Percutaneous Catheter Drainage of Thoracic Fluid: The Usefulness and Safety of Bedside Trocar Placement under Ultrasound Guidance

PURPOSE: The author wanted to evaluate the usefulness and safety of the trocar technique for US-guided bedside catheter placement into thoracic fluid collections, and this technique has generally been reserved for the larger or superficial fluid collections. Materials and Methods: 42 drainage procedures were performed in 38 patients at the bedside. The patients were positioned supine or semi-upright. A drainage catheter system with a stylet and cannula assembly was used and all of the catheters were inserted using the trocar technique. The procedures consisted of drainage of empyema (n=14), malignant effusion (n=13), lung abscess (n=3), massive transudate (n=8), hemothorax (n=2) and chest wall hematoma (n=2). The clinical results were classified as successful (complete & partially successful), failure or undetermined. The medical records and images were retrospectively reviewed to evaluate the success rate, the complications and the procedure time. Results: Technical success was achieved in all of the 42 procedures. With using the trocar technique, all the catheters were placed into even the small collections without significant complications. Drainage was successful in 36 (85.7%) of the 42 procedures. The average volume of thoracic fluid that was aspirated manually at the time of catheter placement was 420 mL (range: 35 to 1470 mL). The procedure time was less than 10 minutes from US-localization to complete catheter placement in all of the procedures. Conclusion: The trocar technique under US guidance can be an efficient and safe alternative to the Seldinger or guide-wire exchange technique for bedside catheter placement in the critically ill or hemodynamically unstable patients.

Fixation Methods for Implantable Port Chamber: Comparative Study Using Glue, Self-stabilizing Leg and Suture Fixations in Rabbits

OBJECTIVE: To evaluate the fixation strength and tissue reaction of the glue fixation and self-stabilizing leg fixation methods and to compare the results with those of the conventional tagging suture fixation method. MATER AND METHODS: Twelve healthy rabbits were selected and three different methods of implanting the port chamber were employed on the back of each rabbit. A total of thirty six port chambers were implanted with these three different methods, viz. the glue fixation method using tissue adhesive, the self-stabilizing leg method using a self-expandable stabilizing leg, and the suture fixation method. The fixation strength and the gross and histopathologic changes of each fixation method were evaluated at three days, one week, two weeks and four weeks after port implantation. RESULTS: The glue fixation method showed a good fixation strength, which was similar to that of the tagging suture method (p=0.3486). Five of the six ports (83%) implanted with the glue fixation method which were examined after two weeks showed cracks on the external surface, but this had no adverse effects on their function. A large amount of granulation tissue reaction was found at the bottom of the chamber (p=0.0025). The fixation with the self-stabilizing leg showed relatively lower fixation strength (p=0.0043), but no turning-over of the chamber occurred. The fixation strength improved with time after the first week, and minimal granulation tissue reaction was observed with this method. CONCLUSION: The glue fixation method exhibited equal fixation strength compared to the suture fixation, but showed cracking and a large amount of granulation tissue, whereas the fixation with a self-stabilizing leg showed weaker fixation strength.

Radiologic Placement of Implantable Chest Ports in Pediatric Patients Under Sedation

PURPOSE: To evaluate the safety and efficacy of the radiologic placement of implantable chest ports under intravenous sedation in pediatric patients with malignancy. MATERIALS AND METHODS: Between October 2001 and June 2002, 20 chest ports were placed in 19 pediatric patients [13 boys and six girls aged 1-11 (mean, 4.7) years] for the purpose of long-term chemotherapy. In three patients, tunneled central venous catheters had been removed because of catheter extraction, infection, and tearing. Under intravenous sedation, the right internal jugular vein was used for access in 19 cases, and the left internal jugular vein in one. Venipucture was performed using a micropuncture needle with real-time ultrasound guidance. A port chamber was created at the infraclavicular fossa, and to prevent catheter kinking, a smooth-angled tunnel was created between the venipuncture site and the subcutaneous pocket. The catheter tip was positioned under fluoroscopy at the junction of the superior vena cava and right atrium. We observed techincal success, complications arouse during and after the procedure, and duration of catheter use. RESULTS: Implantation of the port system was successful in all cases, though slight hematoma, treated with manual compression, occurred at a chamber pocket in one case. In addition, the port system was removed from one patient because of wound infection leading to dehiscence and catheter malpositiong. A new port system was implanted through the left internal jugular vein. The median period during which catheter use was followed up was 118 (range, 18-274) days. CONCLUSION: For long-term chemotherapy in pediatric patients with malignancy, radiologic placement of an implantable chest port under intravenous sedation shows a high technical success rate, with few complications. This method may thus be used instead of surgical port placement.

