Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions.
The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning.
This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia.
7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions.
There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition.
Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.
J Vasc Access 2017; 18(5): 419 - 425
Article Type: ORIGINAL RESEARCH ARTICLE
AuthorsTimothy R. Spencer
- • Accepted on 03/04/2017
- • Available online on 02/08/2017
- • Published in print on 11/09/2017
This article is available as full text PDF.
Centrally inserted central catheters (CICCs) and peripherally inserted central catheters (PICCs) are used extensively in many diverse patient populations in today’s current healthcare practices. The magnitude of parenteral infusions administered through these devices can be from relatively simple therapies, such as intravenous fluids and antibiotics, to more complex therapies such as parenteral nutrition, chemotherapy regimens and critical-care measures. With the large number of devices placed in any given institution today, the potential for device malposition is almost guaranteed at some point.
Placed by physicians and non-physicians alike, many of these devices have been reported widely throughout the literature with varying levels of successes. Operator skill, experience and outcomes, whilst always important, is not always synonymous with professional qualifications, and there have been well documented benefits regarding non-physician-based central venous access device (CVAD) placement services in terms of catheter-related complications and outcomes (1, 2). In particular, nurse-led CVAD placement has shown improvement in organizational efficiency through earlier catheter placement and patient follow-up, along with regular surveillance and consultation to clinicians on appropriateness of device selection, maintenance, troubleshooting and removal. Complications and infection risks were also greatly reduced in some studies (3, 4).
Complications such as arterial puncture, pneumothorax, hemothorax, bleeding, catheter malposition, vessel erosion, catheter fracture and embolism of the catheter are often widely described in literature after central venous cannulation. Misplaced catheters have been reported in almost every possible anatomical position, including the arterial system, mediastinum, pleura, pericardium, trachea, esophagus, subarachnoid space, and other aberrant sites (5). The current ideal position for catheter tip location with the greatest safety profile in adults and children is the cavoatrial junction (CAJ) (6). Strong evidence supports correct tip location to aid in significant thrombosis risk reduction strategies (7, 8). CVAD tip location is supported internationally (Society of Interventional Radiology [SIR], Association of Anaesthetists of Great Britain and Ireland [AAGBI], Association for Vascular Access [AVA], Australia & New Zealand Intensive Care Society [ANZICS], European Society for Parenteral and Enteral Nutrition [ESPEN], Gli Accessi Venosi Centrali a Lungo Termine – Italy [GaVeCelt]) by current clinical practice guidelines, standards and recommendations.
Recent documentation of tracheo-azygos fistula (leading to patient death) after administration of a vesicant chemotherapy agent (rituximab) after a spontaneous malposition of an implanted central venous port was recently published (9). Additionally, Fernando et al (10) described malposition of a PICC in a 21-year-old who had a digital subtraction angiogram (DSA)-diagnosed thrombus in the left brachiocephalic vein (likely caused by the malpositioned left internal jugular CVAD (
Digital subtraction angiogram (DSA) performed during peripherally inserted central venous catheter insertion demonstrates a filling defect in the left brachiocephalic vein (black arrow), representing a thrombus. A left internal jugular vein central line is in situ (white arrow). Reproduced with permission from Fernando et al (10).
Frontal chest radiograph 9 days after peripherally inserted central venous catheter insertion shows a small right-sided pleural effusion (white arrow) and a curve in the distal catheter tip (black arrows). Reproduced with permission from Fernando et al (10).
Frontal chest radiograph 10 days after PICC insertion shows large bilateral pleural effusions with atelectasis. The peripherally inserted central catheter (PICC) tip remains curved (black arrows). Reproduced with permission from Fernando et al (10).
The patient developed an azygos vein perforation after 10 days of a malpositioned PICC tip. This required chest drain insertion and drainage of 2 L of parenteral nutrition solution from the patient’s chest after biochemical confirmation of the collection fluid.
