Tunneled catheters and totally implanted VADs are associated with a lower rate of infection since they are specifically protected from extraluminal contamination. On the other hand, tunneling and SC implantation require a minor surgical procedure, which is contraindicated in patients with low platelet counts or coagulation abnormalities.; . Bishop L, Dougherty L, Bodenham A, et al. Guidelines on the insertion and management of central venous access devices in adults. Int J Lab Hematol 2007;29:261–278.
Interventional radiology lecture 2013
Interventional Radiology for the InternistAnne M Covey MD, FSIRAssociate Professor of RadiologyInterventional Radiology ServiceMemorial Sloan-Kettering Cancer CenterThe following material is intended for MSKCC internal medicine housestaff teaching purposesonly. The slides are courtesy of Dr. Anne Covey and were updated for the LibGuide in 2012-2013.
Commonly Used Devices Non-tunneled central catheters– Midline/PICC– Triple lumen– Hohn Tunneled Catheters– Groshong/Hickman/Broviac– Dialysis/Pheresis Implantable ports
Short term– IV (3-5 days)– Triple lumen catheters (weeks) Intermediate term– Midline/PICC (1-3+ months)– Hohn (1-3 months) Long term– Tunneled catheters• Groshong, Hickman, Broviac (months – years)• Port (months – years)Commonly Used Devices
Catheter options Type of catheter Catheter material Access site: chest vs. arm Subclavian vs. IJ venipuncture Single vs. Double vs. Triple lumen Groshong vs. Open-ended catheter Catheter coating Power injectable
Maintenance Each time port is accessed site must be sterilizedwith Betadine or chlorhexadine Huber needle (non-coring) required for access Each time port is de-accessed catheter must beflushed with heparin Port must be flushed every 4-6 weeks
Complications Pneumothorax Air embolism Catheter migration Port malposition (“flipped port”) Fibrin sheath Catheter occlusion Infection Venous thrombosis Diaphragm failure
Results of recentchemoembolization studiesLlovett et al, Lancet 2002 Randomized between bland embolization, chemoembolization &supportive care 112 patients randomized and treated between 1996 – 2000, groupscontained 37, 40 & 35 patients Embolization with gelatin sponge fragments, chemoembolizationwith doxorubicin, lipiodol and gelfoam Survival benefit demonstrated for chemoembolization oversupportive treatment Study terminated before any conclusion could be reachedregarding effect of bland embolization
Results of recentchemoembolization studiesLlovett et al, Lancet 20021, 2, and 3 year survivals– Supportive care 63%, 27%, and 17%– Gelfoam embolization 75%, 50%, 29%– Chemoembolization 82%, 63%, 29%
Results of recent chemoembolizationstudiesLo et al, Hepatology 2002 Randomized trial of TACE vs supportive care 80 patients randomized between 1996-1997 Chemoembolization performed with cisplatin,lipiodol, and gelatin sponge 1mm pellets Survival benefit demonstrated in TACE group
Results of recentchemoembolization studiesLo et al, Hepatology 20021, 2, and 3 year survival– Supportive care 32%, 11%, and 3%– Chemoembolization 57%, 31%, 26%
Results at MSKCC of ParticleEmbolization for HCCMaluccio, 2006 322 patients treated between 1997-2004 Median follow-up 20 months Median survival 21 months 1, 2, and 3 year survival 70%, 46%, 32% Excluding patients with portal vein tumor orextrahepatic disease 1, 2, & 3 year survival is 85%,68% and 42%
Comparison of survival at 1, 2, and 3 years intreated groups Llovett (doxorubicin)– 82%, 63%, 29% Lo (cisplatin)– 57%, 31%, 26% MSKCC (spherical embolics)– 70%, 46%, 32% (extrahepatic or p.v. involvement)– 85%, 68% and 42%
Summary Image-guided therapies have an importantrole at all stages in the care of the oncologypatient*Diagnosis*Treatment*Palliation
How IR works at MSKCC Available 24/7 2.5 angio, 1 CT, 1 CT-angio Routine cases 8 am – 6 pm Out-patients schedule in am In-patients generally in pm TRIAGE
How you can help us Patient preparation Communicating with IR
Patient preparation Does the patient know about the procedure? Are the labs acceptable? Diet? Contrast allergy? Able to consent? Are antibiotics necessary? Special considerations: position,anesthesia?
Patient preparation WBC/ANC Platelets >50,000 PT/INR <2.0 (except RFA, biliary: <1.5) PTT Creatinine Bilirubin Potassium 3.2-5.6 for central venousaccess
Patient preparation Diet appropriate for procedure?– PICC/hickman removals: regular diet– Most cases NPO * 6 hours Contrast allergy or renal failure?– CVC, abscess drain, ablation DO NOT requirecontrast– Angiogram, biliary, nephrostomy, IVCF requirecontrast
Communicating with IR: language– External: obligate external drainage• Nephrostomy, external biliary, abscess– Internal-external• Nephroureterostomy, int-ext biliary drains– May be capped in some cases– Stents• Internal drainage without exteriorized device***if in doubt, check the most recent IR report inPACS***
Communicating with IR How to order a procedure/consultation– PLACE A REFERRAL IN CIS!!
Communicating with IR When to call IR NP (Beep 2772, 2775, 5032,5810)– Catheter issues (in and out patient)– Post procedure patient care issues When to call IR MD (ext 7514)– Complicated cases/procedures
Communicating with IR When not to call– To get your case done earlier– “Heads up”
IR Clinic Every day at mainhospital Consultations Pre-procedure Care Post-procedure Care