Implantable Central Venous Chemoport: Comparision of Results According to Approach Routes and Methods

PURPOSE: To evaluate the results and complications of placement of implantable port according to approach routes and methods. MATERIALS AND METHODS: Between April 2001 and October 2002, a total of 103 implantable chemoport was placed in 95 patients for chemotherapy using preconnected type (n=39) and attachable type (n=64). Puncture sites were left subclavian vein (n=35), right subclavian vein (n=5), left internal jugular vein (n=9), right internal jugular vein (n=54). We evaluated duration of catheterization days, complications according to approach routes and methods. RESULTS: Implantable chemoport was placed successfully in all cases. Duration of catheterization ranged from 8 to 554 days(mean 159, total 17,872 catheter days). Procedure related complications occurred transient pulmonary air embolism (n=1), small hematoma (n=1) and malposition in using preconnected type (n=2). Late complications occurred catheter migration (n=5), catheter malfunction (n=3), occlusion (n=1) and infection (n=11). Among them 15 chemoport was removed (14.5%). Catheter migration was occured via subclavian vein in all cases (13%, p=.008). Infection developed in 10.7% of patients(0.61 per 1000 catheter days). There were no catheter-related central vein thrombosis. CONCLUSION: Implantation of chemoport is a safe procedure. Choice of right internal jugular vein than subclavian vein for puncture site has less complications. And selection of attachable type of chemoport is convenient than preconnected type. Adequate care of chemoport is essential for long patency.

Evaluation of Anterior Chest Wall Implanted Port: Technical Aspects, Results, and Complications

PURPOSE: To evaluate the technical aspects, results and complications of patients with implanted anterior chest wall port. MATERIALS AND METHODS: Between April 1997 and June 1999, a total of 63 implanted ports were placed at the anterior chest wall of 63 consecutive patients by interventional radiologists. The indications were chemotherapy in 61 patients and total parenteral nutrition in two. The peripheral portion of the subclavian vein was punctured under fluoroscopic guidance via ipsilateral peripheral vein during venography. A central venous catheter was placed in the superior vena cava, and using the subcutaneous tunneling method, a connected infusion port was implanted at the anterior chest wall. Results and complications were reviewed, and by means of Kaplan-Meier survival analysis, the expected patency of the port was determined. RESULTS: The technical success rate for implanted port at the anterior chest wall was 100%(63/63 patients). In two patients, hematoma and oozing were treated by compression. The duration of port implantation ranged from 12 to 855(mean, 187) days, and the port patency rate was 305.7 +/-47.6 days. In seven patients [completed chemotherapy (n=3), central venous thrombosis (n=3) catheter-related infection (n=1)], the port was re-moved. Catheter obstruction occurred in two patients, and in one, the use of urokinase led to successful re-canalization. Sixteen patients died of an underlying malignancy, but no catheter-related death was noted. CONCLUSION: Implantation of an anterior chest wall port is a safe and useful procedure, with long patency, for patients requiring chemotherapy and long-term venous access.

Intra-arterial Port Implantation for Intra-arterial Chemotherapy: Comparison between PIPS(Pe rcutaneouslyImplantable Port System) and Port System

PURPOSE: To compare the techniques and complications of intra-arterial port implantation for intra-arterialchemotherapy between PIPS and the port system. MATERIALS AND METHODS: For intra-arterial port implantation, 27cases in 27 patients were retrospectively evalu-ated using PIPS(PIPS-200, William Cook Europe, Denmark) while for21 cases in 19 patients a pediatric ve-nous port system(Port-A-Cath, 5.8F, SIMS Deltec, U.S.A.) was used. Allintra-arterial port implantation was performed percuteneously in an angiographic ward. Hepatocellular carcinomawas diagnosed in 18 patients and hepatic metastasis in 16. Peripheral cholangiocarcinoma, and pancreatic gastric,ovarian, renal cell and colon carcinoma were included. We compared the techniques and complications between PIPSand the port system. The follow up period ranged from 23 to 494(mean, 163) days in PIPS and from 12 to 431(mean,150) days in the port system. RESULTS: In all cases, intra-arterial port implantations were technicallysuccessful. Port catheter tips were locat-ed in the common hepatic artery(n=8), proper hepatic artery(n=7), righthepatic artery(n=5), gastroduodenal artery(n=2), left hepatic artery(n=1), pancreaticoduodenal artery(n=1),inferior mesenteric artery(n=1), lum-bar artery(n=1), and renal artery(n=1) in PIPS, and in the proper hepaticartery(n=6), gastroduodenal artery(n=6), common hepatic artery(n=3), right hepatic artery(n=4), inferiormesenteric artery(n=1), and in-ternal iliac artery(n=1) in the port system. Port chambers were buried ininfrainguinal subcutaneous tissue. Using PIPS, complications developed in seven cases(25.9%) and of these, four(57.1%) were catheter or cham-ber related. In the port system, catheter or chamber related complications developedin four cases(19.0%). CONCLUSION: Because PIPS and the port system have relative merits and demetrits, successfulintra-arterial port implantation is possible if equipment is properly selected.

