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Vascular and Interventional Radiology |
1 From the Departments of Radiology (M.D.K., S.O.T., J.N., M.S.S., G.M., N.H.P., M.S.J., H.S.) and Medicine, and the Division of Biostatistics (R.S.), Indiana University School of Medicine, University Hospital, Rm 0279, 550 N University Blvd, Indianapolis, IN 46202-5253. Received July 31, 2000; revision requested September 9; revision received October 3; accepted November 1. Supported by grants from Bard Access Systems, Salt Lake City, Utah, and Indiana University Radiology Associates, Indianapolis. Address correspondence to S.O.T. (e-mail: streroto@iupui.edu).
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ABSTRACT |
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MATERIALS AND METHODS: A total of 428 tunneled, cuffed catheters were removed with traction and local anesthesia. Polyester cuff retention was recorded when it occurred, and the effects of cuff retention were determined at a mean follow-up of 250 days. Statistical analysis was performed to determine the variables influencing cuff retention.
RESULTS: Traction removal was successful in 428 (100%) patients. Of 428 catheters removed, 41 (10%) cuffs were retained. Silicone 10-F double-lumen and 9.6-F single-lumen catheters had a higher rate of cuff retention (27 [32%] of 84 and nine [39%] of 23, respectively) than did the split-tip polyurethane hemodialysis catheter (two [1%] of 196; P < .001). Cuff retention rates among other catheter types compared with that of the polyurethane catheter were not significantly different. Duration of catheter dwell did not significantly influence cuff retention. Of 41 retained cuffs, three required removal with cutdown for cuff migration to the exit site, which inhibited healing (n = 1); for suspected infection (n = 1); or for cosmetic purposes as requested by the patient (n = 1). The remaining patients had no complications associated with cuff retention.
CONCLUSION: Traction removal of smaller-bore silicone catheters is more likely to result in cuff retention than removal of larger silicone and polyurethane catheters, and cuff retention is usually inconsequential.
Index terms: Catheters and catheterization, central venous access • Catheters and catheterization, complications, 90.1269, 90.44 • Interventional procedures, complications, 90.1269, 90.44
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INTRODUCTION |
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Catheter removal can be performed with traction (2,4,5) or cutdown (6). During traction removal, some cuffs become separated from the catheter and remain in situ. It has been recommended (Hickman, Leonard, and Broviac central venous catheters, Instructions for Use, Bard Access Systems, July 1997) that all retained cuffs be removed, which requires a cutdown procedure. The purpose of this study was to elucidate the factors that contribute to cuff retention during traction removal of tunneled catheters, as well as to determine the risk of complication associated with polyester cuff retention.
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MATERIALS AND METHODS |
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Insertion of all the catheters was performed with the use of imaging guidance (ultrasonography for venipuncture and fluoroscopy for catheter placement), as described (7) elsewhere. Catheter cuffs were ideally positioned in the subcutaneous tunnel within 2–3 cm of the exit site; however, the primary consideration was correct catheter tip positioning at the vena caval–atrial junction, which ultimately determined cuff position in the tract. Typically, the catheter cuff was pulled close to the venotomy site when the catheter was initially positioned in the tunnel; then, after placement of the catheter in the vein and removal of the peel-away sheath, the catheter was pulled back until the tip was in the appropriate position.
Catheters were removed by physicians (S.O.T., J.N., M.S.S., G.M., N.H.P., M.S.J., H.S.) or trained radiologic technologists either in a procedure room with the patient lying down or in an examination room with the patient sitting up. The procedure consisted of cleansing the area with the use of chlorhexidine gluconate solution and draping sterile towels around the area of insertion. Next, the tunnel was anesthetized with lidocaine hydrochloride, paying careful attention to the tissue near the cuff. The goal was to infiltrate lidocaine around the cuff to loosen the tissue in this region. Then the catheter was removed by using steady traction. As needed, a sterile silver probe (J Jamner Surgical Instruments, Hawthorne, Calif) was used to loosen tissue around the cuff by inserting it along the tract from the catheter exit site.
After the catheter was removed, gentle pressure was applied at the venotomy site until hemostasis was achieved. For all catheters that were removed because of infection or suspected infection, the catheter tip was sent for culturing. If the cuff was retained in the subcutaneous tunnel, this was noted, and the patient was informed of this and instructed to contact us if he or she experienced tenderness, delayed healing of the exit site, or any other problem. Women were informed that the cuff might appear on a mammogram (8,9).
