Central venous catheter pinch-off and fracture: recognition, prevention and management

Abstract

Summary:The so-called pinch-off syndrome is observed in up to 1% of all central venous catheters (CVCs), and is a valuable warning prior to fragmentation, which occurs in approximately 40% of the respective cases. As long-term indwelling CVCs are used with increasing frequency, this paper describes the necessity of pinch-off monitoring following the experiences of a case study and a review of the current literature on this specific topic in order to point out preventive practice guidelines.Besides easy preventive practices such as a high level of suspicion and adequate X-ray controls, findings give strong evidence that the most important specific factor might be the adequate approach.In our hands, the supraclavicular technique has provided the best results with regards to percutaneous introduction of large bore CVCs. Central venous catheters (CVCs) are useful therapeutic and diagnostic devices for administration of fluids, chemotherapeutic agents, parenteral nutrition and for central venous pressure monitoring, for vascular access, for extracorporal treatment regimens, and bone marrow transplantation. [1][2][3] As with most invasive procedures, central venous catheterization is associated with numerous potential complications, both during placement and later in long-term maintenance. Pneumothorax, infection, bleeding, arrhythmias, malposition, and thrombosis are well-known complications. 3,4 A rare but serious complication is catheter fragmentation with subsequent embolization through the heart into the pulmonary artery occurring in approximately 40% of patients who develop the possible precursor warnings of catheter fragmentation, the so-called pinchoff sign described by Aitken and Minton in 1984. [5][6][7] As long-term indwelling, CVCs have often become the patient's lifeline and are used with increasing frequency worldwide, we report a representative case of our own experience and summarize the current literature on this specific topic in order to emphasize preventive practice guidelines. Case reportA 35-year-old female presented with acute lymphatic leukemia in 1988. After treatment with standard chemotherapy she achieved complete remission. After 4 years, she relapsed and required reinduction. Prior to reinduction a port-a-cath was inserted by surgical cut-down technique. After chemotherapy the patient was scheduled for autologous bone marrow transplantation. Since the treating physicians considered an additional long-term device necessary for autologous bone marrow transplantation a double-lumen Hickman-catheter (Bard 12.0 Fr, Round Dual Lumen; Cranston, RI, USA) was inserted by surgical cut-down to access the contralateral subclavian vein. The procedure was performed by the surgeons without complications. The slight kinking of the line on the postprocedural chest radiograph was accepted because the catheter lines were functioning, the catheter tip was positioned correctly and the lumina of both catheter lines were inconspicious.Conditioning chemotherapy was administered and was followed by bone marrow tra...

Thrombolytic therapy for central venous catheter occlusion

“…While the 'pinch-off syndrome' only occurs in about 1% of patients with a CVC, up to 40% of these cases develop fragmentation and subsequent embolization of the catheter tip into the central vascular system. 8,9 Catheter obstructions can also be due to a non-thrombotic internal occlusion, such as precipitation of medications or parenteral nutrition constituents. Obstructions caused by precipitation of medications with a low pH and those due to calcium phosphate crystals can be treated with 0.1% hydrochloric acid (HCl).…”

Totally Implantable Venous Access Devices – 20 Years' Experience of Implantation in Cystic Fibrosis Patients

“…It is well known that 'pinch-off' syndrome can lead to fracture of catheters. 4,9,14,15 'Pinch-off' is thought to occur when acatheter is inserted into the subclavian vein too medially via ap ercutaneous Seldinger approach and becomes compressed between the first rib, clavicle and costoclavicular ligament. All TIVADs in this cohort were inserted by open cut-down; af ew were placed directly in the subclavianvein, but into the middle or lateral third, well away from thec ostoclavicular ligament.…”

Interventional radiological retrieval of embolized vascular access device fragments

“…This leads to catheter fracture with time. It is observed in approximately 40% of catheter embolizations in adult patients (12,13). In our series, pinch-off syndrome caused catheter fracture and embolism in three of five patients, all of whom were adults.…”

“…Fisher and Ferreyro reported that the combined rate of pulmonary thromboembolism, perforation of the right ventricle, cardiac arrest, and death was 71% (13). This high mortality and complication rate might be attributed to the use of rigid materials in the early 1970s.…”