GDC Embolization of Wide-necked Cerebral Aneurysms Using Balloon-Assisted Technique

PURPOSE: The main factor limiting endovascular treatment of intracranial aneurysms is the shape of the a-neurysmal sac, especially the width of the neck. We describe an early experience and technical aspects of treating wide-necked cerebral aneurysm using a Guglielmi detachable coil (GDC) and simultaneous application of a temporary balloon. MATERIALS AND METHODS: Four cases of unruptured wide-necked cerebral aneurysm were treated with GDC, with simultaneous application of a temporary balloon. Patients were aged between 29 and 49 years. On admission, clinical presentation was subarachnoid hemorrhage (SAH) in all cases. Hunt and Hess grade was II in two cases, III in one case, and traumatic SAH in one case. In all patients angiography revealed an asymptomatic a-neurysm after rupture of another aneurysm or traumatic SAH. The aneurysms were occluded with GDC-10, and a Cirrus balloon occlusion system was used simultaneously. All procedures were performed under endo-tracheal general anesthesia and systemic heparinization. RESULTS: All cases were treated successfully, without parent artery compromise. The occlusion rate at the end of the procedure was total in three cases and subtotal in one. In one case a heparin-related hematoma occurred during post-procedural treatment and the patient eventually expired. One patient underwent follow-up angiography after 6 months, and the coil was not changed. CONCLUSION: An aneurysm may not be completely occluded, but with regard to coil compaction and parent artery preservation, the technique is an attractive alternative.

Intra-arterial Port Implantation for Intraarterial Chemoinfusion

PURPOSE: To evaluate, using various port systems, the technique and complications of intra-arterial portimplantation in visceral (mainly hepatic) arteries for intra-arterial chemoinfusion. MATERIALS AND METHODS: Weretrospectively evaluated 30 cases of intra-arterial port implantation in 29 patients. Angiography was performedin all cases, and insertion of an implantable polyurethane port catheter was followed by angiographic exchangewhich, utilizing a .035" hydrophilic guide wire, targeted the artery. If a change in the direction of flow wasrequired, arterial flow control was performed, using an enbolie coil. In order to insert the subcutaneous portchamber, an incision approximately 4cm long was made at the puncture site and subcutaneous tissue was dissected.The port chamber was inserted into the subcutaneous pocket and fixed with a black-silk tagging suture. When thefemoral artery was punctured, the port chamber was inserted into the supra-or infrainguinal area; when the leftsubclavian artery was used, the port chamber was inserted into the lateral one third of the left clavicle. Theport systems used in the procedure were as follows : 5.8F Port-A-Cath (SIMS, Deltec, U.S.A.)(n=20) ; 5.2F A-Port(Therex, U.S.A.)(N=5); 5F PU-Anthron(Deny, Japan)(n=4) ; 5.2F R-Port(Therex, U.S.A.)(n=1). The subcutaneouschambers were inserted into the infrainguinal (n=22), suprainguinal (n=6) or subclavian area(n=2). RESULTS: Theprocedure was technically successful in all 30 cases. Port catheter tips were located in the hepatic arteryproper(n=11), the right hepatic(n=9), gastroduodenal (n=6), common hepatic (n=2), inferior mesenteric (n=1) andinternal iliac artery(n=1). In 12 cases, flow was controlled using embolic coils. Follow-up study was performed in23 cases, with a mean follow up period of 55.8 (11-161) days. Complications were noted in four cases ; two wereprocedure related and two were catheter related. CONCLUSION: Intra-arterial port implantation is a safe procedureand can be performed easily by skilled radiologists; long-term observation is, however, still needed.

Radiologic Placement of Tunneled Central Venous Catheter

PURPOSE: To evaluate the efficacy and safety of fluoroscopy-guided, radiologic placement of a tunneled central venous catheter into the superior vena cava (SVC). MATERIALS AND METHODS: Thirty five patients underwent tunneled central venous catheter placement to facilitate long-term chemotherapy. They included 33 leukemicpatients, one colon cancer patient, and one multiple myeloma patient. After confirming central venous patency witha injection of contrast media via the peripheral cephalic or basilic vein in the wrist joint, the subclavian veinwas punctured under fluoroscopic guidance. A 7F double lumen TPN catheter was placed into the SVC through asubcutaneous tunnel in the anterior chest wall. RESULTS: Catheter placements were successful in all patients. The mean procedure time was 17.2 minutes, mean fluoroscopy time was 1.3 minutes, mean number of punctures was 1.4, and mean volume of injected contrast media was 43.5 cc. Only two of all leukemic patients developed mild hematomas atthe puncture site, but these soon resolved themselves. None of the patients developed pneumothorax or hemothorax.but late complications included local infection in two patients (6%) and thrombotic occlusion of the catheter inone (3%). The occluded catheter was successfully recanalized with Urokinase infusion. CONCLUSION: Fluoroscopy-guided, radiologic placement of a tunneled central venous catheter is an easy and safe method, anduseful for patients requiring long-term venous access.