DOI:10.2214/AJR.06.1064
AJR 2007; 188:1047-1049
© American Roentgen Ray Society
Femoral-to-Port Through-and-Through Wire Access to Reestablish Subcutaneous Port Function
Sergei Sobolevsky1,
Robert G. Sheiman,
Salomao Faintuch and
Laura Perry
1 All authors: Department of Radiology, Beth Israel Deaconess Medical Center,
330 Brookline Ave., Boston, MA 02215.
Received August 10, 2006;
accepted after revision October 4, 2006.
Address correspondence to R. G. Sheiman
(rsheiman{at}bidmc.harvard.edu).
Abstract
OBJECTIVE. Central venous catheter malfunction often results from
fibrin sheath formation and is routinely addressed with thrombolytic therapy
or mechanical stripping. Mechanical stripping from a distant access site such
as a femoral vein is the only option for a subcutaneous port that has failed
thrombolytic therapy. When a fibrin sheath has rendered the catheter tip
inaccessible to snaring, catheter salvage cannot be achieved, requiring port
exchange. We report two cases in which an inaccessible catheter tip was
mobilized via advancing a wire through the port and through the catheter,
allowing for successful snaring, mechanical stripping, and return of normal
port function.
CONCLUSION. Passage of a hydrophilic wire through a subcutaneous
port and beyond the catheter tip is technically possible. The wire can be
snared from a femoral access to achieve successful catheter stripping when
direct catheter snaring is not possible.
Keywords: central venous devices • interventional radiology • venography
Introduction
Totally implantable subcutaneous central venous ports are frequently
used in oncology patients who require chemotherapy infusion and blood
aspiration. One important cause of port failure is formation of a fibrin
sheath around the tip of the catheter
[1,
2]. Common techniques of port
salvage include dissolution of fibrin using intracatheter thrombolysis with
urokinase or tissue plasminogen activator (t-PA) or stripping of the fibrin
sheath from the catheter tip using a snare device
[1,
3-6].
The latter method, although usually successful, may prove cumbersome because
the tip of the catheter that is covered with fibrin may be difficult or
impossible to mobilize and snare, especially if it is adherent to the superior
vena cava (SVC) or atrial wall. In such a scenario, salvage usually cannot be
achieved, requiring port exchange. We present two situations in which fibrin
sheath stripping was achieved via the introduction of a guidewire through the
port into the inferior vena cava (IVC) and subsequently snared from a femoral
access. The wire was then used as a rail for catheter tip repositioning,
snaring, and stripping, resulting in restoration of port function.
Case 1
A 62-year-old woman with recurrent breast cancer presented to our
interventional radiology service due to difficulty with aspiration of her
8-French, single lumen, end-hole subcutaneous chest port, which had been
placed 5 years earlier. The port, placed via the right subclavian vein, had
been functional with respect to infusion of medication and aspiration since
implantation until approximately 2 weeks earlier, when aspiration could no
longer be achieved. Meticulous port care had always been maintained per
hospital policy, which included flushing with heparinized saline daily when
accessed, after each use, and monthly when not accessed.
A venogram via the port using a standard 19-gauge right-angled needle
(Huber Plus, Nowmedical) was obtained and confirmed the presence of a fibrin
sheath around the tip of the catheter by showing flow of contrast material
directed upstream from the catheter tip. The venogram also confirmed wide
patency of the SVC to the right atrium and otherwise showed no caval filling
defects to suggest thrombus. Multiple challenges of 2.5 mg of t-PA through the
port and into the catheter were unsuccessful at restoring blood aspiration, so
catheter stripping was undertaken.
After informed written consent was obtained, access into the right common
femoral vein was gained with a 6-French sheath (Bright Tip Sheath, Cordis). A
6-French nitinol snareguiding sheath was advanced over a Bentson wire
(Angiodynamics) into the SVC, after which the wire was replaced with a 15-mm
snare. Several unsuccessful attempts were made to grasp the catheter tip
within the SVC. The fibrin sheath was thought to be indirectly inhibiting
snaring by encasing the catheter tip and causing adherence to the SVC.
