(Radiology. 2001;218:294-298.)
© RSNA, 2001
Peripheral Placement of Apheresis Catheters in Children: Feasibility, Safety, and Efficacy in the Collection of Blood Stem Cells—Initial Experience1
Roger K. Harned, II, MD,
Sharon S. Kelly, MD,
Nicholas K. Foreman, MB, ChB and
Roger H. Giller, MD
1 From the Departments of Radiology (R.K.H.) and Pathology (S.S.K.), and the Section of Pediatric Hematology/Oncology/Bone Marrow Transplant (N.K.F., R.H.G.), University of Colorado Health Sciences Center and the Children’s Hospital, 1056 E 19th Ave, Denver, CO 80218. From the 1999 RSNA scientific assembly. Received December 6, 1999; revision requested January 14, 2000; revision received March 17; accepted April 20. Address correspondence to R.K.H. (e-mail: harned.roger@tchden.org).
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ABSTRACT
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An 8-F 24-cm-long apheresis catheter was placed in the basilic vein with imaging-guided percutaneous technique in 15 children undergoing leukapheresis for collection of autologous peripheral blood stem cells. There were no immediate or long-term complications. This is a low-morbidity procedure requiring minimal sedation that results in successful collection of peripheral blood stem cells and allows flow rates comparable to those with surgically placed central catheters.
Index terms: Catheters and catheterization, in infants and children, 916.1269 • Interventional procedures, in infants and children, 916.1269 • Veins, access, 916.1269
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INTRODUCTION
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Autologous transplantation of peripheral blood stem cells (PBSCs) after myeloablative therapy has been shown to be effective in children with malignancy (1). The successful harvesting of PBSCs is a multifactorial process requiring adequate mobilization of these progenitor cells, as well as withdrawal and reinfusion of blood at flow rates required for apheresis. Patients who undergo PBSC transplantation frequently have central venous access devices in place for use in delivery of chemotherapy, infusion of supportive medication, and blood tests. Some implantable devices not specifically developed for apheresis, such as double-lumen Broviac catheters (TPN; Cook, Bloomington, Ind), have been used effectively for apheresis (2). However, implanted ports and double- or single-lumen central catheters often do not provide adequate flow rates for harvesting of PBSCs. As a result, these patients typically require surgical placement of a large-caliber apheresis catheter in either the internal jugular or subclavian vein (3,4). This placement necessitates the use of general anesthesia and exposure to the small but potentially lethal risks of pneumothorax, hemothorax, arterial puncture, and air embolism (5).
Placement of a peripherally inserted central catheter avoids the potential morbidity of more centrally obtained access, as well as the additional benefit of avoiding a trip to the operating room because placement can frequently be performed with local anesthesia alone. The standard catheters used for apheresis are larger than the 3- to 5-F peripherally inserted central catheters generally used in children. At our institution, 8 F is the smallest caliber recommended for use during apheresis. The purpose of our study was to evaluate placement of an 8-F catheter in the basilic vein of children undergoing PBSC collection.
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Materials and Methods
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From July 1996 through August 1999, 16 children, adolescents, and young adults (seven male and nine female patients; age range, 8.6–19.2 years; mean age, 14.4 years ± 3.7 [SD]; weight range, 26.0–77.0 kg; mean weight, 45.8 kg ± 13.9) with either an access device with inadequate flow capabilities for apheresis or no need for prolonged central venous access were referred for peripheral placement of a catheter for PBSC collection (Table). The primary diagnosis in the 16 children was Ewing sarcoma (n = 5), Hodgkin lymphoma (n = 4), anaplastic astrocytoma (n = 2), primitive neuroectodermal tumor (n = 1), pineoblastoma (n = 1), cordoma (n = 1), alveolar rhabdomyosarcoma (n = 1), and malignant nerve sheath tumor (n = 1).
Informed consent was obtained from the patient, the patient’s parent, or a legal guardian after full explanation of the planned procedure, the associated risks, and alternative methods of obtaining central venous access. At our institution, peripherally inserted central catheters placed by interventional radiologists and pediatricians are frequently as large as the small veins into which they must be inserted; thus, placement of an apheresis catheter in a basilic vein larger than the catheter diameter was within the standard of clinical practice at our institution.
