Meditheses Home

Venous Access

Preoperative, Operative, and Postoperative Dilemmas

Jeffrey A. Lowell, MD,* and Albert Bothe, Jr, MDt

*Staff, Department of General Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts; and Clinical Instructor of Surgery, Harvard Medical School, Boston, Massachusetts

tAssociate Chairman of Surgery, Department of Surgery, New England Deaconess Hospital; and Associate Professor of Surgery, Harvard Medical School, Boston, Massachusetts

Surgical Clinics of North America 1991;71(6):1231-1246.

PREOPERATIVE ISSUES

[NOTE: The portions of this article on sepsis and thrombosis were covered in Meditheses 1994;1,2(Nov).]

The most important predictor of complications associated with insertion of central venous catheters is the experience a physician has in placement of a catheter. Bernard and Stahl13 found that physicians who had inserted fewer than 50 subclavian vein catheters had a statistically significant greater number of complications associated with catheter insertion, chiefly pneumothorax. In fact, in this study,13 all complications associated with insertion occurred in the group who had placed fewer than 50 subclavian catheters. In addition, physicians with less experience had more than twice the rate of catheter sepsis.13

Unfortunately, in these patients, more than one complication may develop. One study84 found that 50% of all complications associated with central venous catheters occurred in only 2.5% of patients. The complication rate was highest in the subgroup of patients who required emergency placement of central venous catheters. Intravascular volume depletion, alterations in coagulation, or distortion of normal landmarks are among several confounding variables that may appreciably increase the chance of complication. For these reasons, central venous catheters for longterm use should rarely be placed emergently, especially by an inexperienced operator.

Malpositioned Catheters

Malpositioned central venous catheters may lead to arrhythmia, venous thrombosis, or falsely elevated pressure measurements.30 Malpositioned central venous catheters have also been associated with the potentially lethal complication of vascular erosion and perforation, which has led to cardiac tamponade and the delivery of infusate into the thoracic cavity.21,41,74 Correctly placed catheters may intentionally or unintentionally be manipulated by patients, the "twiddler's syndrome."49 The tip of soft pliable catheters may also change position spontaneously as a result of changes in blood flow. Therefore, when infusion or withdrawal is unsatisfactory, when pain is present on infusion, or perhaps when the catheter has not been used for a considerable length of time, the proper position of the catheter should be confirmed by roentgenography of the chest.

Malpositioned catheters can frequently be repositioned using fluoroscopic guidance and steerable guide wires.54,70,92 Fluoroscopy can also be valuable in extraction of fractured catheters from points of distal embolization.79 Some investigators94 have described the placement of central venous catheters using dynamic venography. A contrast agent is injected into the ipsilateral arm or hand, and by means of fluoroscopy, a needle is directed precisely into the opacified subclavian vein.94 This technique has not gained widespread acceptance, but certainly preoperative venography may be of value in patients with altered central venous anatomy, such as patients who have undergone previous neck surgery or patients with known or suspected thrombosis of the great vessel. Patients who have had multiple or prolonged central vein catheterizations or both are clearly at higher risk for the development of great vessel thrombosis. These patients may or may not have the clinical stigmata of central vein thrombosis, such as ipsilateral or bilateral swelling of the neck, prominent venous patterns of the upper extremity, and distention of the distal vein. A positive history, with or without clinical findings, warrants preoperative venography.

Insertion of Central Venous Catheters in Patients with Thrombocytopenia

Patients with thrombocytopenia are of considerable concern. Some investigators4 have demonstrated that central venous catheterization can safely be performed in these patients without an appreciable increase in complications, however. One series29 reported the successful placement of implantable infusion ports without serious bleeding complications by cutdown on the cephalic vein with use of a guide wire and peel-away sheath technique in a series of 100 patients with severe thrombocytopenia. In 33 patients with severe thrombocytopenia (59% with 33,000 platelets/mm or less), another group106 reported that percutaneous placement of tunneled Silastic catheters into the subclavian vein was possible without serious bleeding complications. Platelet transfusion was given preoperatively when platelet counts were less than 50,000/mm.3

Top

OPERATIVE ISSUES

Arrhythmia

Of all complications associated with placement of central venous catheters, one of the most frequent is arrhythmia.40, 108 Stuart et al,109 in 51 insertions of central venous catheters in noncritically ill patients, reported an incidence of atrial arrhythmia of 41%. The incidence of significant ventricular arrhythmia (e.g., ventricular couplets) was 11%. In a series by Brothers et al23 of 300 patients who underwent placement of an implantable infusion port, the incidence of arrhythmia that required chemical or electrical cardioversion was 0.9%.