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Fig. 1A —62-year-old woman with left subclavian port. Anteroposterior
fluoroscopic image of chest shows 0.018-inch wire (arrows) traversing
through left chest subcutaneous port (arrowheads), through catheter,
and into superior vena cava.
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Fig. 1B —62-year-old woman with left subclavian port. Coned-down
anteroposterior fluoroscopic image of chest shows 0.018-inch wire was snared
and then withdrawn through femoral vein to achieve through-and-through access,
allowing catheter tip repositioning and successful mechanical stripping.
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Fig. 2 —61-year-old woman with right subcutaneous port. Axial CT image shows
fibrin sheath (long arrow) as low-density filling defect within
inferior vena cava and surrounding catheter tip (short arrow).
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The port was then accessed with a 19-gauge straight Huber needle. An
0.018-inch glide guidewire (Radifocus Glidewire, Boston Scientific) was
advanced through the needle into the port reservoir and steered under direct
fluoroscopy into the port egress, through the catheter, and into the SVC
(Fig. 1A). This required
approximately 2 minutes of fluoroscopy. The 15-mm snare was then used to pull
the 0.018-inch guidewire from the SVC into the IVC
(Fig. 1B) and then through our
6-French right femoral sheath to achieve through-and-through wire access. By
tracking along the 0.018-inch guidewire with a 15-mm snare and also manually
pulling our through-and-through wire at the femoral access, it was possible to
free the catheter tip from the wall of the SVC, which then enabled easy
repeated snaring and mechanical stripping. Repeat port injection showed no
radiographic evidence of a fibrin sheath, with port aspiration restored. The
port has been functioning well (infusion and aspiration) up to the present
time (8-month follow-up).
Case 2
A 61-year-old woman with metastatic breast cancer presented to our
interventional radiology service because of difficulty with port aspiration
that was unresponsive to treatment with t-PA. Catheter care had also included
adherence to hospital protocol for flushing with heparinized saline. The
8-French port was surgically placed in December 2002 via the right cephalic
vein and was otherwise functional. A CT angiogram of the chest 2 weeks earlier
had shown a fibrin sheath around the catheter with associated SVC luminal
compromise (Fig. 2). After
informed consent was obtained, the right common femoral vein was accessed and
a 6-French sheath placed. A nitinol snare-guiding system was advanced over an
Amplatz Super Stiff wire (Boston Scientific) into the SVC and snaring of the
catheter tip was attempted with a 15-mm- and then 20-mm-diameter nitinol
snare.
Neither snare could be advanced beyond the catheter tip to perform
mechanical fibrin sheath removal. The guiding system was exchanged for a 10 mm
x 3 cm angioplasty balloon (Opti Pro, Cordis Endovascular), which was
inflated adjacent to the catheter tip to disrupt the fibrin sheath or cause
catheter tip repositioning or both. This procedure was followed by repeated
attempts to snare the catheter tip, which again failed. The port was then
accessed with a 19-gauge straight Huber needle and an 0.018-inch glide
guidewire advanced into the port reservoir, through the catheter, into the
SVC, and then into the IVC. The wire was then snared via the previously
obtained femoral access and pulled though the femoral sheath to create
through-and-through access. Tension on both ends of the guidewire enabled
tracking of a 15-mm snare beyond the catheter tip, allowing successful
stripping and restoration of port function. Port function has been maintained
to date (5-month follow-up).
Discussion
Fibrin sheath formation leading to central venous catheter malfunction is a
common phenomenon [4,
7] and can occur as early as 24
hours after catheter placement
[8-10].
Although the radiographic diagnosis of a fibrin sheath can be made
fluoroscopically if injection of contrast medium through the catheter is
possible [11], diagnosis of a
fibrin sheath is often inferred.
Catheter dysfunction can vary from simple difficulty with aspiration, as in
our cases, to complete catheter failure. Increasing accumulation of fibrin can
eventually cause vessel luminal compromise and complete thrombosis. Other
reported complications resulting from fibrin sheath formation include
infection due to bacterial colonization of the sheath itself, catheter
mechanical compromise with fragmentation at the time of removal, and
retrograde tracking of infused chemotherapeutic substances causing cutaneous
or subcutaneous necrosis.
Several techniques have been successfully used for the treatment of a
fibrin sheath involving central venous lines with freely accessible lumens.
