Brief Reports
195
Internal Thoracic Vein Cannulation as a Complication of Central Venous Catheter Insertion Alex C.H. Lee,
MBChB, FRCSEd,
1
Jai V. Patel, MBChB, MRCP, FRCR,2 Susan V. Picton, Roly Squire, MBBS, FRCS, FRCS(Paed)1*
3 BMBS, FRCPCH,
and
Key words: internal thoracic vein; central venous catheter; totally implanted venous access device; surgical complications; malposition of catheter
Children with cancer frequently require central venous access for the administration of cytotoxic chemotherapy medications [1–3]. Insertion of a central venous device via cut-down and direct vision is one of the commonest procedures performed by paediatric surgeons. Complications of the procedure are not uncommon and have been extensively reported in the literature [1,4–8]. Malposition of the tip of the catheter into a small tributary, however, is rare. This report alerts clinicians to the peculiar difficulties encountered if a central venous line tip lies in the internal thoracic vein. A 17-year-old girl diagnosed with a high-grade intramedullary osteosarcoma of the distal femur was treated with chemotherapy, radiotherapy, and subsequent resection of the tumor. Her chemotherapy was administered via a totally implanted venous access device (TIVAD) the catheter tip of which was inserted via the right internal jugular vein to lie in the right atrium. After completion of therapy, the device was electively removed, 4 months prior to the discovery of relapse with pulmonary metastases. Further chemotherapy was planned and she was admitted for insertion of a second TIVAD for this purpose. Pre-operative neck ultrasonographic evaluation confirmed patency of both internal jugular and subclavian systems. Under general anaesthesia, a new TIVAD was inserted via a direct cut-down to the right internal jugular vein without difficulties. The port was noted to flush and aspirate easily. The tip of the catheter was shown to be at the level of mid right atrium on antero-posterior view at fluoroscopy in the operating room, which was considered acceptable. The first dose of chemotherapy, which consisted of ifosfamide, etoposide, and methotrexate, was administered via the device on the following day uneventfully. Five days after the insertion the patient complained of central chest pain and dizziness when the catheter was flushed with normal saline. The catheter continued to flush and aspirate with ease. A postero-anterior chest radiograph was obtained. The tip of the catheter appeared to be in the correct level but the course of the catheter had an unusual configuration (Fig. 1). A contrast study via the device located the catheter tip in the right internal thoracic vein (Fig. 2). The neck wound was re-explored and the line was readjusted. The position was ascertained when the tip was seen to be floating freely in AP and lateral views on fluoroscopy. Post-operatively the patient finished her further courses of chemotherapy and remained well. DISCUSSION
A catheter tip entering a small tributary is unusual, as the tip will preferentially slide into a larger fast flowing tributary [7– ß 2003 Wiley-Liss, Inc. DOI 10.1002/mpo.10120
13]. The inferior thyroidal vein, left pericardiocophrenic vein, left internal superior intercostals vein as well as the internal thoracic vein as described in this case report have been implicated. Aberrant position of the catheter often causes ‘‘line failure,’’ in that it no longer aspirates and flushes freely. However, relying on this sign can be misleading as shown in our case and other reports [4,13]. Confirmation of the position of the catheter tip is usually by means of fluoroscopy in the operating room. However, unless the image is scrutinized carefully, subtle signs can often be missed [7,8], especially during a difficult line insertion, when the catheter finally appears to be correctly inserted, to the relief of the theatre staff. The internal thoracic vein enters the brachiocephalic vein anteriorly on either side. Therefore, when a catheter is located
Fig. 1. Chest radiograph showing an unusual, lateral path of the central venous catheter.
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Department of Paediatric Surgery, St. James’s University Hospital, Leeds, United Kingdom 2 Department of Clinical Radiology, St. James’s University Hospital, Leeds, United Kingdom 3 Department of Paediatric Oncology, St. James’s University Hospital, Leeds, United Kingdom
*Correspondence to: Roly Squire, Department of Paediatric Surgery, St. James’s University Hospital, Leeds, LS9 7TF, United Kingdom. E-mail:
[email protected] Received 23 January 2002; Accepted 22 February 2002
196
Brief Reports electrocardiography) have also been described [14]. Chest pain on flushing the catheter is an important sign of catheter tip malposition, of which the internal thoracic vein would be a likely candidate [7,9,13]. Staff should be alert to the possibility of line problems, when unexplained symptoms develop. REFERENCES
Fig. 2. Intravenous contrast study via the totally implanted venous access device showing its catheter tip in the right internal thoracic vein and the contrast injected into the chest wall collateral veins (arrow–subclavian vein; arrow head–collateral veins).
