British Journal of Radiology (2005) 78, 147-149
© 2005 British Institute of Radiology
doi: 10.1259/bjr/13913517
Technical report: use of ultrasound guidance in the removal of tunnelled venous access catheter cuffs
A M Barnacle, MRCP, FRCR1 and
A W M Mitchell, FRCS, FRCR1
Department of Radiology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
Correspondence: Dr A M Barnacle, Department of Radiology, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK
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Abstract
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Venous access catheters are employed for a wide variety of reasons. On removal of the catheter, the subcutaneous catheter cuff can be difficult to extract; retention of the cuff has recognized complications. We describe a simple ultrasound technique that assists in the identification of the cuff within the subcutaneous tissues, simplifying subsequent cuff removal. This may lead to a reduction in associated complications.
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Introduction
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Venous access catheters are used to deliver long-term intravenous therapy such as haemodialysis, plasmapheresis, parenteral nutrition and chemotherapy, and enable venous sampling in patients with poor venous access. The majority of tunnelled devices have a short polyester cuff attached to the catheter that encourages fibrosis and therefore anchorage within the subcutaneous tissues. Similar cuffs are employed in some peritoneal dialysis catheters. This cuff can be difficult to localize and extract from the soft tissues when the catheter is removed. In some cases, this may be due to failure to localize the cuff within the soft tissues during manual traction, particularly in large or oedematous patients. We describe a new technique that aids in the identification of the subcutaneous catheter cuff both prior to catheter removal and following cuff retention.
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Background
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Catheter removal can be achieved by manual traction or by cutdown. Simple manual traction is the preferred technique in many centres, but results in retention of the cuff in 10–50% of cases [1, 2]. In some instances, a surgical cutdown is performed on to the cuff, under local anaesthetic, at the time of catheter removal [3]. This technique is straightforward when the subcutaneous cuff is palpable or is easily localized during traction. In obese or oedematous patients, identification of the cuff is often difficult and a cutdown procedure in such cases is not without risk.
In the majority of cases, cuff retention is regarded as unfortunate but likely to be inconsequential and the cuff is left within the subcutaneous tissues. However, current guidance by catheter manufacturers states that all catheter cuffs should be removed. The sequelae of retained catheter cuffs are uncommon but well documented. The most common complication is infection, leading to cellulitis, abscess formation or delayed healing [1–4]. Retained venous catheter cuffs have been mistaken for metastatic nodules on chest CT [5] and can cause a wide range of abnormal appearances on mammographic studies [6].
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Technique for cuff visualization
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The polyester cuff surrounding the catheter or retained within the soft tissues is easily visualized on ultrasound, even in overweight or oedematous individuals. In our practice, we use either a L38/10-5 MHz linear array transducer (portable SonoSite 180Plus, SonoSite Ltd, Herts, UK) or a L12-5 MHz linear array transducer (HDI 5000; Philips, Croyden, UK). The venous access catheter itself appears as a linear echogenic structure easily differentiated from the surrounding soft tissues (Figure 1
). At the site of the cuff, the walls of the catheter become ill defined (Figure 2) and attenuation of the ultrasound beam leads to marked shadowing within the tissues deep to the cuff (Figure 3). These findings are reliable and allow for greater accuracy in cutdown procedures on to the cuff.
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Figure 1. Longitudinal ultrasound image demonstrating the central venous catheter within the subcutaneous tissues of the anterior chest wall, before crossing the clavicle. The echogenic walls of the catheter are well defined and do not cast an acoustic shadow deep to the catheter.
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Figure 2. Longitudinal ultrasound image of the catheter demonstrates focal loss of continuity of the well-defined walls at the site of the catheter cuff and marked acoustic shadowing within the soft tissues deep to the cuff.
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Figure 3. Transverse ultrasound imaging of (a) the catheter and (b) the cuff shows poor definition and apparent thickening of the walls at the site of the cuff, with dense acoustic shadowing present.
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Following recent recommendations regarding the use of ultrasound guidance in the insertion of central venous lines, including the NICE guidelines [7], ultrasound equipment should be available in an increasing number of medical departments. The use of ultrasound guidance in selected medical procedures is invaluable and familiarity with ultrasound of the soft tissues should be encouraged. This report illustrates a simple, useful technique for visualization of catheter cuffs both prior to cutdown procedures in obese or oedematous patients in whom cuff localization is not possible and following episodes of cuff retention. This may lead to quicker and easier removal of catheters and a reduction in associated complications. Given the simplicity of the technique and the increasing availability of ultrasound equipment, any technique that has little cost or time implications should be utilized to prevent potential complications.
Received for publication March 22, 2004.
Revision received August 2, 2004.
Accepted for publication October 1, 2004.
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References
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- Kohli MD, Trerotola SO, Namyslowski J, Stecker MS, McLennan G, Patel NH, et al. Outcome of polyester cuff retention following traction removal of tunnelled central venous catheters. Radiology 2001;219:651–4.[Abstract/Free Full Text]
- Fisher WB. Complication of a Hickman line: cutaneous erosion of the Dacron cuff. JAMA 1985;254:2934.[CrossRef][Medline]
- Galloway S, Bodenham A. Safe removal of long-term cuffed Hickman-type catheters. Hospital Med 2003;64:20–3.
- Elkabir JJ, Riaz AA, Agarwal SK, Williams G. Delayed complications following Tenckhoff catheter removal. Nephrol Dial Transplant 1999;14:1550–2.[Abstract/Free Full Text]
- Fernandez GG, Coblentz CL, Cooper C, Sallee DSS. Hickman nodule: a mimic of metastatic disease. Radiology 1989;171:401–2.[Abstract/Free Full Text]
- Ellis RL, Dempsey PJ, Rubin E, Pile NS, Bernreuter WK. Mammography of breasts in which catheter cuffs have been retained: normal, infected and post-operative appearances. AJR Am J Roentgenol 1997;169:713–5.[Abstract/Free Full Text]
- NICE technology appraisal guidance No 49: guidance on the use of ultrasound locating devices for placing central venous catheters. September 2002.
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Abstract
Introduction