Most, or 337 (79%) of 428, of the catheters had been placed via the right internal jugular vein. Sixty (14%) catheters were placed via the left internal jugular vein; seven (2%), via the right external jugular vein; six (1%), via the left external jugular vein; three (1%), via the right subclavian vein; 11 (3%), with the translumbar route into the inferior vena cava; two, with the transhepatic route into the inferior vena cava; and one each via the hepatic and an unidentified collateral vein. A summary of the catheter types used is listed in Table 1. The indications for catheter placement included hemodialysis (n = 278), malignancy (n = 130), parenteral nutrition (n = 8), antibiotic therapy (n = 4), and miscellaneous (n = 8). The indications for catheter removal were completion of therapy or no longer needed (n = 209), infection or suspected infection (n = 95), thrombosis (n = 23), malfunction (n = 51), mechanical failure (n = 19), malposition (n = 3), other (n = 7), or the catheter fell out (n = 21).
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RESULTS |
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Because of the much higher cuff retention rates for the 10- and 9.6-F catheters, these groups were individually analyzed to determine if duration of catheter dwell had an effect on cuff retention. The mean dwell time for catheters in which the cuff was retained was 148 (9.6 F) and 163 (10 F) days, compared with 107 (9.6 F) and 133 (10 F) days for catheters in which the cuff came free. This difference was not statistically significant, however. There was no significant effect of any other variable on whether or not the cuff was retained for the 10- or 9.6-F categories. The eight indications for removal were too many categories for any meaningful analysis.
Of the 41 patients with retained cuffs, six (15%) were lost to follow-up. Mean follow-up (after removal) was 250 days ± 135 (SD). Of the 41 patients with retained cuffs, in three the cuff was removed at a later date. One patient reported that the cuff migrated to the catheter exit site, where it prevented healing; the cuff was removed 2 months after the removal of the catheter. Another patient requested to have the cuff excised 11 months after the catheter had been removed, although there was no indication for removal of the cuff. In the third patient, the cuff was excised 3 months after catheter removal because of persistent erythema and tenderness over the site where the cuff was retained. The indication for catheter removal was completion of therapy in all of these patients.
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DISCUSSION |
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Effects of Cuff Retention
Originally, Bjeletich and Hickman (4) stated that cuff retention was of no concern unless infection was present. A packet insert (Hickman, Leonard, and Broviac Central Venous Catheters; Instructions for Use, Davol [subsidiary of Bard Access Systems], Cranston, RI, March 1988) also reflected this policy, stating,
Experience has shown that the catheter can be removed with steady, firm traction, leaving the Dacron cuff behind in the subcutaneous tunnel. If the Dacron cuff needs to be removed for cosmetic or other reasons, it can be removed through a small incision utilizing local anesthesia.
Since then, there have been several case reports warning of the dangers of allowing polyester cuffs to remain in the subcutaneous tissue. In 1985, Fisher (10) reported a case of spontaneous erosion of the skin overlying the retained cuff 4 months after removal of the catheter. In 1993, al-Wali et al published an article (11) containing two reports: The first detailed the removal of an infected catheter in which the cuff was retained; 18 days after the catheter was removed, the patient developed an abscess that was surgically débrided, and the cuff was removed. The second report described a patient who returned 3 months after removal of an infected catheter with a discharge from the exit site. The catheter cuff was visible at the exit site and was removed. In both cases, the patients’ infections were resolved by using antibiotic therapy.
Ruppel et al (12) described the complications in a patient who received a bone marrow transplant and who had graft versus host disease. In this patient, the retained cuff served as a source of infection that necessitated surgical débridement and removal. These reports might seem to suggest that retained cuffs be excised in cases of removal of infected catheters, as advocated by Bjeletich and Hickman (4). Our experience suggests otherwise: Five of the retained cuffs were from infected catheters, yet none of these manifested symptoms. Conversely, in none of the patients in whom the cuff subsequently required excision were their catheters removed because of infection. While these numbers are small, they suggest no relationship between catheter infection and subsequent complications of cuff retention.
Another possible complication of cuff retention includes appearance of the catheter cuff on a mammogram (8,9). If the reader of the mammogram is not familiar with the appearance of a retained polyester cuff, it could be misinterpreted as a mass. Therefore, female patients should be educated to understand that the cuff may be seen on a mammogram.
