Ports and Lines: Clarifying the Options Babatunde Almaroof, MD April 2, 2011 Objectives • State the indications for central venous access • Discuss types of central venous catheters • “Clarifying the options”/indications for each kind of catheter. Need for central vascular access • There is an increasing need for vascular access as medical care has become more complex. • Most inpatients are able to get their needs served by a peripheral i.v access • Sometimes however, a central access will be needed due to limitations of a peripheral access – Infiltration, extravasation, thrombosis – Infection and sclerosis • This makes central venous access, the preferred choice for long term use as they allow a higher flow and tolerate hyperosmolar solutions not tolerated by peripheral veins Indications for central venous access • TPN • Chemotherapy • Long term antibiotics – Osteomyelitis, endocarditis, fungal infections • Patients with difficult peripheral vein access • Hemodynamic monitoring • Temporary hemodialysis access • Plasmapheresis Historical Background • The first i.v infusion was performed using a cannula made from quill in 1657 • First successful human blood transfusion was performed in 1667 • Seldinger described his technique for catheter insertion in 1953 • Percutaneous placement of a subclavian vein catheter was reported in 1956 Sites of central venous access • Internal Jugular vein • Subclavian vein – Higher risk of pneumothorax • Femoral vein – Higher risk of infection Types of central venous access • PICCs • Ports • Lines PICCs • Peripherally Inserted Central Catheters • Indicated for TPN or long term antibiotics • Usually placed in the non ‐dominant arm using the basilic vein or the cephalic vein • Can be placed under ultrasound ‐guidance or fluoroscopy PICC • They can either be regular PICC lines or • Power PICC lines which can measure CVPs PICCs • Contraindications – Coagulopathy – Renal insufficiency • If Cr > 3 • Place Groshong catheter • Main advantage is that direct puncture of central vein is not required. • Easy removal Ports • The implantable port is referred to by several names including – Port‐a‐cath – Mediport – Powerport – Smart port Ports • These are implantable reservoirs placed under the skin which is connected to a catheter tubing directed into the central veins • The port is usually placed in the chest wall or sometimes in the arm • The port is accessed through the skin using a special needle called a Huber needle whenever access is needed Ports ‐ Types • Single port • Double port Ports ‐ Indications • Chemotherapy • TPN • Delivery of medications • Frequent blood draws • Contrast injection for imaging studies Ports • Subcutaneous – Less risk of infection – Cosmetic; nothing coming out of the skin – Long term use Lines • Non‐tunneled – “Central lines” ‐ Double, triple or quadruple lumen – Uldall, Quinton Catheter • Tunneled – Hickman – Groshong – Broviac – TDC (Tunneled Dialysis Catheter)/PermCath Central lines Indications • Used for hemodynamic monitoring • Lack of peripheral i.v access • TPN • Administration of pressors Central lines • Not suitable for – Dialysis – Chemotherapy – Plasmapheresis • Not indicated for long term use. Uldall Catheter • Non‐tunneled temporary dialysis catheters • Used in patients who need urgent dialysis or who are unstable • Can be placed in femoral, IJ or subclavian veins • Try to avoid subclavian vein if possible to reduce the incidence of central venous stenosis. Uldall Catheter • Similar to central lines but have a larger bore • Usually have 2 ports which are packed with heparin when not in use to prevent clotting • Can also be used for plasmapheresis • Can be placed at patient’s bedside. Tunneled lines • Hickman/Groshong • Have a cuff which stimulates tissue growth to help keep catheter in place. – Single lumen, tunneled catheter • Can be used for long‐term purposes because it’s cuffed • Used for long term antibiotics or TPN • Not to be used for dialysis Hickman catheter • Used for chemotherapy, TPN or long term medications • Frequent withdrawal of blood for analysis Groshong catheter • Similar to a Hickman catheter • Has a three‐way valve at the tip • No need for heparin flushes • Does not need clamping. Complications Acute Late • Arterial puncture • Infection • Hematoma • Catheter thrombosis/DVT • Pneumothorax • Dislodgement • Cardiac arrhythmias • Central venous occlusion • Air embolism • Catheter fracture Conclusion • There are various kinds of catheters for a variety of indications. • Most of these lines can be placed with a very low complication rate. • The overall picture, in addition to objective of treatment helps in access selection. .