The incidence of arrhythmia associated with placement of central venous catheters is a result of overinsertion of the guide wire or catheter. Both of these studies23, 109 demonstrated that overinsertion of the guide wire is not without risk, especially in patients who have a history of cardiac arrhythmia or in patients with alterations in plasma electrolytes or micronutrients. A considerable number of central venous catheters are inserted into patients on wards without electrocardiographic monitoring, making recognition and timely treatment of arrhythmia particularly problematic.

The problem of overinsertion of guide wires will be minimized with the use of a guide wire that has distance markings and that can be advanced through a transparent central venous catheter, permitting precise recognition of the length of guide wire in the central venous system.

Preservation of Central Venous Access

Because patients live longer with devastating illnesses, such as patients with the short-bowel syndrome who require total parenteral nutrition, patients with leukemia who require a bone marrow transplant, or patients with acquired immunodeficiency syndrome who require prolonged administration of antibiotics, a new issue in the care of these challenging patients becomes critical, namely, preservation of central venous access. The central venous catheter is a lifeline for treatment that can be administered into only the central venous system.

Tunneled Silastic catheters and subcutaneously implanted venous infusion ports are used for long-term administration of nutritional supplements, antibiotics, and blood products and for frequent venous sampling. These types of central venous catheters may need to be removed for a number of reasons, such as irreparable damage to the Silastic catheter, displacement or erosion of the infusion port, an infected subcutaneous pocket or exit site, or thrombotic occlusion of the catheter. When continued use of these central venous catheters is required, a new venipuncture, with its associated risks, is traditionally necessary. Two techniques have been described that permit reinsertion of a new tunneled Silastic catheter or venous infusion port without a new venipuncture using the Seldinger technique. One technique brings the catheter through the old tunnel, and the other technique creates a new tunnel.32, 73 The latter technique also permits replacement of these types of central venous catheters when infection occurs at the tunnel or exit site. Prolonged use of each central vein cannulation with prevention of potential complications of venipuncture is a desirable goal.

Innovative Approaches to Central Venous Access

Unfortunately, despite efforts to preserve central venous access and after years of use of central venous catheters, thrombotic occlusion of the superior central venous system eventually develops in many patients. This situation poses a great challenge to the surgeon (Table 1) .

Initial efforts to treat patients with occluded superior central venous systems primarily focused on the creation of an arteriovenous fistula. These fistulas have included the radial artery-to-cephalic vein fistula, superficial femoral artery-to-saphenous vein fistula (using a long mobilized segment of saphenous vein to create a loop), Thomas shunts, and an arteriovenous fistula created using polytetrafluoroethylene.7, 26,101 This solution has not enjoyed much enthusiasm in the literature. Only a few case reports have described employment of this technique with relatively short periods of follow-up time. These types of fistulas (particularly the arteriovenous fistula that uses a long saphenous loop) may prove to be a viable solution in selected patients, however.

Other techniques to obtain central venous access were initially described in the pediatric literature. The most popular of these techniques accesses the saphenous vein and, with use of fluoroscopic guidance, advances the catheter cephalad into the proximal inferior vena cava. These catheters are tunneled and brought through an exit site on the lower part of the chest.45, 46 We have used this technique in adult patients with good success. For all patients with known or suspected abnormalities in venous anatomy, preoperative venography can be invaluable. Operative fluoroscopy is also essential.98 Access into the central venous system using the inferior epigastric vein has also been described.75 Translumbar catheterization of the inferior vena cava has been performed in patients with restricted central venous access.33

An interesting technique described by Torosian et all111 is a combined venographic and operative technique. Venography is obtained to identify a patent peripheral vessel and collateral pathways. By means of fluoroscopy, a guide wire and Dormier basket are advanced retrograde through collateral channels of the occluded venous system to a patent peripheral vein. Venotomy is performed over the guide wire, and the basket is used to pull the catheter into the appropriate position with its tip distal to the thrombus. Pulmonary embolism has not been reported with use of this technique. Another potential benefit of this technique is that it does not risk the complications associated with inferior vena cava thrombosis.

When all other options for central venous access are unavailable, it may be necessary to perform lateral thoracotomy for placement of the catheter into the azygos vein or anterior thoracotomy for placement of the catheter directly into the right atrium.77 86 These procedures are associated with a great deal of morbidity and should be used only as a last resort.

