Minimally Invasive Tumor Therapy (MITT)

Department of Radiology, Charité – Universitätsmedizin Berlin

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References

  1. Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet. 1973 Apr;136(4):602-6. PubMed PMID: 4632149
  2. Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet. 1979 Jun;148(6):871-5. PubMed PMID: 109934.
  3. 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.
  4. 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.
  5. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol. 1953 May;39(5):368-76. PubMed PMID: 13057644.

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.)

Hickman / Broviac Catheter

 

The first tunneled catheter was developed by Broviac in the early 1970s for intravenous feeding in children (1). The original Broviac catheter was modified by Hickman for patients undergoing bone marrow transplantation. The Hickman catheter has two polyester cuffs (2).

 

Figure 1 – Diagram of the Hickman/Broviac catheter. The tip of this central venous catheter is positioned in the area where the superior vena cava enters the heart (right atrium).

 

Today, most tunneled central venous catheters (CVCs) are made of silicone or polyurethane. Like other central lines, a tunneled CVC must be flexible without kinking and allow normal (laminar) blood flow. The material should be skin-friendly and minimize bacterial infection. Most tunneled catheters (Broviac and Hickman) have an outer diameter ranging from 6 to 13 French (2 – 4.5 mm). A tunneled CVC can have several lumens. Outside the body, each lumen is closed separately. The catheter is secured with sutures and/or adhesive tape to prevent accidental displacement (e.g., when sleeping).

 

When Does a Patient Need a Tunneled CVC?

 

There are a number of reasons (indications) for placing a tunneled CVC for longer use. These include:

  • Administration of chemotherapy or regular, long-term delivery of other medications (especially Hickman catheter)
  • Intravenous administration of viscous solutions, e.g., nutrient solutions in patients who cannot eat or absorb food from the gastrointestinal tract (artificial or parenteral nutrition; especially Broviac catheter)

 

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

 

In general, a tunneled CVC is placed under local anesthesia. In most cases, the catheter is inserted into a large neck vein above the collar bone (clavicle) and exits the body at the right chest wall. Between these two sites, the catheter is tunneled through the subcutaneous tissue (the tissue layer between the skin and muscle). Less commonly, a tunneled CVC is inserted into the vein below the clavicle. In some rare cases, there are good reasons to insert the catheter through a vein in the groin (adjusting the exit site accordingly). 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 tunneled 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 2 and Video 1; detailed and informative videos of ultrasound-guided vein puncture are available, for example, from The New England Journal of Medicine (3, 4)).
  • In addition, the interventional radiologist always inserts a tunneled CVC using a safe and gentle catheter placement technique (the so-called Seldinger technique (5)) 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 2 – 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.

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

A tunneled CVC can typically stay in place for 3 to 12 months. In some patients, the catheter needs to be left in place beyond this period. This may be the case if the patient continues to need treatment, tolerates the catheter well, and there is no alternative to deliver the medications.

 

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