Robert P. Lieberman

Hickman catheter-induced thoracic vein thrombosis. Frequency and long-term sequelae in patients receiving high-dose chemotherapy and marrow transplantation

One hundred sixty‐eight bone marrow transplant recipients and 49 patients who received high‐dose chemotherapy were evaluated for symptomatic thrombosis after Hickman catheter placement. The timing of thrombotic complications was different between these two groups, with the transplant group having a significantly lower thrombus‐free survival by 28 days after catheter placement. By 100 days after placement the thrombus‐free survival rates of the two groups were similar. The platelet count at time of catheter placement was significantly lower in the nontransplant group, and the thrombus‐free survival was longer in patients whose catheter was placed when their platelet count was less than 150,000, suggesting that thrombocytopenia delays thrombotic complications. Placement of two Hickman catheters resulted in a 12.9% thrombosis rate (21 of 162 patients) and was significantly more likely to be associated with thrombosis than placement of one catheter. Long‐term follow‐up evaluation of patients treated without successful fibrinolytic therapy showed no residual symptoms of venous obstruction. In those patients presenting with concomitant catheter obstruction resulting from thrombosis, low‐dose fibrinolytic therapy was successful in restoring catheter function 70% of the time. Placement of two Hickman catheters is associated with an inordinate incidence of thrombosis. Thrombocytopenia at the time of catheter placement may delay this complication. Thrombotic catheter obstruction can be treated successfully with low‐dose fibrinolytic therapy. Even without fibrinolytic therapy, catheter‐induced subclavian vein thrombosis rarely causes long‐term disability.

Utility of duplex ultrasound in the diagnosis of asymptomatic catheter-induced subclavian vein thrombosis.

Asymptomatic thrombosis of the subclavian vein is common after placement of indwelling catheters. The sequelae of these thrombi are not known. Investigation is hampered by the requirement for venography for diagnosis; consequently, a noninvasive method of diagnosis would be welcome in this context. We have studied prospectively 32 subclavian catheters to determine the usefulness of duplex ultrasound in diagnosing asymptomatic thrombosis. Sixteen arm venograms were normal and all gave normal duplex scans. No false‐positive scans were obtained. Eleven venograms demonstrated nonocclusive mural thrombi. Only three of these were seen with duplex ultrasound. Five totally occlusive thrombi were seen on venography, of which only two were detected with duplex sonography. The three thrombi not found with duplex ultrasound were short proximal venous occlusions. The insensitivity of this technique to asymptomatic subclavian thrombi limits its usefulness as a screening tool.

Obstructed central venous catheters: Restoring function with a 12‐hour infusion of low‐dose urokinase

Thrombotic obstruction frequently prohibits infusion through or withdrawal of blood from central venous catheters and can occur in conjunction with symptomatic thrombosis of the subclavian vein. Thirty catheters were radiographically proved to be obstructed by thrombus and had not responded to at least one instillation of 5000 units of urokinase. All catheters were treated with a 12‐hour infusion of urokinase at the rate of 40,000 units/hour. the obstructing thrombus was either eliminated or reduced in size in all instances and full function was restored in all but one catheter. No bleeding complications were seen. Six patients with obstructed catheters also had symptoms of subclavian vein thrombosis. All patients with symptoms of subclavian vein obstruction became asymptomatic on anticoagulant therapy even though no attempt at dissolving the thrombus obstructing the subclavian vein was made. A 12‐hour infusion of low doses of urokinase can safely salvage function of obstructed catheters that otherwise may require replacement. Patients with concomitant subclavian vein thrombosis become asymptomatic on anticoagulant therapy without need to dissolve the obstructing thrombus.

Thrombosed Central Venous Catheters: Restoring Function With 6-Hour Urokinase Infusion After Failure of Bolus Urokinase

Nineteen central venous catheters with radiographically proven thrombotic occlusion failed to have function restored with a mean of 1.6 5000-unit boluses of urokinase per catheter. Catheters then underwent a 6-hour infusion of urokinase at 40,000 units per hour followed by repeat contrast injection and evaluation of function. Reduction in thrombus size occurred in all but one patient. Catheter function was restored in 15 patients. In two patients, thrombus dissolved but catheters remained occluded because of tip malposition. In the remaining two patients, catheter function was restored with an additional 6-hour infusion. No adverse reactions to the infusion were seen. After infusion catheters continued to function normally for a mean of 36.2 days. Five catheters rethrombosed, two of which responded to urokinase bolus instillation. Thrombosed catheters failing standard intracatheter bolus urokinase are generally salvaged with a 6-hour infusion of low-dose urokinase.