Table 1. Innovative Approaches to Central Venous Access in Patients with Great Vein Thrombosis

Creation of arteriovenous fistula Azygos or hemiazygos vein catheter
Saphenous vein catheterRight atrial catheter
Inferior epigastric vein catheter Retrograde fluoroscopic manipulation through occluded venous system
Percutaneous translumbar caval catheter

Top

POSTOPERATIVE ISSUES

Catheter-Related Sepsis

Definition. Catheter-related sepsis affects central venous catheters inserted for both short-term or long-term use. The definition of catheter-related sepsis has been based on clinical criteria as well as on qualitative and semiquantitative bacteriologic analysis. The clinical definition of catheter-related sepsis is fever, with or without leukocytosis, that resolves after removal of the central venous catheter.17, 20 This definition is obviously encompassing and, as expected, has a low specificity. With use of clinical criteria alone to identify and treat patients with catheter-related sepsis, as many as 85% of central venous catheters would be removed unnecessarily.17, 19,87, 97 A qualitative bacteriologic definition of catheter-related sepsis is infection that proves to have identical organisms cultured from both the tip of the central venous catheter and blood obtained peripherally without other identified sources of infection for that particular bacterium.17, 34, 76, 87 To increase further the specificity of distinguishing catheter infection from catheter colonization, Maki and colleagues76 developed the technique of semiquantitative culture at the catheter tip, which involves rolling the catheter across an agar plate.31, 76 Using this technique, Maki et al76 distinguished catheter colonization from catheter infection. In this series, specimens from catheter tips having greater than or equal to 15 colony-forming units carried a 16% risk of bacteremia. No episodes of bacteremia occurred in patients with fewer than 15 colony-forming units.76 The most common organisms that cause catheter-related sepsis are coagulase-negative staphylococci, Staphylococcus aureas, and yeast.53

Other types of catheter-related infections may also complicate use of central venous catheters. Infections at the exit site or in the tunnel may lead to abscess formation, particularly in the immunocompromised patient. Septic thrombophlebitis and, rarely, osteomyelitis of the clavicle or mediastinitis may also develop.27, 28

Incidence. The incidence of catheter-related sepsis varies from 2.8% to 18%,8, 19,34, 52, 76, 87, 91, 97 which is 0.08 to 0.14 episodes of catheter-related sepsis/100 catheter days.28, 88,91, 110 With use of semiquantitative culture techniques, the rate of catheter colonization ranges from 6.4% to 33.8%.19, 87 Patients with central venous catheters for administration of chemotherapeutic agents have higher rates of catheter-related sepsis than patients with central venous catheters for administration of parenteral nutrition.88 In the oncologic patient with leukopenia, the absolute neutrophil count has not been shown to correlate with the incidence of catheter-related sepsis.8 In one series91 of 98 consecutive patients with acquired immunodeficiency syndrome, the likelihood of the development of catheter-related sepsis was no greater than that for patients without acquired immunodeficiency syndrome. To date, no prospective randomized study has compared the incidence of catheter-related sepsis in tunneled Silastic catheters and venous infusion ports in patients with acquired immunodeficiency syndrome, although one study52 has shown a lower rate of catheter-related sepsis with venous infusion ports in patients without acquired immunodeficiency syndrome. Patients with Silastic catheters have a lower incidence of catheter-related sepsis than patients with catheters made of polyvinyl chloride.82

The number of patients with central venous catheters and catheter-related sepsis who have central vein thrombosis is low. The number of patients with central vein thrombosis who have catheter-related sepsis is much higher.60, 63, 108,114

The role for tunneling the central venous catheter placed for short-term use is uncertain.17, 66 Tunneling the catheter is an option, however, when the proximity of the exit site of the central venous catheter to an area of burn, infection, tracheostomy, or other source of potential infection makes the risk of contamination high. In patients with a central venous catheter placed into the internal jugular vein, inability to maintain an occlusive dressing, considerable discomfort, and torticollis may also be indications for creation of a subcutaneous tunnel.9

The main problem in the treatment of patients with catheter-related sepsis is that the diagnosis is best made retrospectively. Clinical criteria for the diagnosis of catheter-related sepsis and empiric removal of catheters are associated with an 85% false-positive rate. 17,19,87,97 Removal of a catheter in a patient whose care mandates use of the central venous catheter will subject the patient to the risks associated with reinsertion. To wait for the results of diagnostic bacteriologic tests that are more specific for catheter-related sepsis carries the risks inherent with delay of treatment.

