Minimally Invasive Tumor Therapy (MITT)

Department of Radiology, Charité – Universitätsmedizin Berlin

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References

  1. Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Central venous catheterization. N Engl J Med. 2007 May 24;356(21):e21. PubMed PMID: 17522396.
  2. Ortega R, Song M, Hansen CJ, Barash P. Videos in clinical medicine. Ultrasound-guided internal jugular vein cannulation. N Engl J Med. 2010 Apr 22;362(16):e57. doi: 10.1056/NEJMvcm0810156. PubMed PMID: 20410510.
  3. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol. 1953 May;39(5):368-76. PubMed PMID: 13057644.
  4. O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002 Aug 9;51(RR-10):1-29. PubMed PMID: 12233868.

Video

Video 1 – The video shows the procedure of ultrasound-guided puncture of the vein above the right collar bone (in the video, the patient’s head is on the left). The interventional radiologist observes the needle placement on the ultrasound monitor. In the ultrasound images displayed on the monitor, the vein appears dark. A bright spot within the dark vein indicates that the needle tip has been correctly inserted. Some blood is drawn into the syringe to confirm the correct position before the procedure continues. (The video was kindly provided by Dr. de Bucourt.)

 

Central Venous Catheter (CVC)

 

A central venous catheter (CVC) or central line is a thin plastic tube that is inserted into a large vein, typically in the neck, and advanced toward the heart until the tip comes to lie close to the entrance of the heart (right atrium). A CVC makes intravenous administration of medications and other fluids and repeated blood sampling much easier for both the patient and the physician. A CVC is particularly useful for the safe delivery of chemotherapy. When infused into a small, peripheral vein, the highly concentrated chemotherapeutic agents can damage the vein and cause scarring, especially with repeated infusions. In contrast, when infused into a large vein, the drug is immediately diluted by the blood and rapidly distributed to the entire body.

 

What is a CVC Made of and What is its Design and Why?

 

Today, catheter tubes are most commonly made of polyurethane and less commonly of silicone. A catheter must be flexible without kinking and allow normal (laminar) blood flow. The material should be skin-friendly and minimize bacterial infection. The outer diameter of a CVC typically varies between 2 and 4 mm and largely depends on how many separate internal tubes (lumens) the catheter contains. The number of lumens in turn depends on the intended use (1 – 5 lumens or more). When a multi-lumen central line is used, several medications that should not mix can be given together. Undesired mixing of incompatible medications can lead to precipitation (deposition) of pharmaceutical components, which can cause complications and make the medications less effective. Outside the body, each lumen of a multi-lumen central line can be closed separately. For safety reasons, each lumen is typically closed with at least 2 different techniques. The CVC is secured with sutures and/or adhesive tape to prevent accidental displacement (e.g., when sleeping).

 

When Does a Patient Need a CVC?

 

There are a number of reasons (indications) for placing a CVC. The main indications are:

  • Delivery of chemotherapy and other medications, especially medications with a strong irritating effect on the vessel wall
  • Delivery of nutrition directly into the bloodstream in patients who cannot eat and digest normally (parenteral nutrition)
  • Administration of medicines with potent effects on the heart and circulation, which require accurate dosage and have short half-lives (e.g., catecholamines)
  • Cases where the placement of a catheter in a peripheral, smaller vein is considered less beneficial, difficult, or impossible. This applies in particular to patients
  • in need of long-term infusion treatment
  • who can thus be spared repeated puncture of a peripheral vein
  • with volume depletion
  • who are in shock
  • with reduced body temperature (hypothermia)
  • who have large burns
  • Measurement of central venous pressure
  • Emergencies, for example when a patient needs massive transfusions.

 

What is the General Procedure of CVC Placement and What is Special When it is Done in our Interventional Radiology Unit?

 

In most patients, a CVC is inserted under local anesthesia through a vein in the neck or top of the chest. In some cases, there are good reasons to insert the CVC through a vein in the groin. The procedure can be performed under near-sterile conditions using anatomical landmarks (“blind technique”) or ultrasound guidance.

 

Our interventional radiologists follow a strict set of standards when placing a CVC:

  • A CVC is always placed under strict sterile conditions with maximum barrier protection. This includes meticulous skin disinfection and sterile draping of the area with the personnel wearing sterile attire (sterile gown and gloves, mask, and hair cover).
  • A CVC can be placed with local anesthesia, administration of additional medications, or with general anesthesia performed by an anesthesiologist.
  • To avoid complications, the interventional radiologist always uses ultrasound to guide the puncture procedure (see Figure 1 and Video 1; detailed and informative videos of ultrasound-guided vein puncture are available, for example, from The New England Journal of Medicine (1, 2)).
  • In addition, the interventional radiologist always inserts a CVC using a safe and gentle catheter placement technique (the so-called Seldinger technique (3)) under X-ray guidance.
  • At the end of the procedure, with the patient still on the table, an X-ray is obtained to check for possible complications like a pneumothorax (abnormal collection of air in the pleural space that separates the lung from the chest wall)

 

 

Figure 1 – Depiction of the venous puncture procedure above the right collar bone (in the photographs, the patient’s head is on the left side). In the ultrasound image displayed on the monitor, the vein (indicated by the long thin arrow in the top figure) appears dark with a bright spot in the center. The bright spot is the reflection of the needle tip. Its position indicates that the vein has been accessed properly. Some blood is drawn to confirm the correct position before the procedure continues.

 

 

 

 

 

 

 

 

 

 

 

 

 

What are the Risks of Implantation?

 

The combined use of ultrasound to guide venous puncture and X-ray images to observe advancement and positioning of the catheter allows interventional radiologists to reduce the risks associated with CVC implantation to a very low level. This is the safest method for CVC placement. Possible risks of central venous catheterization include bleeding and hematoma (bruise), accidental puncture of the cervical or subclavian artery, infection or abscess formation, thrombosis of the vein or catheter, escape of air into the pleural cleft (pneumothorax), and injury of neighboring organs.

 

How Long Can a CVC Stay in Place and What are Possible Alternatives?

 

A CVC is a so-called non-tunneled central venous catheter. This means that there is only a short distance between the site where the catheter emerges from the body and its entry point into the vein. The short distance makes it easier for germs from outside the body to reach the bloodstream and cause a systemic infection. This is why non-tunneled central lines are only recommended for short-term use of up to about 2 weeks (4).

 

There are several alternative central venous devices. They are also described on our website:

 

For further information please feel free to contact us. We will be happy to answer any questions you may have.

 

Contact:

Minimally Invasive Tumor Therapy (MITT)

Department of Radiology

 

CVK – Charité, Campus Virchow-Klinikum

Augustenburger Platz 1

13353 Berlin, Germany

Phone: +49 (0)30 – 450 557 309

Fax: +49 (0)30 – 450 557 947

 

CBF – Charité, Campus Benjamin Franklin

Hindenburgdamm 30

12203 Berlin, Germany

Phone: +49 (0)30 – 8445 2852

Fax: +49 (0)30 – 8445 2891

 

CCM – Charité, Campus Mitte

Charitéplatz 1

10117 Berlin, Germany

Phone: +49 (0)30 – 450 527 098

Fax: +49 (0)30 – 450 7527 908

 

minimal-invasive-ambulanz@charite.de oder mia@charite.de