In this case, the PICC was removed and the patient recovered and was discharged without serious consequence (10). This, however, highlights the importance of regular radiographic checks of CVADs for potential secondary spontaneous tip malposition, as occurrence is possibly more frequent than actually estimated. Even relatively simple changes in intrathoracic pressure, such as sneezing, coughing and vomiting can contribute to catheter malposition and should be taken into consideration if the patient has a CVAD
Other risk factors for secondary CVAD migration is movement of the catheter with changes in arm or body position. PICCs inserted in an abducted arm have been shown to migrate caudally by an average of 2 cm in adduction (11). Cranial migration can be caused by changing from a supine to standing position. There have also been reports of catheter malposition due to severe lower airways distortion (12).
To prevent the rare (13), but potentially lethal complication of cardiac tamponade, the catheter tip should ideally lie proximal to the boundaries of the pericardial sac; however, too proximal placement of the tip greatly increases the risk of thrombosis (5). Other parenteral infusions, as mentioned earlier, require greater hemodilution for successful longer-term administration and a greater reduction of potential intimal damage. Placing the CVAD tip in a vessel other than the distal SVC or the proximity of the CAJ increases the risks of catheter wedging, intimal erosion and/or perforation of vessel walls, local venous thrombosis, catheter dysfunction (6), and cranial retrograde injection, in which the infusate is directed to the head instead of the central circulation (14). The more recent benefits in the use of electrocardiogram (ECG) and doppler-based (15, 16) tip navigating technologies have also reduced the incidence of primary catheter tip malposition in both CICCs and PICCs in adult and pediatric populations (17-18-19-20) and is gaining wider acceptance within the device-inserting communities worldwide.
Malpositioning of CVADs has been described in abundance throughout previously published literature, and spontaneous correction of devices, even in infants, has been described to occur within the first 24 hours of diagnosed malposition (21). However, many techniques still require the assistance of the interventional radiology (IR) department, which is potentially costly in terms of delays in patient therapy, expensive additional product use, as well as associated costs per fluoroscopy procedures.
A retrospective database, chart and radiographic review of all CVADs with a malposition tip was performed between 1996-2014. These devices were highlighted through a Microsoft Access™ database query of all CVADs inserted by a nurse-led vascular access service at a 1000-bed multi-specialty university hospital. The study reviewed all secondary catheter malpositioning (noted on the post-insertion chest x-ray [CXR] through digital diagnostic imaging to determine if a high-flow flush technique [HFFT] showed clinical benefit in manipulating the catheter into position without the need for interventional or invasive medical procedures. This process allowed comparison of possible cost implications with other current methods of CVAD repositioning (interventional radiology/fluoroscopy). The HFFT technique can be described as a rapid manual flush using 10- to 20-cc 0.9% sterile sodium chloride, aseptically administered through the catheter via the distal lumen (to demonstrate the HFFT see Video 1 - Courtesy of Dr. J. LeDonne - showing flushing technique and a side-by-side video of catheter movement recorded under fluoroscopic conditions. The video is available online as Supplementary material at
Discovery of a malposition, when not using navigational and tip positioning techniques, can often be frustrating for the inserting proceduralist during the post-insertion x-ray review period. The process of either repeating the insertion, moving to an alternate insertion site, thus risking potential iatrogenic complications, or performing a guidewire or catheter exchange itself, is challenging in terms of clinician time management, considering the number of other competing healthcare-related tasks for the proceduralist. The influence of malpositioned catheters has significant effect on clinician workflow and efficiency, which can add to the significant costs associated with vascular access. Some examples of catheter malposition and repositioning are shown in
L) Side peripherally inserted central catheters (PICCs) curled in brachiocephalic vein (large circle) and catheter tip positioned in L) internal jugular vein (IJV) (small circle).
L) Peripherally inserted central catheters (PICCs) successfully repositioned, however catheter was retracted due to R) atrial entry.