A 22-gauge peripheral intravenous Teflon catheter (Angiocath; Becton-Dickinson, Sandy, Utah) was placed in a hand or forearm vein in 13 of 16 patients. This catheter was placed to allow injection of contrast material (ioversol, Optiray 320; Mallinckrodt, St Louis, Mo) at venography of the arm and for administration of intravenous sedation. A peripheral vein could not be accessed in the three remaining patients, and ultrasonography (US) was subsequently performed to help locate a vein in the upper arm.
In all patients, local anesthesia cream (Emla; Astra Pharmaceutical Products, Westborough, Mass) was placed at least 1 hour before the placement procedure, and 1% lidocaine hydrochloride was injected subcutaneously at the planned puncture site at the time of the procedure. In addition, five (31%) of the 16 patients required intravenous sedation with midazolam hydrochloride and fentanyl citrate. Continuous cardiorespiratory monitoring was performed by a registered nurse.
The right arm was used preferentially (n = 15) because of the decreased distance to the larger central vessels. At the request of one patient, the catheter was placed in the left arm. In each case, the arm was prepared from the shoulder to the wrist with a 10% iodine solution, and this area was draped with sterile towels. Venography was performed in the 13 patients with peripheral access in the preferred upper extremity. The size of the basilic vein was evaluated as were the presence and size of the brachial and cephalic veins. A 7-MHz linear US transducer (Acuson, Mountain View, Calif) was used to evaluate the size of the basilic vein in the remaining three patients. Placement was attempted when the diameter of the basilic vein appeared larger than that of the catheter.
An 8-F 24-cm-long silicone catheter (Pediatric Hemo-Cath; Medcomp, Harleysville, Pa) was initially used in all patients. A 5-F micropuncture introducer kit (Cook) was used to obtain venous access. Venipuncture of the basilic vein just proximal to the axillary vein was performed with the 21-gauge needle with fluoroscopic (n = 12) or US (n = 3) guidance. The skin puncture site was widened with a number 11 scalpel blade. With the Seldinger technique and the 0.018-inch wire, the needle was exchanged for the 5-F dilator. The inner trocar was then removed, and the 0.038-inch J wire supplied with the apheresis catheter was advanced into the vein. The 5-F sheath was exchanged for the 10-F peel-away sheath, and the 8-F catheter was placed through the sheath with the tip as central as possible. After the peel-away sheath was removed, the Dacron cuff of the catheter was placed just deep to the skin incision, and the incision was closed with a single suture (2-0 Prolene; Ethicon, Somerville, NJ). Suture material was also used to fix the hub of the catheter just distal to the incision. Both lumina of the catheter were flushed with sterile saline solution and filled with a 100 U/mL solution of heparin.
Patients were followed up in the outpatient oncology clinic and underwent daily sessions of leukapheresis. The catheter site was examined before each session for signs of infection or bleeding. Change in flow rates, patient symptoms, and limited physical examination were used to evaluate for thrombosis. Leukapheresis was performed with a continuous-flow blood cell separator (Spectra; Cobe BCT, Englewood, Colo). All patients underwent large-volume leukapheresis with target processing of 3.5 times the patient’s total blood volume per session. A prophylactic dose of calcium was given orally to all patients to prevent citrate toxicity secondary to the anticoagulant acid, citrate dextrose, used during each collection procedure. The maximal sustained flow rate, number of collections necessary, CD34 positive cell yield per kilogram of body weight, and problems encountered during apheresis were recorded. Catheters were removed immediately after completion of PBSC harvest.
The laboratory test records of all children who had undergone leukapheresis for collection of blood stem cells with surgically placed central catheters since 1995 were retrospectively searched. A second group of 14 children matched for total blood volume to our current study patients was identified. A statistical comparison of maximal sustained catheter flow rate during apheresis was made with a two-tailed Student t test.