Treatment In the patient with a nontunneled central venous catheter placed for short-term use, clinically suspected catheter-related sepsis warrants exchange of the catheter over a guide wire as a method of bacteriologic sampling. This technique has been shown to be both safe and effective.17, 19, 90 The treatment of presumed or actual catheter-related sepsis in patients with tunneled Silastic catheters or venous infusion ports is more complicated. The administration of antibiotics through the central venous catheter has been effective in the treatment of patients with catheter-related sepsis with permanent Silastic catheters in place.8, 17, 28, 99 Infection with coagulase-negative staphylococcus is the most common cause of catheter-related sepsis, and this infection is usually treated by intracatheter administration of vancomycin (Vancocin) for a course of 7 to 14 days.28 Polymicrobial infections and infections with more virulent bacteria or fungi rarely respond to this method of treatment and typically require removal of the catheter with systemic antimicrobial therapy and replacement of the catheter in a new site when the risk associated with secondary seeding has passed.8,17, 28 In the high-risk patient with limited or no remaining central venous access, the surgeon should consider the exchange of the tunneled catheter or venous infusion port during continued antibiotic treatment (Table 2).73

Tunnel infections respond to antibiotic treatment alone in only 25% of patients and usually require removal of the catheter. A much greater likelihood of successful treatment for infections at the exit site is with combined local treatment and systemic antibiotic therapy that permit salvage of the central venous catheter in about 70% of patients.8, 28

Table 2. Interpretation of Qualitative Cultures and Treatment of Catheter-Related Sepsis

CULTURE RESULT INTERPRET-
ATION		 TREATMENT
Catheter tipPeripheral Blood CountAspiration Blood Culture  Temporary Catheter Long-term Catheter*
Negative Negative Negative No infection NoneNone
NegativePositivePositive Sepsis, not related to catheter Systemic antibiotics; catheter change over guide wire Systemic antibiotics
Negative Positive Negative
Positive Negative Negative Catheter colonization or infection** Catheter change over guide wire Culture-specific antibiotic administration through catheter; catheter removal or exchange over guide wire
Negative Negative Positive
PositiveNegativePositive
Positive Positive Positive Catheter sepsis Catheter removal, culture specific antibiotics, and resite catheter Catheter removal, culture-specific antibiotics, re-site catheter; culture-specific antibiotic through catheter and catheter exchange over guide wire (only for patients with severe limitations in central venous access)
Positive Positive Negative
*Tunneled catheter or implantable venous infusion port.
**Colonization or infection with virulent bacteria (e.g., Staphylococcus aureas) or fungi warrants treatment as catheter sepsis.

Patients with catheter-related sepsis whose infection does not respond promptly to antibiotic therapy may have some degree of unrecognized catheter thrombosis. One series99 described a treatment protocol in which a contrast study was obtained through the central venous catheter in patients whose infection failed to respond to antibiotic therapy. When catheter thrombosis was identified, the addition of thrombolytic therapy through the catheter was successful.

Summary

The past two decades have seen a tremendous increase in the use of central venous catheters and its associated complications. The increased sophistication that physicians now have with regard to nutritional and metabolic needs has escalated the use of central venous catheters. As the acquired immunodeficiency syndrome epidemic grows, so too will the number of patients with infections and metabolic complications, many of whom will have conditions severe enough to benefit from the use of central venous catheters to deliver antimicrobial drugs and other supportive intravenous therapy. Our ability to sustain patients with short-bowel syndrome also relies critically on central venous access. Likewise, treatment of patients with leukemias and certain solid tumors frequently requires placement of these catheters. Central venous catheters are essential for bone marrow transplantation.

Efforts to minimize the risks associated with placement of a central venous catheter by more frequent use of catheter exchange rather than another venipuncture should be encouraged when possible. Techniques to prevent arrhythmia during overinsertion of guide wires are also important. Vigilant searches for, and prompt treatment of, catheter-related sepsis and central vein thrombosis are critical. Better prophylaxis against the development of catheter-related sepsis and catheter-related thrombosis is also needed. Further prospective investigations should be performed, however, to define precisely cost-effective methods of detection and duration of therapy for patients with both catheter-related sepsis and catheter-related thrombosis. Further advances in the technology and management of catheters need to continue to meet these ongoing challenges.

Reprinted with permission from the Surgical Clinics of North America 1991;71(6):1231-1246.

