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Long-term venous access for leukapheresis, repeated blood sampling, and administration of drugs and fluids can be accomplished nonsurgically in Yucatan miniature swine. The catheter is placed under fluoroscopic guidance into the inferior vena cava using a needle and guidewire. This procedure has the advantage that it avoids a surgical incision, allows high flow rates, exists conveniently on the lower back, and can be replaced easily in the event of mechanical failure or thrombosis. Actuarial analysis of the duration of patency disclosed that of 41 catheters placed in 30 animals, the probability of function at 28, 42, and 54 days was 75%, 50%, and 25%, respectively. Eleven nonfunctioning catheters were replaced and nine of these continued to function until the completion of the experiment. No catheters were removed due to infection. Chronic catheterization of the inferior vena cava is a convenient method for long-term venous access in swine.

Nineteen central venous catheters with radiographically proven thrombotic occlusion failed to have function restored with a mean of 1.6 5000-unit boluses of urokinase per catheter. Catheters then underwent a 6-hour infusion of urokinase at 40,000 units per hour followed by repeat contrast injection and evaluation of function. Reduction in thrombus size occurred in all but one patient. Catheter function was restored in 15 patients. In two patients, thrombus dissolved but catheters remained occluded because of tip malposition. In the remaining two patients, catheter function was restored with an additional 6-hour infusion. No adverse reactions to the infusion were seen. After infusion catheters continued to function normally for a mean of 36.2 days. Five catheters rethrombosed, two of which responded to urokinase bolus instillation. Thrombosed catheters failing standard intracatheter bolus urokinase are generally salvaged with a 6-hour infusion of low-dose urokinase.

Subclavian catheterization in patients with cancer is associated with up to a 38% incidence of subclavian vein thrombosis. These thrombi seldom recanalize. The persistent occlusion of the subclavian vein may hinder subsequent catheter placement. To determine the frequency of this occurrence and to determine if preoperative duplex scanning could identify these individuals, we performed preoperative duplex scanning in 22 patients who had previously had an indwelling subclavian catheter for chemotherapy. Subsequent subclavian vein catheterization was attempted without knowledge of the results of the duplex scan. Nineteen scans were normal. Of these, 18 patients underwent successful catheter placement. In one patient, catheterization was unsuccessful and an intraoperative venogram showed a focal obstruction of the proximal portion of the subclavian vein. Three scans showed noncompressibility of the vein, and catheter placement was unsuccessful in these three veins. In patients who have had previous subclavian catheters, persistent obstruction of the vein prevents subsequent catheter placement in 14%. Duplex scanning before subsequent catheter placement generally identifies these individuals.

Translumbar inferior vena cava catheters are a safe method of providing venous access for the collection of peripheral blood stem cells for transplantation. One of the most frequent and consistent problems with these catheters is thrombotic obstruction, occurring in one-fourth of the cases. Aspirin at a dose of 325 mg daily beginning after catheter placement and continuing until completion of stem cell collection has been associated with a reduction in the frequency of catheter thrombosis from 12/60 (20%) to 1/31 (3.2%) (p = 0.007) and an increase in the number of thrombus-free apheresis procedures (p = 0.024) compared to historical controls. No adverse effects of aspirin during stem cell collection have been noted. Daily aspirin ingestion should be considered in patients undergoing peripheral stem cell collection via translumbar inferior vena cava catheters.

Long-term indwelling central venous catheters have eased the administration of drugs, blood products, and hyperalimentation to patients with cancer. However, their use is associated with thrombotic complications. We report here on the thrombotic complications prospectively observed in 46 patients with refractory lymphoma (22 Hodgkin's disease, 24 non-Hodgkin's lymphoma) who had placement of one or more catheters in preparation for autologous stem cell transplantation (ASCT). Thrombosis of 26 catheters in 19 patients was observed. Specific abnormalities of hemostasis were equally common in patients who developed thrombosis and in those who did not. Thrombotic complications were more common in patients with Hodgkin's disease (13/22) than in patients with non-Hodgkin's lymphoma (6/24, p = 0.04). Although more patients with Hodgkin's disease had received prior splenectomy and/or irradiation to the area involved by thrombosis than patients with non-Hodgkin's lymphoma, the incidence of splenectomy and irradiation was similar for patients with Hodgkin's disease who developed thrombosis and those who did not. Therefore, although the etiology remains unexplained, patients with Hodgkin's disease undergoing intensive chemotherapy and ASCT appear to have a higher incidence of catheter-related thrombosis than patients with non-Hodgkin's lymphoma undergoing similar therapy.