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Results
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Fifteen of the 16 patients underwent successful placement of the 8-F catheter in a basilic vein (Table). One of two patients weighing less than 30 kg had basilic, brachial, and cephalic veins that were smaller than the catheter diameter, and placement was not attempted (Fig 1). With the fixed-length catheter (24 cm) and wide variation in patient weight (range, 30–77 kg), there was also variation in the position of the catheter tip. When the right basilic vein was used, the tip was located in the right subclavian vein (n = 4), superior vena cava (n = 9), or right atrium (n = 1). The catheter placed through the left basilic vein terminated in the left brachiocephalic vein (Fig 2).
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Figure 1. Anteroposterior venogram of the right upper extremity. The hemostat marks the preferred venipuncture site just below the axilla. The hemostat compresses the basilic vein from a medial approach to confirm that it is at the same height above the table, thus minimizing the effect of magnification. The contrast material-filled basilic vein is similar in width to the 2-mm tip of the hemostat. An 8-F catheter (not shown) is just less than 3 mm in diameter.
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Figure 2a. Anteroposterior venograms of the chest after peripheral placement of apheresis catheters in four patients. A previously placed central access device (arrowheads), which was inadequate for leukapheresis, was present in each patient. The fixed-length catheter in patients of varied sizes resulted in the tip (arrow) being positioned in the (a) right subclavian vein, (b) superior vena cava, (c) right atrium, and (d) left brachiocephalic vein.
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Figure 2b. Anteroposterior venograms of the chest after peripheral placement of apheresis catheters in four patients. A previously placed central access device (arrowheads), which was inadequate for leukapheresis, was present in each patient. The fixed-length catheter in patients of varied sizes resulted in the tip (arrow) being positioned in the (a) right subclavian vein, (b) superior vena cava, (c) right atrium, and (d) left brachiocephalic vein.
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Figure 2c. Anteroposterior venograms of the chest after peripheral placement of apheresis catheters in four patients. A previously placed central access device (arrowheads), which was inadequate for leukapheresis, was present in each patient. The fixed-length catheter in patients of varied sizes resulted in the tip (arrow) being positioned in the (a) right subclavian vein, (b) superior vena cava, (c) right atrium, and (d) left brachiocephalic vein.
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Figure 2d. Anteroposterior venograms of the chest after peripheral placement of apheresis catheters in four patients. A previously placed central access device (arrowheads), which was inadequate for leukapheresis, was present in each patient. The fixed-length catheter in patients of varied sizes resulted in the tip (arrow) being positioned in the (a) right subclavian vein, (b) superior vena cava, (c) right atrium, and (d) left brachiocephalic vein.
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The initial CD34 positive cell yield per kilogram was low in two of the larger patients (77 and 56 kg), probably as a result of poor stem cell mobilization and relatively low flow rates for the total blood volume. We elected to increase the size and length of the apheresis catheter in an attempt to increase the volume of blood that could be processed in these two patients. With sterile technique, the 8-F catheter in the right arm was exchanged for a 12.5-F 32-cm-long silicone catheter with the tip extending to the superior vena cava. There were no complications related to the 15 original placement procedures and the two subsequent catheter revisions.
A total of 46 sessions of apheresis were necessary for PBSC collection (mean, 3 sessions ± 2; range, 1–6 sessions). The patients tolerated their apheresis procedures well, with three patients experiencing nausea or vomiting. Five patients had episodes when flow dynamics triggered alarms, which required the technician to decrease the flow rates. The mean sustained maximum flow rate was 60 mL/min ± 16 (range, 31–85 mL/min). The number of patient blood volumes processed per session ranged from 2.30 to 5.93 volumes (mean, 4.36 volumes ± 1.04). This number was sufficient to allow successful large-volume leukapheresis in all 15 patients with peripheral apheresis catheters. There were a total of 54 catheter days (mean, 4 days ± 2; range, 1–7 days). No signs or symptoms of arm or neck swelling were reported, and there was no decrease in catheter function to suggest clot formation or decreased venous inflow. The two patients with poor PBSC mobilization had inadequate collection of PBSCs despite an increased flow rate with the larger apheresis catheter. The remaining 13 patients underwent successful collection of PBSCs for subsequent autologous transplantation.