Top

References

  1. Anderson AJ, Krasnow SH, Boyer MW, et al: Hickman catheter clots: A common occurrence despite daily heparin flushing. Cancer Treat Rep 71:651-653, 1987
  2. Anderson GF, Steinberg EP: DRGs and specialized nutrition support: Prospective payment and nutritional support. The need for reform. JPEN 10:3-8, 1986
  3. Ang SD, Daly JM: Potential complications and monitoring of patients receiving total parenteral nutrition. In Rombeau JL, Caldwell MD (eds): Parenteral Nutrition: Clinical Nutrition, vol 2. Philadelphia, WB Saunders, 1986, pp 331-343
  4. Au FC: The anatomy of the cephalic vein. Am Surg 55:638-639, 1989
  5. Aubaniac R: L'injection intraveineuse sous-claviculaire: Avantages et technique. Press Med 60:1456, 1952
  6. Bagwell CE, Marchildon MB: Mural thrombi in children: Potentially lethal complication of central venous hyperalimentation. Crit Care Med 17:295-296, 1989
  7. Baird RM, Rae Al, Chan-Yau C: Long-term parenteral nutrition with arteriovenous fistula. Am J Surg 139:637-640,1980
  8. Benezra D, Kiehn TE, Gold JW, et al: Prospective study of infections in indwelling central venous catheters using quantitative blood cultures. Am J Med 85:495-498, 1988
  9. Benotti PN, Bothe A Jr, Miller JD, et al: Safe cannulation of the internal jugular vein for long term hyperalimentation. Surg Gynecol Obstet 144:574-576,1977
  10. Bern MM, Bothe A Jr, Bistrian B. et al: Prophylaxis against central vein thrombosis with low-dose warfarin. Surgery 99:216-221, 1986
  11. Bern MM, Lokich JJ, Wallach SR, et al: Very low doses of warfarin can prevent thrombosis in central venous catheters: A randomized prospective trial. Ann Intern Med 112:423-428, 1990
  12. Bern M, Lokich J, Wallach S., et al: Very low-dose warfarin prevents thrombosis of central vein catheters. Proc Am Soc Clin Oncol 5:254, 1986
  13. Bernard RW, Stahl WM: Subclavian vein catheterizations: A prospective study. I. Non-infectious complications. Ann Surg 173:184-190,1971
  14. Bernard RW, Stahl WM, Chase RM Jr: Subclavian vein catheterizations: A prospective study. II. Infectious complications. Ann Surg 173:191-200,1971
  15. Blackburn T, Dunn M: Pacemaker-induced superior vena cava syndrome: Consideration for management. Am Heart J 116:893-896, 1988
  16. Bothe A Jr, Piccione W, Ambrosino JJ, et al: Implantable central venous access system. Am J Surg 147:565-569, 1984
  17. Bozzetti F: Central venous catheter sepsis. Surg Gynecol Obstet 161:293-301, 1985
  18. Bozzetti F, Scarpa D, Terno G, et al: Subclavian vein thrombosis due to indwelling catheters: A prospective study on 52 patients. JPEN 7:560-562, 1983
  19. Bozzetti F, Terno G, Bonfanti G, et al: Prevention and treatment of central venous catheter sepsis by exchange via a guide wire: A prospective controlled trial. Ann Surg 198:48-52, 1983
  20. Bozzetti F, Terno G, Camerini E, et al: Pathogenesis and predictability of central venous catheter sepsis. Surgery 91:383-389, 1982
  21. Brandt RL, Foley WJ, Fink GH, et al: Mechanism of perforation of the heart with production of hydropericardium by a venous catheter and its prevention. Am J Surg 119:311-316, 1970
  22. Brismar B, Hardstedt C, Jacobson S, et al: Reduction of catheter-associated thrombosis in parenteral nutrition by intravenous heparin therapy. Arch Surg 117:1196-1199, 1982
  23. Brothers TE, Von Moll LK, Neiderhuber JE, et al: Experience with subcutaneous infusion ports in three hundred patients. Surg Gynecol Obstet 166:295-301, 1988
  24. Broviac JW, Cole D, Scribner BH: A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 136:602-606,1973
  25. Burt ME, Dunnick MR, Krudy AG, et al: Prospective evaluation of subclavian vein thrombosis during total parenteral nutrition by contrast venography. Clin Res 29:264A, 1981
  26. Buselmeier TJ, Kjellstrand CM, Sutherland DE, et al: Peripheral blood access for hyperalimentation: Use of expanding polytetrafluoroethylene arteriovenous conduit. JAMA 238:2399-2400, 1977
  27. Cerame MA, Abdu RA: Osteomyelitis of the clavicle complicating percutaneous subclavian venipuncture. Infect Surg pp 5-8, 32, 1990
  28. Clarke DE, Raffin TA: Infectious complications of indwelling long-term central venous catheters. Chest 97:966-972, 1990