R) Peripherally inserted central catheter (PICC) tightly looped back on itself with catheter tip aiming cephalad.
R) Peripherally inserted central catheter (PICC) now correctly positioned after HFFT.
L) Peripherally inserted central catheter (PICC) looped at subclavian/internal jugular junction (black arrow).
A total of 7450 polyurethane CVADs (ranging in size from 4, 5 or 7 French) were inserted during the review period (1996-2014). PICCs had a slightly higher number of insertions (3996) compared to CICCs (3454). The total number of catheters found to be malpositioned totaled 91/7450 (1.2%). Catheters were reviewed in two groups, pre- or post-2010, as the pre- group (17/91) were all rewired or exchanged. All post-2010 catheters (74/91) were attempted for repositioning using a HFFT. HFFT successfully repositioned 53/74 (71.6%), and 21/74 (28.4%) catheters could not be repositioned (
Catheter types and malposition rate
|CVADs = central venous access devices; PICC = peripherally inserted central catheter; CICC = centrally inserted central catheter.|
|Total CVADs (n = 7450)|
|PICC %||3996 (53.6)|
|CICC %||3454 (46.4)|
|Malpositioned catheters %||91 (1.2)|
|PICC %||86 (94.5)|
|CICC %||5 (5.5)|
Pre- and post-2010 catheter malposition data
|CVADs = central venous access devices; HFFT = high flow flush technique.|
|CVADs (n = 91)|
|Pre-2010 (rewired/exchanged) %||17 (18.7)|
|Post-2010 %||74 (81.3)|
|Rewired/exchanged %||21 (28.4)|
|Total HFFT performed %||53 (71.6)|
Results of this study show most PICCs and CICCs were successfully repositioned using a HFFT on the first attempt (86.8%). Possible limitations for successful repositioning with CICCs may be due to catheter rigidity in relation to catheter French size and anatomical insertion side. Previously reported literature demonstrates that left-sided placements are more prone to malposition (5). In this dataset, it was demonstrated that 30 (58.5%) devices were inserted on the left side, highlighting a greater chance of malposition, as opposed to 20 (41.5%) on the right side (see
Catheter malposition based on side of insertion
|PICCs = peripherally inserted central catheters; CICC = centrally inserted central catheter.|
|Malposition vessel n (%)|
|L) Basilic (PICCs)||30 (56.6)|
|R) Basilic (PICCs)||20 (37.7)|
|R) Axillary (CICC)||2 (3.8)|
|L) Internal jugular (CICC)||1 (1.9)|
Number of high flow flush technique (HFFT) attempts to reposition device based on side/site of insertion
|Number of HFFT attempts|
|Site of insertion||HFFT 1 46 (86.8%)||HFFT 2 5 (9.4%)||HFFT 3 2 (3.8%)|
|L) Basilic vein||25||4||1|
|R) Basilic vein||19||1||-|
|L) Internal jugular vein||1||-||-|
|R) Axillary vein||1||-||1|
A recent study in a US cancer-designated institute demonstrated 68% success on application of a flushing protocol by a vascular access team using a simultaneous rapid saline flush technique (SRSFT) (22). In addition, the use of the SRSFT showed a cost savings of up to 90% compared with traditional interventional repositioning procedures. This study also highlighted a low correction rate for double-lumen catheters and situations in which CVAD tips had curled or migrated into smaller veins, such as the azygos and mammary vessels (22); however, it did not specify catheter French size. Other previously documented success rates of adjusted malpositioned PICCs have been reported at 77% to 85%, which is higher than the levels reported in other studies (23).
At the time, patients were routinely sent to the Interventional Radiology (IR) department for correction, adding increased costs for catheter repositioning. These procedures were generally completed within ≤3 days of initially identifying the malposition on chest radiograph. Consequences of a prolonged malposition catheter tip delays parenteral medication administration, increases risk of thrombotic complications or exacerbates chemical-related injury due to drug therapies. This identified delay for catheter repositioning prompted the vascular access team to initiate a repositioning protocol using a documented algorithm (22). The SRSFT involved flushing both lumens simultaneously with a saline power flush using 10-cc syringes. This technique has been used successfully for approximately 10 years. Malpositioned catheters that could not be repositioned with SRSFT were over-wire or sheath exchanged using fluoroscopy.
