PermacathPlacement under US guaidance DR. muhammad Bin Zulfiqar

Permcath Placement; Role of Interventional Radiologist

Dr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical

Sciences / [email protected]

Idea Behind Permcath

• Central venous catheters (CVC) or lines (CVL) refer to a wide range of central venous access devices but can broadly be divided into four categories. They may be inserted by physicians, surgeons or radiologists.

Classification

peripherally inserted central catheters (PICC)non-tunnelled CVCs

e.g. used in ICU or ED for emergent or short-term (<7-10 days) accesse.g. Vascath used for haemodialysis, apheresis, stem cell collection,

etctunnelled CVCs

e.g. Hickman catheters, Broviac line, Permcath implantable ports

e.g. Port-a-Cath, Infus-a-Portmay be located in the chest or arm (brachial)may be single or dual lumen

K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

Permacath• Permacath (or permcath)

are a type of tunneled central venous catheter. It is a split catheter - this means that the two lumens have unequal lengths with one opening a few centimeters distal to the other giving a staggered or step tip appearance. It is often used for hemodialysis.

1. Funaki B. Central venous access: a primer for the diagnostic radiologist. AJR Am J Roentgenol. 2002;179 (2): 309-18.

Advantage of tunneled and Temporary catheter

• Less infection, Long duration (1-12 months), less malpositioning, reliable and comfortable.

Port Catheter resovoirs• A Port is a catheter placed in a vein of

the neck, chest or arm under ultrasound guidance. This long catheter has it's tip in the main vein near the heart and has a reservoir implanted under the skin surface

• long term intravenous therapy like chemotherapy.

• The reservoir or port can be accessed through the skin surface with a special needle.

• Once the tiny incision heals the entire system is beneath the skin and less prone to infection. Port catheters can remain implanted for years.

Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

PICC Catheter•

A PICC line is a catheter which is placed in the arm with ultrasound guidance to Superior Vena Cava. It has no reservoir ,exits through the skin and can only be left in place for up to six months.

• The venous access catheters described above are placed in the angiography room utilizing both ultrasound and x-ray guidance under sterile conditions.

Characteristics of an Ideal Catheter

• Easy to insert and remove• Inexpensive• Free of infection• Free of fibrin sheath (“invisible to body”)• Does not cause venous thrombosis or stenosis• Delivers high flow (>400ml/min) reliably• Durable• Comfortable and acceptable to the patientScott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

Sites

• most commonly including:• internal jugular vein • subclavian vein• femoral vein (typically only short-term access)• For PICCs and implantable ports)– brachial– basilic – cephalic veins

K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

Preprocedure Mapping

• Look for SVC, Right Brachiocephalic vein, Internal jugular Vein and subclavian vein under USG guidence for any evidence of

• Stenosis and occlusion• Thrombosis• Occlusion• Variation in anatomy• Collaterals• Accessory Veins.

K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

Technique

• Informe and written consent,• Sedation• Aseptic measures• One small incision in the skin commonly in the

lower neck. Using ultrasound guidance, the vein is punctured with a needle (usually the jugular vein at the base of the neck), and a small guide wire is advanced into the superior vena cava.

Technique

• A second small skin incision may be made below the first, and a tunnel under the skin is then created.

• Using USG guidance, the catheter is placed through the tunnel into the vein, and the tip of the catheter is placed into the SVC.

• Finally, stitches applied.

Normal Position of Permcath

• Right internal jugular vein permacath with distal tip at the cavo-atrial junction. No pneumothorax.

Malpositioned Permcath

• The proximal permacath tip is malpositioned in the right internal jugular vein.

Complications• pneumothorax• haemothorax• infection• mediastinal haematoma• infusothorax• arterial placement• perforation of vein needing a stent• pinch off syndrome• retained guidewire• guidewire shearing and fragment embolisation

K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658

Take Home Message• Radiological placement is consistently more reliable

than surgical placement. There are fewer placement complications and fewer catheter infections overall.

• It is convenient for the patient, quick, time saving, and cost effective

• Interventional radiologists – placement and – management – research and development of hemodialysis catheters

K.D. and Surgical Placement of Central Venous Catheters. Cardiovasc Intervent Radiol (1997) 20:17-22Scott O. Trerotola, MD. Hemodialysis Catheter Placement and Management1. Radiology 2000; 215:651–658Lund G.B. et.al. Outcome of Tunneled Hemodialysis Catheters Placed by Radiologists’ Radiology 1996; 198:467-472