Sonographische Nachuntersuchung der Vena jugularis interna nach venenerhaltender, chirurgischer Implantation eines Port-a-Cath® oder Hickman-Katheters®

Ritz, Laura Antonia (2023): Sonographische Nachuntersuchung der Vena jugularis interna nach venenerhaltender, chirurgischer Implantation eines Port-a-Cath® oder Hickman-Katheters®. Dissertation, LMU München: Medizinische Fakultät

Abstract

Introduction: Hickman Catheter® or Port-a-Cath® are subcutaneously tunneled central venous long-term catheters (catheters) commonly used in pediatrics. This study followed up on children who had a catheter implanted in the internal jugular vein (IJV) using vessel sparing surgical venous cut-down (surgical exposure and opening of a vein). The aim of the study was to describe the condition of the IJV. The results obtained should be compared with the results from the literature, in particular with the results after implantation of a catheter using the Seldinger technique (sonographic-assisted puncture of the vein with insertion of a catheter with the aid of an elastic guide probe). Material and methods: Patients of up to and including 18 years of age with unilateral surgical catheter placement and removal at the time of the study were included. Surgery and Doppler sonographic follow-up examinations were performed at the Department of Pediatric Surgery at the Dr. von Hauner Children’s Hospital, Ludwig-Maximilians-University of Munich. In the course of the follow-up, the IJV was examined for two possible outcomes: relevant and non-relevant vascular changes. A vascular change (venous occlusion, stenosis, dilatation, endothelial vascular lesion) was considered relevant if it caused a Doppler sonographic change in the blood flow pattern. Results: There were 100 patients followed up, 58 of whom were boys. Age ranged from 33 days to 18 years (mean, M: 6 years). In 93 patients (93%) the catheter was implanted for chemotherapy or stem cell transplantation, in only 7 patients (7%) for parenteral nutrition (PN). The catheter remained in place for 25 days to 3.8 years (M: 271 days). The follow-up interval ranged from same-day follow-up to 13 years after catheter removal (M: 54 months). All catheters (100%) were safely placed in the IJV, with no surgery-associated complications. Surgical time varied between 20 and 115 minutes (M: 56 minutes). Twenty-two patients (22%) showed relevant venous change, of which 13 patients (13%) with high-grade stenosis or lesion and 9 patients (9%) with venous occlusion. Discussion: Our data shows that venous cut-down is associated with a longer operation time (56 minutes versus 19 minutes using the Seldinger technique) on the one hand, but on the other hand with successful implantation (100% versus 90.3-91.6% using the Seldinger technique) without operation-associated complications (such as pneumothorax, hemopericardium, catheter malposition). Since a correct position and immediate accessibility of the catheter is indispensable for most indications for a Hickman Catheter® or Port-a-Cath®, this represents the main advantage of venous cut-down over the Seldinger technique. However, relevant venous changes occur almost twice as often after venous cut-down as after the Seldinger technique (22% versus 12%). The difference is even more pronounced in the occlusion rate, which is 3 times higher after venous cut-down than using the Seldinger technique (9% versus 3%). Despite the occurrence of relevant venous changes after venous cut-down in almost a quarter of patients, only catheter-associated sepsis and tumor-associated thrombosis correlated significantly with the development of relevant venous changes in the statistical analysis. However, due to the small number of cases, the results should be evaluated with caution. Some occurrences should nevertheless be highlighted, even if no statistically significant correlation could be described. For example, the dwell time of the catheter seems to have an effect on the development of relevant venous changes. Patients with a catheter indwelling time of > 365 days showed almost twice as many relevant venous changes as patients with an indwelling time of < 1 year. It becomes even clearer when the patients are examined separately with regard to PN and chemotherapy or stem cell therapy. Here, relevant venous changes occur in 43% (after PN) compared to 20% (after chemo- or stem cell therapy) of the cases. This also corresponds to the results of other publications. Since the catheter is usually used for several years in the case of PN, this also supports the hypothesis of a correlation between long indwelling time and the development of relevant venous changes. In summary, venous cut-down can be seen as a safe method without surgery-associated risks. Therefore, this method appears superior to the Seldinger technique when the indication is an upcoming chemotherapy or stem cell therapy. In these cases, safe placement of the catheter, which is immediately accessible, should be seen as a priority. However, if the indication for the long-term catheter is PN and, as in the case of short bowel syndrome, it is usually needed for many years, it seems advisable to use the less traumatizing Seldinger technique. This allows for multiple punctures of the vein over the course of a lifetime.

• Dokumententyp: Dissertationen (Dissertation, LMU München)
• Keywords: Hickman Katheter, Gefäßerhaltende Venae sectio, zentral venöser Langzeitkatheter, Gefäßveränderungen nach Langzeitkatheter, Kinderchirurgie
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften ; 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• Fakultäten: Medizinische Fakultät
• Sprache der Hochschulschrift: Deutsch
• Datum der mündlichen Prüfung: 25. Mai 2023
• 1. Bericht­erstatter:in: Hubertus, Jochen