Catheter tip positioning control in chest port implantation. Luc Rotenberg 2018

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Catheter tip positioning
Luc ROTENBERG*, Christian JAYR**,
*Clinique Hartmann – Ambroise Paré
26-27 bd Victor Hugo, 92200 Neuilly Sur Seine – France
www.radiologieparisouest.com
dr.rotenberg@radiologieparisouest.com
**Hôpital René Huguenin- Institut Curie
Saint-Cloud, France
Johannesburg Oct 4th 2018

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Hôpi
tal
What is the rationale?
Blood flow is maximum below
azygos vein

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Correct positioning of the distal
tip of the catheter
3
4
2nd interior intercostal space
Port
Distal tip of the
catheter
Subcutaneous
catheter path
Intravascular
path of the
catheter
Dr E. DESRUENNES
Distal end of
the catheter
(junction between
Superior Vena Cava
and Right Atrium)

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Correct positioning of the distal
tip of the catheter
S  Catheter tip malposition leads to severe complications
“Short” or malpositioned in a SVC
collateral
•  Venous thrombosis
•  Intimal damage (tip impinging against vein wall)
and venous wall erosion/perforation
•  Sleeve
•  Persistent Withdrawal Occlusion (PWO)
•  Tip migration
“LONG”
•  Arrythmias
•  Valvular lesions
•  Atrial thrombosis
•  Cardiac tamponade
Petersen Am J Surg 1999
Luciani, Radiology 2001
Puel, Cancer 2003
Melina Verso, J Clin Oncol 2003
Caers, Support Care Cancer 2005
Huygens, Acute Care 1985
Collier, Angiology 1988
Korones, J Pediatr 1996
Robinson, Arch Intern Med 1995
Collier, JACS 1995
Booth, BJA 2001

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MALPOSITION: CLINICAL PROBLEMS
2 cm
4 cm
6 cm
86 %
31 %
16 %
14 %
1.2 %
Dysfonctionnement (1) Thrombose (2)
86% 45,2%
31% 19%
16% 4,2%
14% 1,5%
1,2% 5,6%
1- Petersen et al, Am J Surg 1999, 178:38-41
2 - J. Caers, Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports - 2005

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Thrombosis and tip position of the catheter (retrospective,
437 oncologic patients)

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The Anatomy of the frontal chest X-Ray
SVC BCV
RA
PA
SCV

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Different faces of good position
Swedish Clinical Guidelines. Acta Anaesthesiol Scand. 2014 May;58(5):508-24.

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Bedside
Trunk rotation
Cardiothoracic surgery
Pulmonary “central” oedema
?
Accuracy of radiological landmarks

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Right atrium ?

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A LATERAL VIEW IS MANDATORY
Right atrium ? No, Azygos vein !!!

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Right atrium ?

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Right atrium ? No, Internal mammary !!!
A LATERAL VIEW IS MANDATORY

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ECG Technique:
principles and interest

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ECG Technique
S  Importance of catheter tip
position for central venous
catheter
S  Endocavitary ECG technique
S  Pilot® ECG System

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ACTUAL PROBLEMS
Time consumption, costs and logistics of fluoroscopy
Time consumption and costs of post-procedural tip control
(chest X-Ray)
Accuracy of radiological tip control (chest X-Ray, Fluoroscopy)
Incidence of primary malposition: 2-30%
Ports << PICC
Costs of a primary malposition
Time consumption and costs of repositioning procedures
Home placement of PICCs
Operators’ discomfort and frustration

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Endocavitary ECG Technique
Entry in the right Atrium = Maximum high of the P
wave = correct position of the catheter tip
Pictures from Dr Rosay, CLB, Lyon

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Endocavitary ECG visualization– P wave evolution
a- P wave has normal dimension, equal to P wave of the
surface ECG. At this point the catheter tip is in the superior part
of the superior vena cava.
b- Catheter tip is progressing into the vena cava superior, P
wave is growing
c- P wave has reached its maximal amplitude and there is no
negative component noticeable before the positive P wave, the
catheter tip is located at the vena-cava / right atrium junction.
d- P wave is gradually reducing and a small negative
component is appearing before the positive P wave. That’s the
first sign showing that the catheter tip is entering in the right
atrium.
When P wave become biphasic (going up and down the
reference line), catheter tip is in the inferior part of the right
atrium / superior part of the right ventricle.
To be sure that you’ve reach the maximum of amplitude of the P wave and you are at the vena cava /
right atrium junction, it’s required to push the catheter on (1 or 2 cm more)
Pull the catheter out for few cm to see maximal P wave of endocavitary ECG reappear (as sown in the
picture c)

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SVC
INTRACAVITARY ECG GUIDANCE

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Medium-distal SVC
Endocavitary p wave =
1/3 - 1/2 of the maximal

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Distal segment of
SVC/AC junction
Endocavitary P = 2/3 of
the maximal or first
maximal

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Atriocaval junction/entrance
of right atrium (crista terminalis)
Endocavitary P =
first maximal

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First 1/3 of atrium
Endocavitary P =
Maximal for 1-3 cm, then decreases;
appearance of a negative component