  29. Coit DG, Turnbull AD: A safe technique for the placement of implantable vascular access devices in patients with thrombocytopenia. Surg Gynecol Obstet 167:429-431, 1988
  30. Conces DJ Jr, Holden RW: Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 119:293-295, 1984
  31. Corona ML, Peters SG, Narr BJ, et al: Infections related to central venous catheters. Mayo Clin Proc 65:979-986,1990
  32. Curelaru ID, Linder LE, Gustavsson BG, et al: Exchange of occluded, tunnelled, subclavian central venous catheters: A technique reusing the existing tunnel. Acta Chir Scand 152:583-586, 1986
  33. Denny DF Jr, Greenwood LH, Morse SS, et al: Inferior vena cava Translumbar catheterization for central venous access. Radiology 172:1013-1014, 1989
  34. Dillou JD Jr, Shaffner W, Van Way CW, et al: Septicemia and total parenteral nutrition: Distinguishing catheter-related from other septic episodes. JAMA 223:1341-1344,1973
  35. Donayre CE, White GH, Mehringer SM, et al: Pathogenesis determines late morbidity of axillosubclavian thrombosis. Am J Surg 152:179-184, 1986
  36. Dudrick SJ, Wilmore DW: Long-term parenteral feeding. Hosp Pract 3:65-78, 1968
  37. Dudrick SJ, Wilmore DW, Vars HM, et al: Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 64:134-142, 1968
  38. Dupas JL, Remond A, Vermynck JP, et al: Superior vena cava thrombosis as a complication of peritoneovenous shunt. Gastroenterology 75:899-900, 1978
  39. Dye LE, Segall PH, Russell RO Jr, et al: Deep venous thrombosis of the upper extremity associated with use of the Swan-Ganz catheter. Chest 73:673-675, 1978
  40. Eisenhauer ED, Derveloy RJ, Hastings PR: Prospective evacuation of central venous pressure (CVP) catheters in a large city-county hospital. Ann Surg 196:560-564, 1982
  41. Ellis LM, Vogel SB, Copeland EM III: Central venous catheter vascular erosions: Diagnosis and clinical course. Ann Surg 209:475478, 1989
  42. Fabri PJ, Mirtallo JM, Ebbert ML, et al: Clinical effect of nonthrombotic total parenteral nutrition catheters. JPEN 8:705-707, 1984
  43. Fabri PJ, Mirtallo JM, Ruberg RL, et al: Incidence and prevention of thrombosis of the subclavian vein during total parenteral nutrition. Surg Gynecol Obstet 155:238-240, 1982
  44. Feliciano DV, Mattox KL, Graham JM, et al: Major complications of percutaneous subclavian vein catheters. Am J Surg 138:869-874, 1979
  45. Fonkalsrud EW, Ament ME, Berquist WE, et al: Occlusion of the vena cava in infants receiving central venous hyperalimentation. Surg Gynecol Obstet 154:189-192, 1982
  46. Fonkalsrud EW, Berquist W, Burke M, et al: Long-term hyperalimentation in children through saphenous central venous catheterization. Am J Surg 143:209-211, 1982
  47. Fonkalsrud EW, Murphy J, Smith FG Jr: Effect of pH in glucose infusions on development of thrombophlebitis. J Surg Res 8:539-543, 1968
  48. Gale GB, O'Connor DM, Chu JY, et al: Restoring patency of thrombosed catheters with cryopreserved urokinase. JPEN 8:298-299, 1984
  49. Gebarski SS, Gebarski KS: Chemotherapy port "twiddler's syndrome": A need for preinjection radiography. Cancer 54:38-39, 1984
  50. Gilligan JE, Phillips PJ, Wong CH, et al: Streptokinase and blocked central venous catheter [letter]. Lancet 2:1189, 1979
  51. Glynn MF, Langer B, Jeejeebhoy KN: Therapy for thrombotic occlusion of long-term intravenous alimentation catheters. JPEN 4:387-390, 1980
  52. Greene FL, Moore W, Strickland B, et al: Comparison of a totally implantable access device for chemotherapy (Port-A-Cath) and long-term percutaneous catheterization (Broviac). South Med J 81:580-583, 1988
  53. Hampton AA, Sheretz RJ: Vascular-access infections in hospitalized patients. Surg Clin North Am 68:57-71, 1988
  54. Hawkins IF Jr, Paige RM: Redirection of malpositioned central venous catheters. AJR 140:393-394, 1983
  55. Herbst CA Jr: Indications, management, and complications of percutaneous subclavian catheters: An audit. Arch Surg 113:1421-1425, 1978
  56. Hickman RO, Buckner CD, Cliff RA, et al: A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 148:871-875, 1979
  57. Hill SL, Martin D, Evans P: Massive venous thrombosis of the extremities. Am J Surg 158:131-135, 1989
  58. Horattas MC, Wright DJ, Fenton AH, et al: Changing concept of deep venous thrombosis. Surgery 104:561-567, 1988
