Identification of catheter misplacement in early port CVC dysfunction

Abstract

The use of port central venous catheters (CVCs) for chemotherapeutical use has seen exponential growth over the last decades. However, port CVC misplacement may lead to catheter malfunction (such as partial or total catheter blockade), which might be complicated by thrombosis and catheter superinfections, and these in turn may lead to pulmonary embolism and bloodstream infections. The overall occurrence of port CVC misplacement is up to 6%; nonetheless, port CVC misplacement may occur in up to 67% of patients with early CVC dysfunction (occurring within three months of catheter insertion). Thereafter, the prompt evaluation of catheter position among patients with first-trimester CVC dysfunction is extremely important. The aim of the present manuscript is to support medical oncologists, haematologists, and clinicians in timely suspicion and recognition of port CVC misplacement among patients with early CVC dysfunction. Radiological educational iconographic materials that will assist a prompt estimate of port-CVC dislocation are provided.

Keywords: CVCs; central venous catheters; chemotherapy; dysfunction; misplacement; port.

Fig. 1

Correct placement. Catheter tip terminates in the superior vena cava, just upstream of the right atrium

Fig. 2

Correct placement. Catheter tip terminates in the superior vena cava, just upstream of the right atrium

Fig. 3

Catheter kinked due to compression between the first rib and the clavicle, thus resulting in pinch-off syndrome

Fig. 4

Long catheter with catheter tip reaching the inferior vena cava

Fig. 5

Catheter makes a loop in the ipsilateral jugular vein

Fig. 6

Catheter makes a loop in the ipsilateral jugular vein

Fig. 7

Catheter is too long and ends in the contralateral subclavian vein

Fig. 8

Catheter has entered the right subclavian vein and then continues to the right internal jugular vein

Fig. 9

Tight suture generating a catheter kinking right after the port. As a result, there is a mechanical obstruction that blocks flow in any direction

Fig. 10

Tight suture generating a catheter kink right after the port. We can also see catheter length with catheter tip misplaced and reaching the inferior vena cava

Fig. 11

Chest X-ray indicates a long catheter with endocardial loop in the right atrium

Fig. 12

The chest X-ray shows a catheter fracture in the right atrium. The fragment must be removed immediately to avoid life-threatening complications. We can also see a pinch-off syndrome due to catheter compression between the first rib and the clavicle

Fig. 13

The chest X-ray (profile view) shows a catheter fracture in the right atrium

Fig. 14

Short catheter with catheter tip just at the entrance of the right subclavian vein. There is an extremely high risk of drug extravasation with minimal catheter back movement/migration

Fig. 15

Short catheter: due to its shortness the catheter has migrated outside the superior vena cava

Fig. 16

Catheter length with a narrow angle loop immediately after the port and a second narrow angle distortion before its entrance in the subclavian vein

Fig. 17

Catheter length with a narrow angle loop immediately after the port

Fig. 18

Flow chart with suggestions on how to manage port-catheter misplacement