Duplex ultrasonography as a noninvasive technique forassessing portal hemodynamics

Duplex ultrasonography was evaluated as a noninvasive, quantitative technique of assessing portal hemodynamic characteristics. Portal blood flow measured by duplex ultrasonography was significantly decreased in patients with portal hypertension (450 +/- 86 ml/min) compared with control subjects (874 +/- 44 ml/min; p less than 0.001). Quantitative assessment of portal blood flow by duplex ultrasound correlated with qualitative portal perfusion grading by angiography, and direction of flow was always accurately determined by duplex ultrasonography. Although the angiographic portal perfusion grade did not change significantly in the early postoperative period after distal splenorenal shunting, a decrease in mean portal blood flow of more than 50 percent was documented by duplex ultrasonography. Duplex ultrasonography appears to be at least as accurate as angiography and is an acceptable alternative to this more invasive technique for the longitudinal assessment of portal blood flow.

Defining the Risks of Subclavian-Vein Catheterization

Infusion of blood products, medications, and fluids and removal of blood for testing are essential in treating many critically ill patients. Central venous catheterization through the subclavian ve...

Translumbar inferior vena cava catheters: Experience with 58 catheters in peripheral stem cell collection and transplantation

Most patients who need peripheral stem cell transplantation do not have peripheral venous access to allow apheresis for stem cell collection. Subclavian apheresis catheters have an unacceptably high incidence of thrombosis-related access failure. We have used a technique for translumbar insertion of permanent, subcutaneously tunnelled silicone rubber apheresis catheters into the inferior vena to place 58 catheters in 54 patients for stem cell collection. 37 catheters have been left in place for venous access during the transplantation procedures. These catheters had a very low rate of apheresis-related complications (3.6%). Access failure occurred due to thrombosis in 14 catheters (24%) and mechanical complications in 8 (14%) but these responded to standard therapy in all except 3 cases. Catheters functioned well as venous access devices during transplantation with only rare complications during this time. Withdrawal venograms at time of removal of 20 catheters showed a fibrin sheath in 17 cases but caval occlusion in none. There was no clinical or CT scan evidence of bleeding after placement or removal of the catheters. Percutaneously placed translumbar inferior vena cava apheresis catheters are an effective route for peripheral stem cell collection and can be left in place for venous access during transplantation.

Silicone rubber catheter venography using standard angiographic techniques.

Single- and double-lumen silicone rubber central venous catheters were subjected toin vitro destructive testing. Using this data we devised a clinical technique for the detection of central venous thrombosis incorporating mechanical injection of the catheters, serial filming, and magnification radiography. In 20 patients studied, thrombosis was detected in 12 and extravasation in 3. Two partially occluded catheters burst during forceful injection. Our technique demonstrated the presence and extent of thrombosis at the cathetel tip more clearly than did other venographic methods and has been especially useful in assessing the results of thrombolytic therapy.

Urokinase infusion restores function of thrombotically-occluded inferior vena cava apheresis catheters refractory to bolus urokinase therapy

Abstract Translumbar inferior vena cava catheters have been shown to be safe and effective in providing venous access for apheresis collection of peripheral blood stem cells for transplantation. Thrombotic occlusion of these catheters can limit their effectiveness for apheresis. While some of these occlusions respond to installation of the 5000 unit “Open-Cath ® ” dose of urokinase, there are no guidelines for therapy of occluded catheters not responding to this treatment. We have performed low-dose urokinase infusion on 11 IVC apheresis catheters radiographically documented to be occluded by thrombus. These catheters had failed a mean of 1.5–5000 unit boluses of urokinase. Seven catheters underwent urokinase infusion at 40,000 units/ h for 12 h. All had complete restoration of catheter function and 6 had total dissolution of thrombus on post-therapy X-ray. Because of the initial success of the 12 h infusion, we treated 4 catheters with the same dose of urokinase for 6 h. All 4 had complete restoration of catheter function and 2 had total thrombus dissolution on X-ray. No bleeding complications were seen. For occluded IVC apheresis catheters, initial therapy should be the installation of at least one 5000 unit bolus of urokinase. For catheters not responding to this therapy, radiographic evaluation should be conducted. If thrombotic occlusion is found, a 40,000 unit/h infusion of urokinase for 6–12 h can safely salvage catheter function and allow continued apheresis.

An unopened titanium Greenfield IVC filter: intravascular ultrasound to reveal associated thrombus and aid in filter opening.

A titanium Greenfield filter did not open following placement in the infrarenal inferior vena cava (IVC). Abdominal radiograph and cavogram showed no definite reason for filter malfunction. Intravascular ultrasound (IVUS) demonstrated the unopened filter in the IVC with thrombus binding the legs. The thrombus was disrupted with a catheter, and the filter completely expanded with a balloon. IVUS documented full-filter opening in addition to residual thrombus in the filter following manipulation.