To investigate the potential role of magnetic resonance imaging and duplex scanning in the diagnosis of catheter-induced subclavian vein thrombosis, we correlated the results of 43 arm phlebograms with duplex scans; 28 of these phlebograms were also correlated with magnetic resonance imaging scans of the thoracic veins. Eighteen of the 43 phlebograms were normal, and all had normal magnetic resonance imaging and duplex studies. Eleven subclavian veins were totally occluded on phlebography; all had duplex scans, and five were also scanned with magnetic resonance imaging. Duplex scans detected 6 of 11 occlusions, whereas magnetic resonance imaging detected 4 of the 5 occlusions scanned. The five occlusions that were not detected by either magnetic resonance imaging or duplex scans were short segmental occlusions of the medial one third of the left subclavian vein. Of 14 nonocclusive thrombi seen on phlebography, duplex scans correctly identified 8. Magnetic resonance imaging was done on eight nonocclusive thrombi but identified only two. All abnormal findings on duplex scanning and magnetic resonance imaging were confirmed by phlebography. Short occlusions of the proximal portion of the left subclavian vein were often undetected by duplex scanning but occasionally seen with magnetic resonance imaging. Neither modality was sensitive to the presence of nonocclusive mural thrombi. Magnetic resonance imaging is highly reliable in ruling out the presence of a thrombotic process in the subclavian vein, but it may on occasion fail to detect the presence of subclavian thrombi. For this reason, in cases with suspected subclavian vein thrombosis magnetic resonance imaging cannot be used as the only diagnostic modality.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombotic obstruction frequently prohibits infusion through or withdrawal of blood from central venous catheters and can occur in conjunction with symptomatic thrombosis of the subclavian vein. Thirty catheters were radiographically proved to be obstructed by thrombus and had not responded to at least one instillation of 5000 units of urokinase. All catheters were treated with a 12-hour infusion of urokinase at the rate of 40,000 units/hour. The obstructing thrombus was either eliminated or reduced in size in all instances and full function was restored in all but one catheter. No bleeding complications were seen. Six patients with obstructed catheters also had symptoms of subclavian vein thrombosis. All patients with symptoms of subclavian vein obstruction became asymptomatic on anticoagulant therapy even though no attempt at dissolving the thrombus obstructing the subclavian vein was made. A 12-hour infusion of low doses of urokinase can safely salvage function of obstructed catheters that otherwise may require replacement. Patients with concomitant subclavian vein thrombosis become asymptomatic on anticoagulant therapy without need to dissolve the obstructing thrombus.

One hundred sixty-eight bone marrow transplant recipients and 49 patients who received high-dose chemotherapy were evaluated for symptomatic thrombosis after Hickman catheter placement. The timing of thrombotic complications was different between these two groups, with the transplant group having a significantly lower thrombus-free survival by 28 days after catheter placement. By 100 days after placement the thrombus-free survival rates of the two groups were similar. The platelet count at time of catheter placement was significantly lower in the nontransplant group, and the thrombus-free survival was longer in patients whose catheter was placed when their platelet count was less than 150,000, suggesting that thrombocytopenia delays thrombotic complications. Placement of two Hickman catheters resulted in a 12.9% thrombosis rate (21 of 162 patients) and was significantly more likely to be associated with thrombosis than placement of one catheter. Long-term follow-up evaluation of patients treated without successful fibrinolytic therapy showed no residual symptoms of venous obstruction. In those patients presenting with concomitant catheter obstruction resulting from thrombosis, low-dose fibrinolytic therapy was successful in restoring catheter function 70% of the time. Placement of two Hickman catheters is associated with an inordinate incidence of thrombosis. Thrombocytopenia at the time of catheter placement may delay this complication. Thrombotic catheter obstruction can be treated successfully with low-dose fibrinolytic therapy. Even without fibrinolytic therapy, catheter-induced subclavian vein thrombosis rarely causes long-term disability.

Most patients who need peripheral stem cell transplantation do not have peripheral venous access to allow apheresis for stem cell collection. Subclavian apheresis catheters have an unacceptably high incidence of thrombosis-related access failure. We have used a technique for translumbar insertion of permanent, subcutaneously tunnelled silicone rubber apheresis catheters into the inferior vena to place 58 catheters in 54 patients for stem cell collection. 37 catheters have been left in place for venous access during the transplantation procedures. These catheters had a very low rate of apheresis-related complications (3.6%). Access failure occurred due to thrombosis in 14 catheters (24%) and mechanical complications in 8 (14%) but these responded to standard therapy in all except 3 cases. Catheters functioned well as venous access devices during transplantation with only rare complications during this time. Withdrawal venograms at time of removal of 20 catheters showed a fibrin sheath in 17 cases but caval occlusion in none. There was no clinical or CT scan evidence of bleeding after placement or removal of the catheters. Percutaneously placed translumbar inferior vena cava apheresis catheters are an effective route for peripheral stem cell collection and can be left in place for venous access during transplantation.

Forty-six silicone rubber catheters were placed in the inferior vena cava (IVC) of 40 patients via a translumbar approach. No patient suffered retroperitoneal bleeding as determined by means of clinical observation (n = 46), computed tomography (CT) (n = 31), or autopsy (n = 5). Twenty-four catheters were removed after a mean of 51 (range, 2-137) days. No bleeding occurred after catheter removal, as determined by means of clinical observation (n = 24), CT (n = 13), or autopsy (n = 2). Nineteen catheters remained in place after a mean of 65 (range, 13-236) days. Thrombosis-related catheter dysfunction occurred in eight patients, two of whom developed IVC occlusion. Thrombolytic therapy restored catheter function and dissolved clots in all patients. Ten catheter malpositions resulted in venous access failure. Five of these catheters were replaced, four were repositioned, and one spontaneously resumed the original position. It is concluded that percutaneous placement of silicone rubber catheters in the IVC is a satisfactory alternative when catheter placement in the subclavian vein is not feasible.

Single- and double-lumen silicone rubber central venous catheters were subjected to in vitro destructive testing. Using this data we devised a clinical technique for the detection of central venous thrombosis incorporating mechanical injection of the catheters, serial filming, and magnification radiography. In 20 patients studied, thrombosis was detected in 12 and extravasation in 3. Two partially occluded catheters burst during forceful injection. Our technique demonstrated the presence and extent of thrombosis at the catheter tip more clearly than did other venographic methods and has been especially useful in assessing the results of thrombolytic therapy.