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HOW I DO IT
Year : 2021  |  Volume : 54  |  Issue : 1  |  Page : 36-38

Retaining venous access and eliminating radiation exposure during Hickman-Broviac catheter replacement for difficult-line insertion patients with intestinal failure


1 Department of Biology, Bioethics Program, Trinity International University, Deerfield, IL, USA; Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
2 Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
3 Department of Surgery, Far Eastern Memorial Hospital, New Taipei City; Department of Chemical Engineering and Materials Science, Yuan Ze University, Chung-Li, Taoyuan, Taiwan

Date of Submission04-Jun-2020
Date of Acceptance05-Aug-2020
Date of Web Publication22-Jan-2021

Correspondence Address:
Yun Chen
Department of Surgery, Far-Eastern Memorial Hospital, No. 21, Section 2, Nan-Ya South Road, Banciao, New Taipei City 220
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_90_20

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  Abstract 


Hickman-Broviac catheters are commonly used to access central veins for the purposes of intravenous nutrition delivery for intestinal failure (IF) patients. While these catheters are good options for accessing central veins, they often have to be replaced if catheter-related infection or occlusion occurs. Frequent replacement can be hampered by the limited venous access sites in these patients and reduce the access site's lifespan. In this technical note, we describe a technique to periodically replace Hickman-Broviac catheters without having to create a new venous access site. Without requiring radiation exposure by standardized guidewire insertion, we safely utilize the fibrotic pseudocapsule that forms around the old catheter to guide the new catheter to the central veins while creating a different exit site to prevent infection. The procedure should be performed periodically – we advocate annually – before catheter-related infection occurs. In this way, we hope to be able to provide a solution for IF patients who require life-long catheter usage but have limited venous access, while also reducing the risk of related injuries such as pneumothorax, arterial injury, or radiation exposure.

Keywords: Hickman-Broviac catheter, intestinal failure, retaining central venous access


How to cite this article:
Chu JT, Koh CC, Chen Y. Retaining venous access and eliminating radiation exposure during Hickman-Broviac catheter replacement for difficult-line insertion patients with intestinal failure. Formos J Surg 2021;54:36-8

How to cite this URL:
Chu JT, Koh CC, Chen Y. Retaining venous access and eliminating radiation exposure during Hickman-Broviac catheter replacement for difficult-line insertion patients with intestinal failure. Formos J Surg [serial online] 2021 [cited 2021 Mar 8];54:36-8. Available from: https://www.e-fjs.org/text.asp?2021/54/1/36/307626

Justin T. Chu and Chee-Chee Koh has contributed equally for this study





  Introduction Top


Hickman-Broviac catheters are a type of central venous line commonly used to access central veins in intestinal failure (IF) patients to administer total parenteral nutrition (TPN).[1] However, difficult central-line insertion is still a major problem in these patients. It is standard practice to replace catheters when catheter-related infection, catheter dislodging, breakage, or occlusion occurs. Replacing catheters means that doctors are at risk of losing the limited venous access sites that they have at their disposal. In addition, creating new access sites can be a hazardous task. Line insertions can be very difficult, and additional possible complications from placing central lines include arterial or venous injury, hematoma, pneumothorax, or arrhythmia.[2]

This technical note describes our method of retaining central venous access sites when replacing a Hickman-Broviac catheter. We safely utilize the fibrotic pseudocapsule that forms around the old catheter and without requiring radiation exposure, guide the new catheter to the same central veins while creating a different exit site to prevent infection. The procedure might be performed annually before catheter-related infection occurs. In this way, we successfully retain venous access sites for a longer period of time without risking injury to the patient or complications with infections.


  Technical Note Top


This technique is performed with the patient under general anesthesia. At the venous entrance site of the old catheter an incision is made, and the catheter is mobilized with the pseudocapsule. An 8-mm longitudinal incision is then made along the catheter using a scalpel. A small cross incision is made on the old catheter and a guidewire (0.89 mm, 80 cm in length, Radifocus Guidewire M Standard type® for 6.6Fr catheter or 0.46 mm for small caliber catheter) that is 10 cm longer than the old catheter tip is inserted [Figure 1]. Keeping the guidewire in place, the old catheter is transected at the guidewire insertion site and removed carefully. Another incision is then made for the new catheter exit site approximately 2 cm medial or lateral to the old exit site. A stylus with the new catheter attached is tunneled under the skin from the new exit site to the first incision site. After trimming the catheter to the superior vena cava level, the distal guidewire is then inserted through the new catheter tip until it comes out through the catheter end. Keeping the guidewire in place, the new catheter tip can be inserted through the pseudocapsule [Figure 2]. The guidewire is then removed, and the catheter is flushed with heparinized normal saline to test the patency. The distal part of the old catheter is then removed after suturing. No C-arm is used during this procedure. From 2016.1.1 to 2018.7.31, we performed this procedure 15 times without complications.
Figure 1: Incision through the venous insertion site and mobilization the fibrotic pseudocapsule for guidewire insertion

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Figure 2: Create a new exit site and insertion the new catheter tip through the guidewire and pseudocapsule

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  Discussion Top


Conventionally, replacing a Hickman-Broviac catheter requires surgeons to remove the existing catheter in its entirety from the venous access site and to tunnel a new catheter to a new venous access site. This becomes difficult in the long term because access sites will eventually become more difficult to access due to venous thrombosis. In addition, these procedures risk harming other anatomical systems during the process of placing the new catheter.

We report a central venous catheter technique that allows surgeons to retain venous access sites while minimizing the risk for infection and injury to the patient. At least, one other study has reported on this technique with positive results.[3] It should be noted that this is not a viable technique for patients with an infected catheter. In such cases, feeding the guidewire through the infected catheter would contaminate the guidewire and put the patient at risk for further infection. In these instances, the catheter must first be removed and replaced after the infection is controlled. Retaining old access sites using this technique is advantageous because it allows access sites to be used for longer periods of time. Using an old fibrotic pseudocapsule reduces the risk of injuring the vessels or organs near the insertion site. Annual replacement can prevent catheter-related infection and ensure pseudocapsule formation. Furthermore, a 10 cm guidewire longer than the old catheter tip can guide the new catheter to the same location without intraoperative fluoroguidance. In this way, venous access sites can be maintained while reducing the risk of bodily harm to the patient. This technique should be advocated in IF patients who need long-term TPN.

This is the first report of annual replacement of Hickman-Broviac catheters through retained venous access sites by using the fibrotic pseudocapsule through standardized guidewire insertion (about 10 cm longer than the previous catheter tip). This replacement technique can help to prevent catheter-related infection and can ensure accurate placement of the new catheter tip without radiation exposure. We hope that this technique can prolong the lifespan of venous access sites so that the best care can be provided for IF patients.

Acknowledgment

We would like to thank Miss Liang-Ying Chen for her contribution in drawing the illustration of the procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Teh A, Leong KW. Insertion of Hickman catheters by the percutaneous technique. Med J Malaysia 1995;50:353-8.  Back to cited text no. 1
    
2.
Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015;5:170-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Johnson SM, Garnett GM, Woo RK. A technique for re-utilizing catheter insertion sites in children with difficult central venous access. Pediatr Surg Int 2017;33:113-7.  Back to cited text no. 3
    


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