  59. Hurtubise MR, Bottino JC, Lawson M, et al: Restoring patency of occluded central venous catheters. Arch Surg 115:212-213, 1980
  60. Imperial J, Bistrian BR, Bothe A Jr, et al: Limitation of central vein thrombosis in total parenteral nutrition by continuous infusion of low-dose heparin. J Am Coll Nutr 2:6373, 1983
  61. Jacobs MB, Yeager M: Thrombotic and infectious complications of Hickman-Broviac catheters. Arch Intern Med 144:1597-1599, 1984
  62. Jeejeebhoy KN, Langer B, Tsallas G, et a: Total parenteral nutrition at home: Studies in patients surviving 4 months to 5 years. Gastroenterology 71:943-953, 1976
  63. Kahn SE, Goldstein J, Cope C: Low-dose streptokinase therapy for SwanGanz catheter-induced thrombosis. Am Heart J 110:891-893,1985
  64. Kaufman J, Demas C, Stark K, et al: Catheter-related septic central venous thrombosis: Current therapeutic options. West J Med 145:200-203, 1986
  65. Kaye CG, Smith DR: Complications of central venous cannulation. Br Med J 297:572-573, 1988
  66. Keohane PP, Jones BJ, Attrill H, et al: Effect of catheter tunnelling and a nutrition course on catheter sepsis during parenteral nutrition: A controlled trial. Lancet 2:1388-1390, 1983
  67. Kunkel JM, Machleder HI: Treatment of Paget-Schroetter syndrome: A staged, multidisciplinary approach. Arch Surg 124:1153-1157,1989
  68. Leiby JM, Purcell H, DeMaria JJ, et al: Pulmonary embolism as a result of Hickman catheter-related thrombosis. Am J Med 86:228-231, 1989
  69. Lindblad B: Thromboembolic complications and central venous catheters [letter] . Lancet 2:936-937, 1982
  70. Lois JF, Gomes AS, Pusey E: Nonsurgical repositioning of central venous catheters. Radiology 165:329-333, 1987
  71. Lokich JJ, Becker B: Subclavian vein thrombosis in patients treated with infusion chemotherapy for advanced malignancy. Cancer 52:1586-1589, 1983
  72. Lokich JJ, Bothe A Jr, Benotti P, et al: Complications and management of implanted venous access catheters. J Clin Oncol 3:710-717, 1985
  73. Lowell JA, Shikora SA, Stuart RK, et al: A new technique for the exchange of tunneled Silastic catheters and implantable infusion ports. Am J Surg, in press
  74. Luks FI, Picard DL, Pizzi WF: Electocardiographic guidance for percutaneous placement of central venous catheters. Surg Gynecol Obstet 169:157-158,1989
  75. Maher JW: A technique for the positioning of permanent central venous catheters in patients with thrombosis of the superior vena cava. Surg Gynecol Obstet 156:659-660,1983
  76. Maki DG, Weise CE, Sarafin HW: A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J Med 296:1305-1309, 1977
  77. Malt RA, Kempster M: Direct azygous vein and superior vena cava cannulation for parenteral nutrition. JPEN 7:580-581,1983
  78. Marder VJ, Soulen RL, Atichartakam V, et al: Quantitative venographic assessment of deep vein thrombosis in the evaluation of streptokinase and heparin therapy. J Lab Clin Med 89:1018-1029, 1977
  79. Massumi RA, Ross AM: Atraumatic, nonsurgical technique for removal of broken catheters from cardiac cavities. N Engl J Med 277:195-196, 1967
  80. McDonough JJ, Altemeier WA: Subclavian venous thrombosis secondary to indwelling catheters. Surg Gynecol Obstet 133:397-400, 1971
  81. Mendoza GJ, Soto A, Brown EG, et al: Intracardiac thrombi complicating central total parenteral nutrition: Resolution without surgery or thrombolysis. J Pediatr 108:610-613, 1986
  82. Mitchell A, Atkins S, Royle GT, et al: Reduced catheter sepsis and prolonged catheter life using a tunnelled silicone rubber catheter for total parenteral nutrition. Br J Surg 69:420-422, 1982
  83. Neiderhuber JE, Ensminger W, Gyzes JW, et al: Totally implanted venous and arterial access system to replace external catheters in cancer treatment. Surgery 92:706-712, 1982
  84. Nelson EW: Venous access techniques. Urol Clin North Am 13:475-487, 1986
  85. Oakes DD, Wilson RE: Malposition of a subclavian line: Resultant pleural effusions, interstitial pulmonary edema and chest wall abscess during total parenteral nutrition. JAMA 233:532-533, 1975
  86. Oram-Smith JC, Mullen JL, Harken AH, et al: Direct right atrial catheterization for total parenteral nutrition. Surgery 83:274-276, 1978
  87. Padberg FT Jr, Ruggieor J, Blackburn GL, et al: Central venous catheterization for parenteral nutrition. Ann Surg 193:264-270,1981