A radiology-based service described repositioning of malpositioned PICCs using both bedside and imaging-guided techniques over an 18-month period (24). Of the 2367 attempted bedside PICC placements, 1654 (70%) were successful, with a malposition rate of 163 (10%), yet only 132 had complete documentation. Although this publication used radiological imaging to reposition the 132 malpositioned catheters, catheter exchange was performed in 76 of the 132 (58%), repositioning in 48 (36%), spontaneous correction occurred in 7 (5%) and one resulted in catheter removal (1%). While most repositions were performed using a guidewire procedure, there was only a 64% success rate described when performed at the patient’s bedside (24).
The repositioning cost of a catheter utilizing the HFFT was noted to be significantly reduced if the PICC was successfully repositioned on the first flush ($47.62), in comparison to interventional repositioning ($337.20), an overall 86% cost saving (
Cost differences between IR reposition, bedside rewire and HFFT ($AU)
|Procedural cost differences|
|Item costs (2014)||Procedure cost||Savings|
|IR = interventional radiology; HFFT = high flow flush technique; PICC = peripherally inserted central catheter; CXR = chest x-ray.|
|Fluoroscopic PICC repositioning||$337.20||$337.20||-|
|Cost for bedside replacement||$200.55||$136.65|
|Use of HFFT|
|1st HFFT (prefilled)||$0.53||-||-|
|Cost of HFFT||$47.68||$289.52|
Procedural item costs ($AU) comparing plain and pre-filled syringes
|Individual item costs|
|HFFT||CXR||0.9% Sodium chloride (10 cc)||Blunt needle||Syringe||CHG/IPA swab||Total cost|
|HFFT = high flow flush technique; CXR = chest x-ray; CHG = chlorhexidine gluconate; IPA = isopropyl alcohol.|
Malpositioned catheters that are often considered clinically dubious are generally removed or replaced (potentially after some delay). In some instances, these malpositioned devices can be inappropriately left in place, putting the patient at serious risk of venous thrombosis from vessel injury to more serious complications. This little-known procedure is based on an old maneuver, occasionally adopted in clinical practice – yet it is rarely described in the literature.
This study shows hopeful signs that the use of HFFT demonstrates a suitable and potentially safe and cost-efficient process to reposition CVADs found during the post-insertion review process. This study demonstrated a reduction of potential radiological interventions required to reposition the catheter. This saved considerable time, particularly in patient treatment delays, as well as a relative cost saving compared to more invasive interventions.
Non-invasive techniques, such as HFFT or SRSFT (22) help optimize repositioning of vascular access devices when performed by appropriately trained vascular access teams and other specialist clinicians knowledgeable in this technique. Adding to this is the importance of ECG for catheter tip positioning during the insertion process, which would potentially reduce any primary catheter malposition.
Ongoing research is still essential to evaluate the success of CVAD repositioning using the HFFT in comparison to bedside over-wire catheter exchanges and interventional or fluoroscopic repositioning. This straightforward practice-based evidence indicates that this procedure is a relatively safe, cost-efficient intervention to undertake catheter repositioning with minimal delay to patients’ prescribed therapies within either an inpatient or outpatient settings.
Wagner R Pokorny P Cernosek J Karampinis D Comparison between novel tip positioning technology using ECG and Doppler and 2-D Echocardiography for the placement of central catheters. Available from http://www.teleflex.com/en/usa/productAreas/vascularAccess/documents/vps-posters/2014-2732.pdf.Accessed April 30, 2017.
Article usage statistics
This article has supplementary materials available to download.
Download any of the following attachments: