The Importance of Radiology in Interventional Venous Procedures: An Unexpected Malposition Including Full-Length of Port Catheter

Abstract

Turkish Abstract

Introduction

Port catheters entered medicine to facilitate vascular access in 1980s.  Since venous port catheters have lower risk of infection, increased durability and patient comfort than tunneled venous catheters, they are increasingly preferred. Even though port catheter placement was performed surgically for a long time, recently radiology assisted placement has also gained attention¹. Utilization of imaging guidance during port catheter placement decreases complications and shortens duration and success of the procedure^2,3. Moreover, fluoroscopy helps to assure correct positioning of the catheter tip. We, hereby report an interesting patient demonstrating malposition who underwent surgical port insertion without imaging guidance and shortening of the catheter tip that ascended up to orbital level in internal jugular vein lumen.

Case Report

A 59-year old male patient with the diagnosis of rectal carcinoma was referred to our clinic because of pain and swelling in the right side of the neck. He had a history of port catheter placement surgically using right internal jugular vein due to planned chemotherapy, 5 months ago. Superficial ultrasonography (US) revealed tubular structures that filled and expanded right internal jugular vein (IJV). Postero-anterior cranial and cervical X-rays demonstrated full-length venous port catheter twisting within IJV with the catheter tip in inferior orbital level (Figure 1). 

Figure 1 Full-length post catheter within right internal jugular vein

The patient was admitted to our interventional radiology unit in order to remove port catheter. Following local anesthesia and sterile draping, the port area was incised. Upon mobilization of port body, catheter was pulled applying mild pressure. However, only the initial 10-15 cm of catheter could be freed.  Keeping the risk of vascular injury and catheter embolism in mind, we avoided higher tension. Afterwards, the patient was referred to cardiovascular surgery where the port catheter was removed under general anesthesia.

Since the patient still required long-term central access for chemotherapy, he was referred to our clinic for venous port catheter placement from the opposite site. A venous port catheter was placed successfully under local anesthesia, using US and fluoroscopy guidance via left internal jugular vein in our interventional radiology unit. During 4-months follow-up the patient remained asymptomatic without complications.

Discussion

Venous port catheters are currently placed by both surgeons and radiologists. The technique of surgical and radiological intervention is similar. Puncture is based on anatomical landmarks in the surgical technique; catheter position is assessed using chest X-ray after insertion. The radiologic method utilizes US and fluoroscopy; puncture is performed with visual assessment. Moreover, the orientation and exact localization of catheter tip may be evaluated in interventional radiology unit using fluoroscopy. Ideal positioning of the catheter tip may not possible without fluoroscopy⁴. Imaging guidance increases success and significantly decreases procedure duration and complications like pneumothorax, hemothorax, artery puncture, nerve damage, arrhythmia and catheter malposition^2,3,5.

Common routes of port insertion are internal jugular and subclavian veins. Right IJV is most commonly utilized due to straight course, higher rates of success and lower risk of thrombosis⁶.Assessment of right IJV just prior to port insertion increases the likelihood of successful puncture and decreases complications⁷.

Malposition is one of the most common complications after catheter placement. Catheter tip may lie in IJV, contralateral jugular, axillary, or azygos vein. If the catheter is too long, the tip may coil in right atrium or inferior vena cava. Usually, fluoroscopic guidance prevents this complication. Even if catheter is placed at bedside catheter tip must be checked by chest X-ray³. Malposition increases the risk of thrombosis and perforation. Therefore, an incorrect tip position must be amended as soon as possible. Besides simply exchanging the malpositioned catheter, there are interventional methods which may facilitate correct catheter positioning⁸.

Here, we reported an interesting malposition case including full-length of port catheter without any shortening. To our knowledge, there is not any case like ours in current medical literature. Utilization of radiologic guidance and placement of port catheters in interventional radiology unit may decrease these complications. 

Acknowledgement: This paper was presented at 31th National Radiology Congress on October 7-12, 2012, in Antalya.

References

1. Morris SL, Jaques PF, and Mauro MA. Radiology-assisted placement of implantable subcutaneous infusion ports for long-term venous access. Radiology, 1992;184: 149-51.
2. Dede D, et al. Ultrasonography and fluoroscopy-guided insertion of chest ports. Eur J Surg Oncol, 2008;34: 1340-3.
3. Funaki B. Central venous access: a primer for the diagnostic radiologist. AJR Am J Roentgenol, 2002;179: 309-18.
4. McGee WT, et al. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Crit Care Med, 1993;21: 1118-23.
5. Funaki B, et al. Radiologic placement of subcutaneous infusion chest ports for long-term central venous access. AJR Am J Roentgenol, 1997;169: 1431-4.
6. Trerotola SO, et al. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology, 2000;217: 89-93.
7. Yip D and Funaki B. Subcutaneous chest ports via the internal jugular vein. A retrospective study of 117 oncology patients. Acta Radiol, 2002;43: 371-5.
8. Teichgraber UK, et al. Central venous access catheters: radiological management of complications. Cardiovasc Intervent Radiol, 2003;26: 321-33.

Information Presentation

31.Ulusal Radyoloji Kongresi, 7-12 Kasım 2010, Antalya, P117