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[Secondary migration of a central venous catheter linked to an implantable port]
Abstract
The secondary migration of the distal part of a central venous catheter with implantable port is rarely described. This study reports a case in which the distal part of a catheter with implantable port moved spontaneously, a month after its implantation in a branch of the internal jugular vein without any other complication. The discussion is about modalities, frequency and explanation mechanisms of the complications due to central catheters. The conclusion insists on systematical radiologic control of the position of implantable port with central venous access, and in case of bad working or any sign of thrombo-phlebitis.
Objective: In general surgery, venous port catheters (VPC) are useful for maintaining long-term parenteral nutrition and protecting the venous system from trauma due to repeated access, such as in cancer patients. However, the most common users of this technique are cardiovascular surgeons and radiologists. The most popular route for long-term central venous catheterization is the subclavian vein, although it carries a 12% rate of peri-procedural complications. The aim of this retrospective study was to investigate the early and late complications associated with percutaneous insertion of VPCs by general surgeons and to compare the complication rates with those reported in the literature. Material and Methods: We investigated clinical and demographical data of 238 cancer patients who underwent totally implantable, indwelling, subclavian port catheterization in our General Surgery Clinic between March 2006 and December 2009. The port catheters implanted to the patients by the two experienced surgeons, using the same technique. Results: One patient developed pneumothorax (0.42%) and in 4 (1.68%) patients inadvertent subclavian artery puncture was occurred. Catheter migration developed in 3 (1.26%) cases, two caused by spontaneous catheter rupture (Pinch-off Syndrome) and the other one caused by catheter disconnection. Conclusion: In experienced hands, percutaneous implantation of an indwelling port catheter through the subclavian vein is safe with low complications and a high success rate. Good patient monitoring and a multidisciplinary approach are important for management of any likely complications.
The aim of this study was to analyse the complications and the outcome in 59 patients with 60 implantable ports for cancer chemotherapy. Perioperative complications included : subcutaneous haematoma (n = 6), wrong position of the catheter tip (n = 2), accidental intravascular injection of lidocaine with adrenaline (n = 1), vagal reflex (n = 1) and pneumothorax (n = 1). Late complications included extravasation of drugs (n = 4), wound dehiscence (n = 1), spontaneous migration of the catheter tip (n = 2), venous thrombosis (n : = 2), septicaemia (n = 6), local discomfort (n = 6) and ports' obstruction (n = 15). In 11 cases, repermeabilisation was possible with heparin or streptokinase. Patients were followed up to 40 months, 37 % died with a patent port, 6 % died with an obstructed port and 45 % are still alive with a functional port. Twelve percent of the ports were removed. The lack of life-threatening complications, the high rate of satisfied patients (85 %) and the long mean periode of use (11 months) in this study are similar to those published in the literature and confirm the value of implantable ports for chemotherapy.
We report two patients with spontaneous intrajugular migration of Hickman catheters which were initially correctly placed with the tip in the right atrium, via the right subclavian vein. In one patient the catheter remained in situ for 40 days without any sequelae; in the second patient the catheter was removed immediately. In the first patient two interim chest radiographs disclosed the catheter's course suggesting a possible mechanism of migration. Since early detection of this complication allows interventional repositioning, periodic monitoring of indwelling catheters by chest X-ray is recommended.
In the field of gynaecological oncology, which is characterised by the frequent application of cytotoxic drugs strongly necrotising to tissue, fully implantable venous port systems are of particular relevance. Frequent and serious complications such as infection, thrombosis, obstruction, leakage, or paravasation detract considerably, however, from the advantages otherwise deriving from a safe and reliable means of accessing a patient's venous system. Most complications are caused by the inexpert handling of these fully implantable catheters and should, therefore, be avoidable. In many cases, it will be possible after efficient diagnosis to solve the complication and keep the port functioning. On the basis of 8 actual cases typical and frequent complications observed in connection with port systems are described, together with preventive measures, diagnosis and therapy.
Post-operative difficulties apart, venous thrombosis, extravasation and dislocation, obstruction, catheter leakage and local and systemic infections are the typical complications associated with venous port systems. Such complications considerably reduce the benefits otherwise accruing from a reliable access to the venous system of patients with malignant tumours. The vast majority of such disadvantages are attributable to the inexpert handling of ports and, therefore, should be avoidable. This applies to such areas as selecting the right port system, the proper installation of the port chamber and catheter and also to efficient handling and maintenance by trained staff. In may cases it will be possible, with the help of a specific diagnostic investigation, to identify and correct a fault and this ensure that the system installed continues to function. Typical and frequent complications observed (with specific examples) in connection with port systems are described together with preventative measures, diagnosis and therapy.
The authors report a case of acute vagus nerve paralysis that appeared during a course of chemotherapy. The drugs had been administered through a totally implantable venous access device (TIVAD), whose catheter tip had migrated into the right internal jugular vein (IJV) and was surrounded by a complete venous thrombosis. The supposed aetiology of this paralysis was a leakage of the cytotoxic drug (5-fluorouracil) from the vessel wall into the surrounding carotid space, because of the stagnation of the chemotherapeutic agent above the thrombosis. Four months after cessation of chemotherapy, the laryngeal paralysis was still evident.
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