Malpositioning of Hickman catheters, left versus right sided attempts

1. Introduction 

Venous access is an important issue in the care and management of patients with a wide variety of malignancies. Hickman- or Broviac-like catheters are made of barium impregnated silicone rubber which can be tunnelled under the skin and have a Dacron cuff which is implanted in the subcutaneous tissue above the exit site [1], [2].

Subclavian vein (SCV) catheterization is a well known method of central venous catheterization as was first described by Aubeniac in 1952 [3]. However, this method has many mechanical complications including pneumothorax, cylothorax and hydrothorax, perforation of the vessels, air embolism, brachial plexus and arterial injury and malpositioning [4], [5], [6], [7]. One of the most frequent mechanical complication is malpositioning. There is a well-known tendency for unexplained reasons to use the right site for catheter insertion [7].

The purpose of this study was to analyse the incidence of malpositoning for right and left side catheter insertion attempts for Hickman catheters in a randomized trial.

2. Patients and methods 

A sequential-randomized study was performed at the Ankara University School of Medicine, Department of General Surgery and Section of Surgical Oncology.

Between January 2000 and July 2001 75 patients underwent placement of long-term tunnelled central venous access devices by a single surgeon (AEU) at the Ankara University Medical School.

Patients with thorax deformity, prior surgery in the subclavian region (mastectomy, axillary dissection, thoracotomy), previous SCV catheterization, a mass at the supraclavicular region were excluded from the study.

After obtaining oral informed consent about the complications of catheterization including hemorrhage, pneumothorax, thrombosis, air embolism, malpositioning, and sepsis all patients underwent catheterization under local anesthesia. Double-lumen 12 F Hickman catheters were used (GISH Inc., Irvine, CA). The catheters were tunnelled under the skin with the cuff 2 cm above the exit site. In every case described in this report, the catheter tip was checked by regular chest X-ray and also for the possible complication of a pneumothorax.

Catheters were inserted by a percutaneous technique, sequentially randomized by AEU at the operating theatre for right or left.

Statistical analysis was performed by using the Chi-square test, a p value of less than 0.05 was considered to be statistically significant. All analyses were performed with the use of SPSS software.

3. Results 

Ninety-three attempts were performed in 82 patients, 48 for the left and 45 for the right site. Seven patients were excluded from the study because of failure of insertion, three left and four right. Success rates of catheter insertion were 92.4% for the left side attempt and 90.7% for the right. Thirty-six patients were sequentially randomized to the left side insertion arm and 39 patients to the right side insertion arm. The characteristics of the patients are described in Table 1. There were two malpositioning in left site attempts (5.55%) one right SCV, one left internal jugular vein and eight (20.51%) in right site attempts, five right internal jugular vein, two left SCV and one left internal jugular vein. The total malpositioning rate of this series was 14.66%. The jugular vein was the most common malpositioning site (six out of nine).

Table 1. Patient characteristics and procedure related variables

	Sex
	Female	33
	Male	42
	Median age (years, range)	36±1.20 (18–61)
	Malignancy
	Leukemia	57
	Lymphoma	18
	Mechanical complications
	Right	1 pneumothorax
		1 arterial puncture
		8 (20.51%) malpositioning; 5 right internal jugular vein
		2 left SCV
		1 left internal jugular vein
	Left	2 arterial puncture
		2 (5.55%) malpositioning; 1 right SCV
		1 right internal jugular vein
	Insertion site
	Right	39
	Left	36

Five patients were excluded from the study because of failure to successfully puncture the SCV (two right, one left), two patients refused to have a tunnelled catheter because of the pain experienced during insertion of the guide wire.

The results of 75 patients were analyzed. One pneumothorax was seen due to catheter insertion and required the insertion of a chest tube. Three arterial punctures were seen two from the left and one from the right site.

There was no significant difference between right and left sided attempts regarding mechanical complications except malpositioning (p<0.05). Left sided attempts had a lower incidence of malpositioning (p=0.032).

4. Discussion 

Initially implemented by Broviac et al. in 1973 [1] and modified by Hickman in 1979 [2], indwelling central venous devices took their place in the care and treatment of cancer patients and found application for hemapheresis procedures such as progenitor cell collection in the field of hematology–oncology and stem cell transplantation.