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Deep atrium
Biphasic

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IVC
Negative

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GUIDELINES ?
Since 1998, the German Society of Anaesthesiologists has
concluded that the ECG method can replace the standard
chest X-Ray (provided that early pleural complications can be excluded by
means of other methods) :
- at least comparable to radiological location of the tip (both
with metal guidewire as well as with column of saline techniques)
- less resources expenditure
- less exposition to ionizing radiation (patients and operators)

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Present technique: Fluoroscopy
Expensive
Inaccuracy of radiological landmarks
Accurate for assessment of both direction of the catheter and
position of the tip
X-ray exposure
Not appropriate for bedside VADs (PICC, CVC)

ACCÈS
VASCULAIRE MOYEN
& LONG TERME
pilot®, ECG guidance system

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ECG technics
Oreillette gauche
Nœud sinuso-
atrial
Oreillette
droite
Nœud
sinuso
atrial
Nœud
atrio
ventriculairOnde P max.
e

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pilot®
Ø  Endocavitary ECG guidance system ECG for real time
positioning of central venous catheter distal tip: CCI,
CVC and PICC-line
Ø  Distal tip precise positionning in Atriocaval junction/
entrance of right atrium (crista terminalis)

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pilot®
Tablette avec
application pilot
Câble 4 dérivations
Boitier patient

Interface
Tracé de
surface
Tracé
endocavitaire
Possibilité de marquer par une barre l’onde P
et/ou QRS
Informations
patient
Freeze
Print
CAAF Mode
Save & review
P wave value «pilot» mode
Cardiac frequency

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Unique feature
•  The height of the P wave is measured and expressed as a value
> makes it easier to follow its evolution

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•  Unique device on the market with a dedicated mode for
AFib patients (Cardiac Arrhythmia by Atrial Fibrillation)
Unique feature

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•  Colored indicator that makes it possible to assess
the progression of the catheter : « Pilot » mode
RED : QRS negative
Unique feature

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Green : QRS positive
Unique feature

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Orange : biphasic P wave
Unique feature

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> Saline
pilot® - Système ECG
•  UNIVERSAL
•  All central venous catheters PICC, CCI and CVC
•  and non-captive implant
•  can work with all implants on the market
17

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ü  P wave expressed as a value
ü  dedicated mode for CAAF patients
ü  Colored indicator
ü  Useful for PICC, PORTS and CVC
Unique feature

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Placement Costs: PICC in USA
S  M. Smith (Wisconsin), DIVLD congress – Paris, 2011
Main operator Environment Instrument. Ancillary
oper.
$ 5000 Surgeon OR Fluoroscopy Scrub nurse
$ 2800 Interventional
radiologist
Angiography
suite
Fluoroscopy Radiology
Technician
$ 1800 Anesthesiologist bedside ___
$ 875 Nurse bedside ___
Note: all us-guided procedures

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Placement Costs: Port in the US
AVA Congress 2010
Technique of
venous access
Tip position Environment Costs
90’s Open (surgical) Fluoroscopy OR $ 5000
Today Percutaneous
US-Guided
Intracavitary
ECG
DH $ 950

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ECG-based PICC tip verification system :
an evaluation 5 years on
Gemma Oliver and Matt Jones
Vascular Access and Hospital-at-Home Matron, East
Kent Hospitals University NHS Foundation Trust, Kent
British Journal of Nursing, 2016, (IV Therapy Supplement) Vol 25, No 19
Ward PICC placed using ECG-guided tip locationWard PICC placed and tip position checked with
post-procedural X-ray

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ECG-based PICC tip verification system :
an evaluation 5 years on
Gemma Oliver and Matt Jones
Vascular Access and Hospital-at-Home Matron, East
Kent Hospitals University NHS Foundation Trust, Kent
British Journal of Nursing, 2016, (IV Therapy Supplement) Vol 25, No 19
Although limitations were noted, using ECG to place PICC lines was found to be a
cheaper, more accurate and a more efﬁcient method for PICC placement than using a
post-procedural chest X-ray.

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ECG method summary
1. Allows an INTRAOPERATIVE control of tip position
2. Feasible in the vast majority of patients
2. High accuracy (direct anatomical-electrophysiological correlation)
3. Safe
4. Non invasive and thus repeatable
5. Single-operator procedure (from device insertion to postoperative control
6. Reproducible among different operators
7. Cheap
8. Easy to use, easy to learn
9. Allows documentation (late malpositions/dislodgements) – prevention of
medical legal litigations.

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Fluoroscopy
More expensive
Real time and easy positionning
Carefull with radiological landmarks
Accurate for assessment of both direction of the catheter and
position of the tip
X-ray exposure
Not appropriate for bedside VADs (PICC, CVC)

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Conclusion :
Benefits of ECG method vs Fluoroscopy
Cost saving:
Fluoroscope > 100 000€
Lead apron ≈ 700€
Dosimeters: operational (≈ 10.5€/ trimester/person) + box
and base
For operators For the patient
No X-ray
No radioprotection
No discomfort at work
Repeated X-ray exposition= increase
cancer in children

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Conclusion
S  Contreversy remains
S  where to locate the tip of the
catheter
S  on how deep to locate it
S  Morbidity is still signifcant for
S  Standardizing the method
S  Expanding new, easy and
consistant technologies with
acceptable sensitivity and
specificity

Catheter tip positioning control in chest port implantation. Luc Rotenberg 2018

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Catheter tip positioning control in chest port implantation. Luc Rotenberg 2018