Traction Removal versus Excision
As previously mentioned, Bjeletich and Hickman (4) advocated traction removal. Traction is our principal method of removal. Only in the rare case of catheter fracture or failure of traction removal is a cutdown performed. One exception is made with regard to Tesio (Medcomp) catheters; we have found that these catheters fracture easily with traction removal, and we now remove them with cutdown. Also, there is one catheter (Schon; Angiodynamics, Queensbury, NY) that, by design, cannot be removed with traction and must be removed with cutdown (Geer D, Angiodynamics, oral communication, October, 2000).
Ruppel et al (12) reported that removal of tunneled venous catheters with traction causes pain and increased probability of catheter fracture. Similar considerations led to the description (6) of a surgical procedure for catheter removal. These authors suggested that all catheters be removed with a cutdown procedure. However, it is our experience that with the use of lidocaine, patients do not complain of discomfort. Further, it is our belief that infiltration of the area surrounding the cuff with lidocaine aids in the release of the cuff from the subcutaneous tissue in many instances. It has also been our experience that traction removal of non-Tesio catheters only rarely results in catheter fracture; in this series, catheter fracture did not occur. When catheter fracture does occur during traction removal, the fracture is nearly always at the cuff, and cutting down on the cuff allows removal of the remainder of the catheter. In this instance, compression of the remaining catheter fragment is necessary to prevent bleeding and/or air embolism.
Currently, Bard Access recommends that tunneled catheters be removed with either traction or surgery but that retained cuffs be removed with cutdown: "If the cuff remains in the subcutaneous tissue, dissect it out through a small incision utilizing local anesthesia" (Hickman, Leonard, and Broviac Central Venous Catheters, Instructions for Use, Bard Access Systems, July 1997). Medcomp recommends that the Ash Split catheter be removed with only cutdown (Instructions for Use, Medcomp, September 1999). We believe these recommendations are overly conservative; while there may be a minimally increased risk associated with retention of polyester cuffs, there is certainly risk associated with any cutdown procedure. The risk of infection, as well as the permanent scarring associated with a cutdown, should be taken into consideration when making a decision about removing a retained cuff.
In conclusion, we have shown that traction removal of tunneled catheters is safe and effective, and we believe it should be the primary method of tunneled catheter removal, with the exceptions listed previously. Polyester cuff retention occurs to a variable degree, depending principally on catheter type, and is of little clinical consequence in all but a handful of patients. When a retained cuff becomes symptomatic for whatever reason, it is easily removed. We recommend that retained polyester cuffs be left behind, because the benefits of avoiding a cutdown outweigh the small risk of subsequent infection or extrusion of the cuff. As with any other procedure, the key to success is patient education. Patients should be educated about the nature of the foreign body left behind, as well as the possible radiologic implications and rare infectious complications that could follow.
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APPENDIX |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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A logistic regression model is used to compare various levels of a factor that is categorical (indication for treatment and catheter type) with a reference level. Since there was no natural reference level for either of these variables, we designated one as such, on the basis of the distribution of categories and cuff retention rate in the various categories.
Indication for Treatment
As seen in Table 2, more than half the patients (n = 275 [64%]) were undergoing dialysis, and the cuff was retained in three (1%) of those patients. We combined total parenteral nutrition, antibiotics, and miscellaneous categories, since the cuff retention rate was similar in these, and we could obtain a reasonable sample size for statistical analysis. The proportion of cases in which the cuff was retained in the two groups other than dialysis is different from 1%, making this category a good choice for reference.
Catheter Type
From Table 3, we see that nearly half (n = 196 [46%]) the patients received the Ash Split catheter, and the cuff retention rate was 1%. The 10- and 9.6-F catheters had similar cuff retention rates, and the other three categories had retention rates similar to that of the Ash Split catheter. Hence, the Ash Split catheter was chosen as the reference category.
In both cases just mentioned, it is easily shown that in the reference categories, the cuff came out along with the catheter. Inferences about other indications and catheter types will have to be made by determining whether the odds of cuff retention are significantly higher than for the reference categories.
Analyses of both the effect of catheter type and the effect of indication for use on cuff retention, were performed. In the initial analysis, differences were found among indications for treatment and catheter type with respect to cuff retention. On that basis, subset analysis was performed separately for the two catheter types (10- and 9.6-F) for which the cuff was more likely to be retained, compared with other types. For each subset, we used logistic models with catheter days, sex, and indication for removal as covariates.
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONAPPENDIXREFERENCES |
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This article has been cited by other articles:
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  A M Barnacle and A W M Mitchell Technical report: use of ultrasound guidance in the removal of tunnelled venous access catheter cuffs Br. J. Radiol., February 1, 2005; 78(926): 147 - 149. [Abstract] [Full Text] [PDF]
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