Routine fluoroscopic guidance is not required for placement of Hickman catheters via the supraclavicular route

Abstract

Summary:The purpose of this study was to evaluate the efficacy and safety in placement of Hickman catheters via the supraclavicular route without fluoroscopic guidance. We studied 81 consecutive percutaneous placements of dual lumen Hickman catheters via the supraclavicular route without the use of fluoroscopic guidance. Success rates, technical problems, complications, infections and reasons for explantation were recorded prospectively. Seventy-nine punctures were successful (97.5%). One pneumothorax (1.2%) and three accidental arterial punctures (3.7%) occurred. Difficulties in introducing the catheter through the peel away sheath or misplacement were not observed. The catheters remained in place for a total of 7657 days (mean 94.5, range 3-392 days). Sixteen blood cultures were positive (2.1/1000 catheter days). Five catheters (6.1%) were lost because of mechanical complications. Forty-two lines (52%) were removed electively, 23 (28.4%) because of suspected infection, and two (2.5%) because of tunnel infection. Nine patients died with a functioning catheter. We conclude that the supraclavicular approach to the subclavian vein is safe and efficient for introduction of Hickman catheters. Using this access, routine fluoroscopic or sonographic guidance is not required for proper placement. Implantation of the lines in an intensive care unit did not lead to higher infection rates than those reported in the literature. Keywords: Hickman; supraclavicular access; fluoroscopic guidance; infection; bone marrow transplantation Central venous access for antineoplastic treatment, supportive therapy and parenteral nutrition is required in most patients scheduled for bone marrow transplantation (BMT). In many centers a Hickman catheter is routinely inserted before BMT. [1][2][3] Usually the infraclavicular route to the subclavian vein is chosen for percutaneous implantation of the line. [4][5][6] Pneumothorax, arterial puncture and chylothorax are well known complications of this approach. 7 number of problems occur during placement of permanent catheters from the infraclavicular site: failure to pass the gap between the first rib and the clavicle, kinking of the guide wire and the introducer sheath and misplacement of the line into adjacent vessels such as the contralateral subclavian vein or both internal jugular veins. 6-10 For these reasons implantation is usually performed under fluoroscopic guidance in the operation theatre or angiogram suite, 5,6 which is expensive and causes exposure of the patient to radiation and potential nephrotoxic contrast media. Secondary migration, compression (the pinch off sign) and fragmentation of the catheter are other adverse events related to the infraclavicular approach. 6,11,12 The obvious disadvantages of the infraclavicular route prompted us to evaluate a 'new' approach for placement of Hickman catheters in patients scheduled for BMT. Supported by our previous experience, 9,13,14 our hypothesis was that routine fluoroscopic guidance could be avoided by using the supraclavicular ac...

Central venous catheters inserted percutaneously via the femoral vein can be used long-term in recipients of allogeneic peripheral blood stem cell transplants

“…Hickman catheters have been generally inserted into the right atrium or superior vena cava via the jugular or subclavian vein. 1,2 In some patients, such as those with thrombosis of the subclavian veins or mediastinal tumors, insertion of the central venous catheter into the upper part of the body may be difficult or contraindicated. 3 Anecdotally, these catheters were placed in the inferior vena cava using saphenous or femoral veins even in severely immunocompromised patients.…”

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

“…6 In contrast to the infraclavicular approach, where guide wire kinking and compression of the peel-away sheath appear in 10-15%, [24][25][26] the supraclavicular technique avoids these difficulties because the coaxial lie of the line in the vessels. 23,[26][27][28] Although it has been reported to be less likely because of the more obtuse angle, 25 even a left-sided infraclavicular insertion, as experienced in our case, is not able to protect against catheter fragmentation.…”

“…10,20,21 The pinch-off sign with the possibility of subsequent catheter fragmentation is specifically associated with the infraclavicular approach, 22 which is still the preferred means for insertion of temporary or permanent CVC. 23,24 This association is attributable to the small gap between the first rib and the clavicle leading to mechanical compression and shearing forces acting on the catheter lines. 6 In contrast to the infraclavicular approach, where guide wire kinking and compression of the peel-away sheath appear in 10-15%, [24][25][26] the supraclavicular technique avoids these difficulties because the coaxial lie of the line in the vessels.…”

Supraclavicular approach of central venous catheter insertion in critical patients in emergency settings: Re-visited

“…[34567] In addition, the supraclavicular approach less often necessitates interruption of CPR than the infraclavicular method. [89]…”

“…The needle is inserted 1 cm lateral to the lateral head of the sternocleidomastoid muscle and 1 cm posterior to the clavicle and directed at a 45-degree angle to the sagittal and transverse planes and 15 degrees below the coronal plane aiming toward the contralateral nipple. [7] The needle bisects the clavisternomastoid angle as it is advanced in an avascular plane, away from the subclavian artery and the dome of the pleura, entering the junction of the subclavian and internal jugular veins[3616] [Figures 1]. …”