in the right internal thoracic vein, it appears to be more lateral than it should be on postero–anterior chest radiograph. This is because it follows a course into the internal thoracic vein from the brachiocephalic vein proximal to the superior vena cava [13]. On the left, the catheter appears to pass through or to the left of the aortic knob, a feature also common to left superior vena cava or left superior intercostals vein cannulation [1,13]. Post-operative postero–anterior and lateral chest radiographs can be used to assess line position but when there is doubt, contrast study will help to confirm the exact location of the line tip [1,10,13]. Other useful non-radiologic methods (e.g., using
1. Krasna IH, Krause T. Life-threatening fluid extravastion of central venous catheters. J Pediatr Surg 1991;26:1346–1348. 2. Wiener ES, McGuire P, Stolar CJ, et al. The CCSG prospective study of venous access devices: an analysis of insertions and causes for removal. J Pediatr Surg 1992;27:155–163. 3. Tweddle DA, Winderbank KP, Barrett AM, et al. Central venous catheter use in UKCCSG oncology centres. Arch Dis Child 1997;77:58–59. 4. Johnson EM, Saltzman DA, Suh G, et al. Complications and risks of central venous catheter placement in children. Surgery 1998;124:991–996. 5. Cameron GS. Central venous catheters for children with malignant diseases: surgical issues. J Pediatr Surg 1987;22:702–704. 6. Bagwell CE, Salzberg RE, Sonnino RE, et al. Potentially lethal complications of central venous catheter placement. J Pediatr Surg 2000;35:709– 713. 7. Shapiro MJ, Allen HM, Talpos GB. Internal thoracic vein cannulation as a complication of central venous catheterization. Am Surg 1982;48:408– 411. 8. Conces DJ Jr, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293– 295. 9. Webb JG, Simmonds D, Chan-Yan C. Central venous catheter malposition presenting as chest pain. Chest 1986;89:309–312. 10. Zaman MH, Mitra P, Bondi E, et al. A rare malposition of central venous catheter. Chest 1990;98:768–770. 11. Muhm M, Sunder-Plassmann G, Duml W. Malposition of a dialysis catheter in the accessory hemiazygos vein. Anesth Analg 1996;83:883– 885. 12. Ovenfors CO, Ounjian ZJ. Aberrant position of central venous catheter introduced via internal jugular vein. Am J Roentgenol 1977;128:483– 484. 13. Brandi LS, Oleggini M, Frediani M, et al. Inadvertent catheterization of the internal thoracic vein mimicking pulmonary embolism: a case report. J Parenter Enteral Nutr 1988;12:221–222. 14. Hoffman Ma, Langer JC, Pearl RH, et al. Central venous catheter—No X-rays needed: a prospective study in 50 consecutive infants and children. J Pediatr Surg 1988;23:1201–1203.
Vascular Endothelial Growth Factor in Monitoring Therapy of Hepatic Haemangioendothelioma Sabina Szymik-Kantorowicz,
MD,
1
Lukasz Partyka, MD,2 Aldona Dembinska-Kiec, MD, PhD,2* and Anna Zdzienicka, MSc2
Key words: VEGF; haemangioendothelioma; childhood cancer; angiogenesis
Angiogenesis, the formation of new capillaries, is critical for physiologic processes. The main regulators of angiogenic response include vascular endothelial growth factor (VEGF), acidic and basic fibroblast growth factor (aFGF, bFGF), angiopoetins 1 and 2, hepatocyte growth factor, platelet derived growth factor, and interleukin 8 (IL 8). VEGF exists in four isoforms (121, 165, 189, 206 aminoacids) varying in heparin affinity. It is released from macrophages, fibroblasts, vascular and skeletal muscle cells, ß 2003 Wiley-Liss, Inc. DOI 10.1002/mpo.10128
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Department of Pediatric Surgery, Polish-American Institute of Pediatrics, Jagiellonian University School of Medicine, Krakow, Poland. 2 Department of Clinical Biochemistry, Jagiellonian University School of Medicine, Krakow, Poland.
*Correspondence to: Aldona Dembinska-Kiec, MD, PhD, Department of Clinical Biochemistry, Jagellonian University School of Medicine, Kopernika 15A, 31-501 Krakow, Poland. E-mail:
[email protected] Received 9 July 2001; Accepted 20 February 2002
