Power Injection via a Venous Port: A New Challenge for Radiologists

Letter to the Editor:

Dear Editor,

With respect to the paper entitled ”Risk of extravasation after power injection of contrast media via the proximal port of multilumen central venous catheters: case report and review of the literature.” recently published in the RöFo journal, by Schummer et al. [1], we congratulate the authors and would like to make some comments.

First and foremost, it seems widely accepted that the regular position of an indwelling venous catheter tip is two vertebral bodies below the carena projection on a chest X-ray [2]. In Schummer’s report, Fig. 1 clearly shows that the catheter tip was trimmed too short and too high and was located in the right inominate vein [1].

Puel et al. and Luciani et al. have demonstrated that a catheter tip that is located too high results in a 5 % and 28.8 % risk of superior vena cava thrombosis on the right and left sides, respectively, due to the catheter rubbing against the SVC wall periodically with cardiac rhythm and respiratory cycle [2] [3].

The second aspect that we would like to comment on is that the patient’s arm abduction and elevation result in catheter retraction [4] and bending along with the abduction and elevation of the patient’s arm. This explains the mechanism of contrast medium extravasation during CT scanning in Fig. 2 [1]. Since the catheter tip was too high and was trimmed too short, it abutted the medial wall of the right inominate vein. As a result of this positioning perpendicular to the vein wall, the power injection of contrast medium into the catheter probably induced a whiplash shift of the catheter tip outside the vein into the mediastinal fat. Furthermore, obesity and the supine position with the arms elevated and abducted (CT position) probably resulted in increased venous bending and thus sudden venous catheter retraction. On the other hand, enlarged mediastinal fat (obese patient) might have prevented the creation of a large hemodiastinum in swabbing the small acute venous breach.

The third aspect concerns future developments in daily radiology practice. A recent communication reported up to 1 % hemomediastinum cases, 2 % related sepsis and 3 % venous thrombosis cases when this innovative technique was routinely performed in the daily radiology clinical routine [5].

To summarize, distances between CVC port openings and the catheter tip must be acknowledged for safe intravenous administration of fluids. Moreover, knowledge of the correct catheter tip position at the atrial caval junction is also mandatory before initiating contrast medium injection. With respect to the future, the expected worldwide distribution of ”power injectable ports” will make chest scout view testing on a patient in CT position mandatory. Secondly, the radiologist will have to check the catheter tip position before initiating contrast medium power injection. Thirdly, the radiographer will have to perform port needle puncture under strict aseptic conditions (using 3 applications of povidone-iodine) and securely fasten the needle (to the port chamber and skin). Though a little time-consuming, this innovative technique is promising. It should be noted, however, that it may be the source of complications if not adequately controlled by the radiologist. In our opinion, the Schummer et al. case report is very important because it raises new problems for the radiology team and the future daily radiology routine. We thank the Editor for giving us the opportunity to state our opinion, including detailed advice on the procedure, to this journal.

Pierre-Yves Marcy, Head & Neck and Interventional Radiology Department; Andrea Figl, Department of Oncology Surgery; Juliet Thariat, Department of Radiation Therapy, Antoine Lacassagne Cancer Research Center; SophiaAntipolis University, Nice, France

References

• 1 Schummer C, Sakr Y, Steenbeck J et al. Risk of extravasation after power injection of contrast media via the proximal port of multilumen central venous catheters: case report and review of the literature.  Fortschr Röntgenstr. 2010;   182  14-19
• 2 Puel V, Caudry M, Le Métayer P et al. Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports.  Cancer. 1993;  172 2248-2252
• 3 Luciani A, Clement O, Halimi P et al. Catheter-related upper extremity deep venous thrombosis in cancer patients: a prospective study based on Doppler US.  Radiology. 2001;  220 655-660
• 4 Wojciechowski J, Curelaru I, Gustavsson B et al. ”Half-way” venous catheters. III. Tip displacements with movements of the upper extremity.  Acta Anaesthesiol Scand Suppl. 1985;  81 36-39
• 5 Rotenberg L. New trends: central venous catheter and contrast medium injection. New Imaging in oncology-Proceeding in 21st ICACT-2010 / 02 / 01 – 05. Palais des Congrès. Paris;
• 6 Schummer W, Schummer C, Schelenz C et al. Optimierte Positionierung zentraler Venenkatheter durch eine modifizierte Anwendung der intravasalen Elektrokardiographie. Validierung mithilfe der transösophagealen Echokardiographie.  Anaesthesist. 2005;  54 983-90
• 7 Chu K S, Hsu J H, Wang S S et al. Accurate central venous port-A catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography.  Anesth Analg. 2004;  98 910-914
• 8 Maki D G, Ringer M, Alvarado C J. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters.  Lancet. 1991;  338 339-343