Devdutta Warhadpande and Gregory J. Woodhead

Familiarity with lines and drains is a must for IR trainees. These procedures, while considered bread and butter by many, have the potential to create headaches if not approached with diligence. Take some time to learn about the different types of equipment, the indications for each, and the complications which may arise.

While many different specialties can place central lines, those placed by IR have greater technical success and are associated with fewer complications. The use of imaging guidance decreases the risk of procedural complications, and adhering to sterile technique in the controlled environment of the IR suite reduces the risk of infection.

Practices vary a great deal from hospital to hospital, both by the preferences of referring physicians and the policies of the IR department. The guidelines presented in this chapter should be taken with a grain of salt, as they may vary depending on your practice setting.

In patients with a history of multiple line placements, review the prior imaging to assess vein patency and history of access complications. Patients who have had prior central lines will often have occluded or thrombosed veins, and will require scrutiny when choosing an appropriate access site.

It should also be determined whether a reason exists for a line to not be placed in a specific location. This is especially important when placing PICCs or subclavian vein lines in patients with renal insufficiency, when there may be an anticipated need for dialysis access creation. These types of lines should be avoided in patients who may eventually require a fistula, but if one is absolutely necessary, it should go contralateral to the arm selected for fistula creation. A fistula is most commonly placed in the nondominant extremity, so a PICC/subclavian line should be inserted into the dominant arm.

Venous access is broadly divided into four types: PICC, nontunneled central line, tunneled central line, and implantable ports.

A PICC is placed via a peripheral vein (basilic, cephalic, or brachial). Indications for a PICC include a long-term need for intravenous antibiotics, total parenteral nutrition (TPN), fluids, and other medications. In many hospitals, these can be placed on the floor by a team of specially trained nurses and physician extenders. IR is typically consulted for challenging cases, including patients with history of prior occlusions, failure of bedside placement, those requiring sedation, and neonates/infants. A PICC can remain in place for a duration of weeks to months.

IR generally does not maintain involvement in the care of patients after a line is placed, unless there are complications. Immediate complications are those encountered during the procedure, and are uncommon due to the use of image guidance. Late complications typically involve malfunction of the catheter in some way or another.

The risk of pneumothorax is greatest when accessing the subclavian vein, and lowest with ultrasound-guided internal jugular access. A pneumothorax may be recognized during fluoroscopy or on a postinsertion chest radiograph, and only rarely are they large enough for the patient to become symptomatic. If small and incidentally noted, close observation is often sufficient. Larger pneumothoraces may require chest tube placement.

If not recognized by the pulsatility of blood return during the initial access steps, an inadvertent arterial puncture is quickly recognized under fluoroscopy when the guidewire courses along the aortic arch (left of the vertebral bodies). As long as only the guidewire is inserted, the needle and guidewire can simply be taken out and pressure held over the arteriotomy before reattempting. If an arterial puncture goes unrecognized and a sheath/dilator is inserted into the artery, this becomes a more serious problem. Depending on the size and location of the inadvertent arterial access, consideration of most appropriate repair should include both endovascular and open surgical options.

Although rare, an air embolism can be fatal. This usually occurs after the peel-away sheath’s inner dilator is removed, before the catheter is inserted. Some sheaths have a one-way valve that prevents air from entering, but a good practice is to simply cover the sheath with a finger whenever the dilator is out so air doesn’t get sucked in. In the rare event it occurs, the patient may become short of breath, hypotensive, tachycardic, confused, or experience chest pain. If suspected, place the patient in the left lateral decubitus position and provide 100% oxygen. Severe cases may require hyperbaric oxygen therapy or extracorporeal oxygenation (ECMO) until the air has resolved.

Until you have put in many lines and become proficient, one of the challenges of the procedure is ensuring that the catheter runs smoothly in its course. When the catheter bends at an acute angle, it can kink and malfunction. For tunneled catheters, this can be minimized by making sure that the subcutaneous tunnel is an adequate distance lateral to the vein, and that the venotomy where the catheter courses downward is made just about a centimeter above the clavicle. Kinks may be correctable using fluoroscopic manipulation to straighten or reposition the catheter, but sometimes it is just easier to remove it and place a new line. In the rare event of a fracture, as can happen with pinch-off syndrome, the distal fragment may embolize to the heart. An embolized catheter tip should be retrieved if possible. In some cases the risk of retrieval is greater than the risk of leaving the fragment in place. These patients need to be referred to a center experienced in difficult retrievals, and counseled on the risks of removal versus simply leaving it alone before an attempt is made.

Catheter removal is necessary when a line infection is the presumed cause of severe sepsis, hemodynamic instability, or infective endocarditis. Erythema or purulence around the catheter insertion site, even in the absence of culture confirmation, is an indication to remove a catheter.

In cases of suspected CRBSI, empiric vancomycin and piperacillin–tazobactam are started after blood cultures are drawn. Antibiotics are deescalated based on the results of blood cultures and sensitivities. Blood cultures are also drawn daily until they are cleared and the patient is afebrile.

Catheter salvage may be attempted in select cases. Antimicrobial lock therapy is a method of instilling a high-concentration antibiotics into the catheter lumen and is done in tandem with systemic antibiotics. The patient must not have any purulence or other signs of infection at the exit/tunnel site, otherwise this strategy will not be helpful. Certain microbes including Staphylococcus aureus and Candida are also a relative contraindication. If cultures remain positive for more than or equal to 72 hours after attempted salvage therapy, the catheter must be removed.

Exchanging catheters over a guidewire at a venous insertion site is a relatively common practice in cases of uncomplicated CRBSI. If the tip of the removed catheter tip shows evidence of phlebitis, thrombus, or purulence, then exchange is inappropriate and a new catheter must be inserted at a different site.