The 14 patients in the control group had a mean total blood volume of 3,382 mL ± 1,197, which was not significantly different from the mean volume of 3,380 mL ± 946 for the study group (P = .99). All patients in the control group had institutionally approved apheresis catheters placed surgically from an internal jugular or subclavian vein approach. Tip placement was in the right atrium. Catheter sizes were 9 F (n = 2), 12.5 F (n = 9), and 13.5 F (n = 3). The mean sustained maximum flow rate in the control subjects was 62 mL/min ± 18 (range, 35–86 mL/min). There was no significant difference in maximum sustained flow rate between the control and study groups (P = .70).
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Discussion
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In patients who undergo PBSC transplantation without any form of venous access, a dual-lumen catheter suitable for apheresis may be placed with a tunneled or nontunneled approach in the subclavian or jugular vein. A suitable catheter placed in this position may be left in place for long-term use during the patient’s chemotherapy, transplantation, and subsequent recovery period (2,3). Other patients undergo autologous PBSC collection with another device in place from previous treatment for their primary malignancy. Although strategies have been devised to use previously placed chest ports or single-lumen catheters along with a peripheral intravenous cannula, the sustained flow rates achieved with this type of peripheral access is less than optimal (6). Thus, these children need a safe short-term form of high-flow venous access to undergo efficient PBSC harvest.
A conventional peripherally inserted central catheter is too small to produce the flow rates needed for apheresis, but the method of peripheral placement in a vein of the upper arm is safe and avoids the potential for pneumothorax, hemothorax, air embolism, or major vessel disruption (7). We successfully placed a larger institutionally approved apheresis catheter from this same peripheral approach. Eleven of 16 patients required only local anesthesia, and there were no procedure-related complications. We recognize that larger catheter size and tip placement proximal to the distal superior vena cava have been implicated as risk factors in catheter-related thrombosis (8). In our small patient study group, however, no thrombotic complications were detected.
The flow rates achieved with peripherally placed apheresis catheters compared favorably with rates for those placed surgically from internal jugular or subclavian sites. We decided to increase the size of the catheter in the two patients in whom it was initially believed that lower flow rates had contributed to inadequate CD34 positive cell yield. This decision allowed use of the longer catheter (32 cm), which was manufactured in only the 12.5-F diameter. Because two catheter parameters (length and diameter) were changed, it is uncertain whether the larger lumen or the placement of the tip further into the central vasculature accounted for the subsequent increase in available blood flow. Further investigation with custom-manufactured 8-F catheters in longer lengths will be necessary to isolate the effect of tip position. Nonetheless, although higher flow rates were achieved with the longer and larger catheters, PBSC yields remained low in these two patients owing to poor mobilization, which was most likely the result of reduced marrow stem cell pools.
Our experience with the 8-F central catheter placed from a peripheral approach suggests that it can be successfully and safely used in patients older than 8 years who weigh at least 30 kg. We did not place the catheter in one of two patients who weighed less than 30 kg owing to the small size of veins demonstrated at venography. Currently, patients weighing less than 30 kg are considered on a case-by-case basis, and those with inadequate peripheral vein size at US or venography undergo placement of a catheter via an internal jugular or subclavian vein approach.
Peripheral placement of large-caliber apheresis catheters has implications beyond the population of patients in this study. Both autologous and allogeneic PBSC transplantation are performed successfully for treatment of childhood malignancy (9). Allogeneic PBSC harvest from healthy donors performed through peripheral access with small catheters but low flow rates, which necessitates subsequent placement of central catheters, has been reported in 3%–100% of donors (10–12). More recently, there have been reports of healthy donors undergoing US-guided placement of internal jugular catheters (13). Although imaging guidance reduces the risk of pneumothorax or inadvertent carotid puncture, these risks are not eliminated, and there is still the risk of embolization of air through the large centrally located sheath necessary for placement (13,14). Peripheral placement essentially eliminates these risks and provides a reasonable alternative to placement in the jugular or subclavian vein for allogeneic PBSC donors weighing at least 30 kg.
It has been our initial experience that it is possible to safely place a functional apheresis catheter from a peripheral vein approach. Catheter placement was well tolerated, and only local anesthesia was necessary in the majority of patients. These findings suggest that this procedure may be reasonable in healthy volunteers donating PBSC for allogeneic transplantation.
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ACKNOWLEDGMENTS
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The authors thank Karen Prothe, MT, from the Section of Pediatric Hematology/Oncology/Bone Marrow Transplant, for her assistance in data acquisition and Todd Mackenzie, PhD, and Misoo Ellison, MSc, from the Department of Preventative Medicine and Biometrics, for their assistance in data analysis.
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FOOTNOTES
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Abbreviation: PBSC = peripheral blood stem cell
Author contributions: Guarantor of integrity of entire study, R.K.H.; study concepts, R.K.H., R.H.G., N.K.F.; study design, R.K.H., R.H.G.; definition of intellectual content, R.K.H., R.H.G.; literature research, R.K.H.; clinical studies, R.K.H., S.S.K.; data acquisition, R.K.H., S.S.K., R.H.G.; data analysis, R.K.H., S.S.K., R.H.G.; statistical analysis, R.K.H.; manuscript preparation, R.K.H.; manuscript editing, R.K.H.; manuscript review, all authors.
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REFERENCES
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Leibundgut K, Hirt A, Luthy AR, et al. Autotransplants with peripheral blood stem cells and clinical results obtained in children: a review. Eur J Pediatr 1993; 152:546-554.[Medline]
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Leibundgut K, Muller C, Muller K, Ridolfi-Luthy A, Wagner HP, Hirt A. Tunneled, double lumen Broviac catheters are useful, efficient and safe in children undergoing peripheral blood progenitor cell harvesting and transplantation. Bone Marrow Transplant 1996; 17:663-667.[Medline]
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Hahn U, Goldschmidt H, Salwender H, Haas R, Hunstein W. Large-bore central venous catheters for the collection of peripheral blood stem cells. J Clin Apheresis 1995; 10:12-16.[Medline]
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Madero L, Díaz MA, Benito A, Villa M, Valdivielso A. Non-tunneled catheters for the collection and transplantation of peripheral blood stem cells in children. Bone Marrow Transplant 1997; 20:53-56.[Medline]
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Meisenberg BR, Callaghan M, Sloan C, Sampson L, Miller WE, McMillan R. Complications associated with central venous catheters used for the collection of peripheral blood progenitor cells to support high dose chemotherapy and autologous stem cell rescue. Support Care Cancer 1997; 5:223-227.[Medline]
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Kevy SV, Fosburg M. Therapeutic apheresis in childhood. J Clin Apheresis 1990; 5:87-90.[Medline]
-
Chait PG, Ingram J, Phillips-Gordon C, Farrell H, Kuhn C. Peripherally inserted catheters in children. Radiology 1995; 197:775-778.[Abstract/Free Full Text]
-
Bona RD. Thrombotic complications of central venous catheters in cancer patients. Semin Thromb Hemost 1999; 25:147-155.[Medline]
-
Diaz MA, Alegre A, Villa M, et al. Allogeneic peripheral blood progenitor cell transplantation in children with haematological malignancies. Br J Haemotol 1997; 96:161-164.[Medline]
-
Wiesneth M, Friedrich W, Bunjes D, et al. Mobilization and collection of allogeneic peripheral blood progenitor cells for transplantation. Bone Marrow Transplant 1998; 21(suppl 3):S21-S24.
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Bishop MR, Tarantolo SR, Jackson JD, et al. Allogeneic-blood stem-cell collection following mobilization with low-dose granulocyte colony–stimulating factor. J Clin Oncol 1997; 15:1601-1607.[Abstract]
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Russell JA, Luider J, Weaver M, et al. Collection of progenitor cells for allogeneic transplantation from peripheral blood of normal donors. Bone Marrow Transplant 1995; 15:111-115.[Medline]
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Sadler DJ, Gordon AC, Klassen J, Saliken JC, So CB, Gray RR. Image-guided central venous catheters for apheresis. Bone Marrow Transplant 1999; 23:179-182.[Medline]
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Mauro MA, Jaques PF. Radiologic placement of long-term central venous catheters: a review. J Vasc Interv Radiol 1993; 4:127-137.[Medline]
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ABSTRACT
INTRODUCTION