It is very important to optimize the procedure of subclavian catheterization which is associated with many complications which may be life-threatening.

There are different techniques for inserting these catheters into a central vein, however percutaneous insertion via the SCV or the internal jugular vein are the most widely used insertion techniques and routes [3], [8], [9]. It is very important to maximize the chance of successful placement of catheterization of the SCV, as there are many but rare life threatening mechanical complications such as pneumothorax, hemothorax, arterial puncture, perforation of the great vessels and myocardium, catheterization of the aorta, and cardiac tamponade [4], [5], [6]. Malpositioning is one of the most important complications because of its high incidence, failure of use of the catheter and the need to re-position and/or re-insert, which may cause morbidity [7].

The reported malpositioning rates in different series vary from 5.5% to 30% [5], [6], [7]. It is known that, for some unexplained reasons, there is a tendency to use the right SCV for insertion of central venous devices. The smaller caliber of the left SCV and the risk of ductus thoracicus injury are the most important risk factors for not choosing the left site. But, to date the complication rates of left SCV insertion for central venous devices are not well documented. The experience on left sided attempts are published in only a few articles [10], [13], [14]. Mansfield et al. [10] reported a complication rate of 10.6% for the left site and 9.5% for the right site (p=0.11) in a randomized trial using ultrasound for location of the SCV but they did not randomize their patients (208 patients had left sided catheterization out of 821). They explained the predominance for right SCV utilization in this series as a lower expectancy of catheter related thrombosis on the right SCV [10]. Catheter related thrombosis of the large-bore veins due to long-term catheterization is encountered in 50% of all catheterized patients [11], the catheter related variables for venous thrombosis were catheter diameter and location of the catheter tip [12]. Eastman et al. [13] reported no statistically significant difference for catheter related thrombosis between a right versus left sided approach.

The aim of this study was to evaluate the difference in malpositioning rate of right versus left sided attempts for Hickman catheters in order to find the easy and secure route to avoid malpositioning without using fluoroscopy. The results of our study showed a significant difference between left and right site attempts by means of malpositioning (p=0.032). Also, there were no significant differences for other mechanical complications. The rate of pneumothorax in this series was 1.3% and arterial puncture (4%) was comparable to other series. Fluoroscopy can be used intra-operatively to reduce the risk of malpositioning and to evaluate the catheter tip position. Nightingale et al. [15] recommended routine use of fluoroscopy during insertion in order to correct the guide wire if malpositioned, but, after removing the dilatator and guide wire, there is still a risk of malpositioning during insertion of the catheter, so multiple fluoroscopic images should be taken in order to see the position of the catheter tip. Left sided attempts may reduce the use of fluoroscopy during insertion because of the lower incidence of malpositions.

Malpositioning is the most common mechanical complication during insertion of Hickman catheters without fluoroscopy. In light of this sequentially randomized study of the right versus left subclavian approach the left subclavian catheter insertion is significantly different from the right site approach. There is no clinical trial indicating the superiority of using the right site, although the majority of central venous catheterizations are right sited. Perforation of the ductus thoracicus is the only mechanical complication of left sided attempts to be avoided [7], however this is a very rare complication except in cirrhotic patients as they have an enlarged ductus thoracicus due to increased lymphatic drainage because of portal hypertension [17]. The right SCV has a sharp angulation with the right internal jugular vein, so that the catheter tip collides with the medial wall of the right brachiocephalic vein. This may be an explanation for the higher rate of malpositioning to the jugular vein with right sided attempts. Because of the slightly curved, long left brachiocephalic vein and the less sharp angulation between the left SCV and the left internal jugular vein, malpositioning of left sided attempts were fewer. Although it is very rare, malpositioning to the internal mammary vein may occur [16] and, as the right internal mammary vein overlies the superior vena cava, anteroposterior images may confusingly show a properly positioned catheter. In contrast, with the left sided aprroach the anteroposterior image is adequate to evaluate the right position.

Left subclavian Hickman catheterization can be used as a safer method to aviod malpositioning to the internal jugular vein, and also is safer than a right subclavian approach regarding other mechanical complications. Furthermore, the left site approach may be preferred for long-term purposes, as it may be much more comfortable as the vast majority of patients are right handed.