  88. Pessa ME, Howard RJ: Complications of Hickman-Broviac catheters. Surg Gynecol Obstet 161:257-260, 1985
  89. Pollak EW, Walsh J: Subclavian-axillary venous thrombosis: Role of noninvasive diagnostic methods. South Med J 73:1503-1506, 1980
  90. Porter KA, Bistrian BR, Blackburn GL: Guidewire catheter exchange with triple culture technique in management of catheter sepsis. JPEN 12:628-632, 1988
  91. Prichard JG, Nelson MJ, Burns L, et al: Infections caused by central venous catheters in patients with acquired immunodeficiency syndrome. South Med J 81:1496-1498,1988
  92. Recht MP, Burke DR, Meranze SG, et al: Simple technique for redirecting malpositioned central venous catheters. AJR 154:183-184, 1990
  93. Reed WP, Newman KA, Tenney JH, et al: Autopsy findings after prolonged catheterization of the right atrium for chemotherapy in acute leukemia. Surg Gynecol Obstet 160:417-420, 1985
  94. Richards MJ, Metcalf SA: Fluoroscopic guidance of intravenous puncture for catheter placement. Radiology 146:226, 1983
  95. Rubenstein M, Creger WP: Successful streptokinase therapy for catheter-induced subclavian vein thrombosis. Arch Intern Med 140:1370-1371, 1980
  96. Rubin RN: Local installation of small doses of streptokinase for treatment of thrombotic occlusions of long-term access catheters. J Clin Oncol 1:572-573, 1983
  97. Ryan JA Jr, Able RM, Abbott WM, et al: Catheter complications in total parenteral nutrition: A prospective study of 200 consecutive patients. N Engl J Med 290: 757-761,1974
  98. Selby JB, Tegtmeyer CJ, Amodeo C, et al: Insertion of subclavian hemodialysis catheters in difficult cases: Value of fluoroscopy and angiographic techniques. AJR 152:641-643, 1989
  99. Schuman ES, Winters V, Gross GF, et al: Management of Hickman catheter sepsis. Am J Surg 149:627-628, 1985
  100. Scott WL: Complications associated with central venous catheters: A survey. Chest 94:1221-1224, 1988
  101. Shils ME, Wright WL, Turnbull A, et al: Long-term parenteral nutrition through an external arteriovenous shunt: Report of a case. N Engl J Med 283:341-344, 1970
  102. Sitzmann JV, Townsend TR, Siler MG, et al: Septic and technical complications of central venous catheterization: A prospective study of 200 consecutive patients. Ann Surg 202:766-770, 1985
  103. Smith DC, Pop PM: Malposition of a total parenteral nutrition catheter in the accessory hemiazygous vein. JPEN7:289-292, 1983
  104. Smith NL, Ravo B, Soroff HS, et al: Successful fibrinolytic therapy for superior vena cava thrombosis secondary to long-term total parenteral nutrition. JPEN 9:55-57, 1985
  105. Soto-Velasco JM, Steiger E, Rombeau JL, et al: Subclavian vein thrombophlebitis: Complication of total parentera nutrition (TPN). Cleve Clin Q 51:159-166, 1984
  106. Stellato TA, Gauderer MW, Lazarus HM, et al: Percutaneous Silastic catheter insertion in patients with thrombocytopenia. Cancer 56:2961-2963, 1985
  107. Stewart A, Mayne EE: Rapid resolution of subclavian vein thrombosis by tissue plasminogen activator [letter]. Lancet 1:890, 1988
  108. Stillman RM, Soliman F, Garcia L, et al: Etiology of catheter-associated sepsis: Correlation with thrombogenicity. Arch Surg 112:1497-1499, 1977
  109. Stuart RK, Shikora SA, Akerman P, et al: Incidence of arrhythmia with central venous catheter insertion and exchange. JPEN 14:152-155,1990
  110. Takasugi JK, O'Connell TX: Prevention of complications in permanent central venous catheters. Surg Gynecol Obstet 167:6-l l, 1988
  111. Torosian MH, Meranze S, McLean G, et al: Central venous access with occlusive superior central venous thrombosis. Ann Surg 203:3033, 1986
  112. Valerio D, Hussey JK, Smith FW: Centra vein thrombosis associated with intravenous feeding: A prospective study. JPEN 5:240-242, 1981
  113. Wanscher M, Frifelt JJ, Smith-Silvertsen C, et al: Thrombosis caused by polyurethane double-lumen subclavian superior vena cava catheter and hemodialysis. Crit Care Med 16:624-628, 1988
  114. Welch GW, McKeel DW Jr, Silverstein PM, et al: The role of catheter composition in the development of thrombophlebitis. Surg Gynecol Obstet 138:421-424, 1974
  115. Wilson JN, Grow JB, Demong CV, et al: Central venous pressure in optimal blood volume maintenance. Arch Surg 85:563-578, 1962

Top