These include simple catheter exchange over a wire with tip positioning beyond
the fibrin sheath confines [9];
catheter removal, intravascular fibrin sheath disruption with a balloon
catheter, and catheter replacement; and mechanical sheath disruption using
wires or brushes passed through the line itself. Such techniques, however, are
not readily applicable to central lines accessed from a subcutaneous port.
Salvage of a malfunctioning central venous port by dissolution of the
fibrin sheath using thrombolytic agents can be effective
[11,
12] and was the initial mode
of attempted treatment for our patients. The success of this method is
believed to be related to addressing the pericatheter thrombus formation
sometimes associated with a fibrin sheath
[12]. Both urokinase and t-PA
have been shown to restore catheter function (aspiration and infusion) in more
than 90% of patients who present with first-time catheter malfunction related
to fibrin sheath formation [2].
However, the durability of chemical thrombolysis infusion therapy may be quite
short [1,
12]. It may also be
contraindicated in patients with recent major surgery, prior hemorrhagic
cerebrovascular accident, and thrombocytopenia.
Because of the lack of response to t-PA infusion directly into the port and
catheter of our patients, mechanical stripping of the fibrin sheath from the
catheter wall was undertaken before considering port removal and replacement.
Fibrin sheath stripping using a snare inserted through the common femoral vein
has been used on all types of central venous catheters with mixed results.
Although some published series have shown excellent results, with patency
rates of 100% at 3 months [1,
13], others have shown dismal
postprocedural patency rates, with 70% of catheters requiring retreatment at
20 days [14]. The snare placed
around the tip of a malfunctioning catheter, passed retrograde beyond all
catheter openings, tightened, and then gently pulled along the catheter can
enable removal of the sheath and restoration of catheter function. Although
this method is associated with some potential complications, including
pulmonary artery thrombosis of the disrupted sheath
[11], it is generally safe and
well tolerated by the patient.
Our initial attempts to snare the catheter in either patient via a femoral
approach were unsuccessful because of the absence of a free catheter tip,
likely due to fibrin surrounding the tip and, in the first case, fibrin also
causing adherence of the tip to the SVC wall. Such obstacles were overcome by
placing a wire into the chest port, through the central venous catheter, and
then snaring the wire from a femoral site and using this through-and-though
wire to successfully snare the catheter tip. To our knowledge, this approach
has not been applied previously to subcutaneous ports because of the perceived
inability to pass a wire through the port orifice, catheter, and beyond the
catheter tip. By using a noncoring straight Huber needle and an 0.018-inch
tapered hydrophilic wire, we were able to achieve through-and-through wire
placement and perform this salvage maneuver successfully and with long-term
results.
There are potential drawbacks to our approach, however. We found that only
an 0.018-inch hydrophilic wire with a curved tip could allow port orifice
selection. We were unsuccessful with braided wires. The potential for
hydrophilic wire fragmentation or shearing of the coating does exist during
attempts to negotiate the port orifice. We try to aim the access needle toward
the orifice using fluoroscopy and to enter the port as obliquely as possible
to minimize the angle between the access needle and wire. We also do not
recommend wire withdrawal through the needle. If the wire must be withdrawn
from the port, we remove it and the access needle as a unit to ensure that
there is no relative movement of the wire and needle tip.
Finally, we have been able to perform this procedure in other patients who
have single ports with success, but we have not been able to access either
port orifice in patients who have failing double ports, regardless of the port
manufacturer. This is likely due to the angle or position of the orifice of
both port chambers. We should also add that both of our patients had silicone
catheters, which allowed hydrophilic wire passage. However, catheters made of
other polymers may not be traversed with a hydrophilic wire as easily.
Overall, in patients with failing subcutaneous ports in whom thrombolytic
agents are contraindicated or unsuccessful and who cannot undergo stripping
because of catheter tip inaccessibility due to position or adherence to a
vessel wall, port salvage is still possible. Snaring of an 0.018-inch
hydrophilic wire through the port orifice and beyond the catheter tip to
achieve through-and-through access for tip snaring and stripping can be
performed successfully. However, caution must be exercised to minimize the
chances of wire fragmentation and shearing.
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Abstract
Introduction
