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Systematic review of the safety and efficacy of contrast injection via venous catheters for contrast-enhanced computed tomography

Open AccessPublished:October 03, 2017DOI:https://doi.org/10.1016/j.ejro.2017.09.002

      Highlights

      • In ICU patients, contrast injection via central venous catheters is a safe alternative to peripheral injection.
      • Implementing a safety protocol before power injection via central venous catheters is advisable.
      • The quality of scans varies and remains not sufficiently investigated in scans with higher flow rates.

      Abstract

      Objective

      To examine the safety and efficacy of contrast injection through a central venous catheter (CVC) for contrast-enhanced computed tomography (CECT).

      Methods

      A systematic literature search was performed using PubMed. Studies were deemed eligible if they reported on the use of CVCs for contrast administration. Selected articles were assessed for their relevance and risk of bias. Articles with low relevance and high risk of bias or both were excluded. Data from included articles was extracted.

      Results

      Seven studies reported on the use of CVCs for contrast administration. Catheter rupture did not occur in any study. The incidence of dislocation ranged from 2.2-15.4%. Quality of scans was described in three studies, with less contrast enhancement of pulmonary arteries and the thoracic aorta in two studies, and average or above average quality in one study. Four other studies used higher flowrates, but did not report quality of scans.

      Conclusion

      Contrast injection via CVCs can be performed safely for CECT when using a strict protocol. Quality of scans depended on multiple factors like flow rate, indication of the scan, and cardiac output of the patient. In each patient, an individual evaluation whether to use the CVC as access for contrast media should be made, while bolus tracking may be mandatory in most cases.

      Abbreviations:

      CVC (central venous catheter), CECT (contrast-enhanced computed tomography), PICC (peripherally inserted central catheter), TIVAP (totally implantable venous access ports), SVC (superior vena cava), PIPICC (power injectable peripherally inserted central catheter), CT-PICC (CT-injectable peripherally inserted central catheter)

      Keywords

      1. Introduction

      Central venous catheters (CVCs) are frequently used in critically ill patients requiring continuous intravenous infusions. In many of those patients, CVCs remain the only venous access site, because placement of peripheral intravenous catheters is challenging due to edematous states or recurrent phlebitis. CVCs are also used in patients in need of frequent intravenous access or when toxic drugs need to be administered. Different types of CVCs exist: classic and most frequently used non-tunneled and tunneled CVCs, implantable ports, and peripherally inserted central catheters (PICC) [
      • Plumb A.
      • Murphy G.
      The use of central venous catheters for intravenous contrast injection for CT examinations.
      ]. Each type of catheter has its own maximal flowrate and pressure limit according to the manufacturer [
      • Plumb A.
      • Murphy G.
      The use of central venous catheters for intravenous contrast injection for CT examinations.
      ]. When present, CVCs are the easiest way for the administration of iodine-based contrast for performing enhanced computed tomography (CECT) examinations. Standard CT injection protocols require contrast volumes ranging from 75 to 150 mL with an injection rate between 3 and 5 mL/s [
      • Friebe M.
      Computed tomography and magnetic resonance imaging contrast media injectors: technical feature review −what is really needed?.
      ]. Currently, most manufacturers of CVCs do not recommend high flow rates via CVCs, due to the risk of rupture, displacement, contrast media extravasation, catheter dysfunction, and thrombosis [
      • Carlson J.E.
      • Hedlund L.J.
      • Trenkner S.W.
      • Ritenour R.
      • Halvorsen R.A.
      Safety considerations in the power injection of contrast media via central venous catheters during computed tomographic examinations.
      ,

      FDA, Reminders from FDA Regarding Ruptured Vascular Access Devices from Power Injection, http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm070193.htm. (Accessed 18 September 2016).

      ]. Several manufacturers produce CVCs specifically designed for so-called power injection [

      Bard Access Systems, Power PICC, http://www.bardaccess.com/products/nursing/powerpicc. (Accessed 12 February 2017).

      ,

      Cook Medical, Turbo-Ject Power-Injectable Peripherally Inserted Central Catheters, https://www.cookmedical.com/products/ir_tjpicvc_webds/. (Accessed 12 FEBRUARY 2017).

      ,

      Arrow International, Arrow Pressure Injectable PICC, http://www.arrowintl.com/products/literature/#16. (Accessed 12 February 2017).

      ,

      AngioDynamics, Morpheus CT Peripherally Inserted Central Catheter, http://www.angiodynamics.com/product-price-list/?id=26. (Accessed 12 February 2017).

      ]. This systematic review evaluates whether CVCs can be safely used for the administration of intravenous contrast agents, particularly at higher injection rates for obtaining high-quality images.

      2. Methods

      2.1 Search strategy and selection

      A systematic literature search was performed on September 10th, 2016 using PubMed. A search query was built by linking two content areas: ‘central catheter’ and ‘contrast enhanced’ with relevant synonyms for both areas: ((central line[Title/Abstract] OR central catheter[Title/Abstract] OR CVC[Title/Abstract] OR central venous[Title/Abstract] OR PICC[Title/Abstract] OR port-a-cat*[Title/Abstract] OR PAC[Title/Abstract] OR Port a cath[Title/Abstract] OR jugular line[Title/Abstract] OR jugular catheter[Title/Abstract] OR subclavian line[Title/Abstract] OR subclavian catheter[Title/Abstract])) AND (CT[Title/Abstract] OR CECT[Title/Abstract] OR contrast enhanced[Title/Abstract] OR contrast-enhanced[Title/Abstract] OR power injection[Title/Abstract] OR power injector).
      PubMed was searched systematically to identify original publications on the use of CVCs for contrast administration for CT-scans focusing on safety, efficacy, and complications. Exclusion criteria included: no full-text available, publication not written in English or Dutch, review articles, case reports, and studies focusing on the use of CVCs in pediatrics. Duplicate publications were excluded. A cross-check of reference lists from selected articles was performed to identify articles missed by the initial search. Screening of title, abstract, and full text was performed by two authors (SBB, MWB) independently. Disagreements were discussed until consensus was reached. The reference lists of the selected articles were hand searched for relevant cross-References

      2.2 Study assessment

      The remaining articles were assessed for their relevance and risk of bias by two authors (SBB, MB) independently using predefined criteria (Table 1). Studies were classified as highly relevant if they complied with all criteria and moderately relevant if the reported outcome only included safety or efficacy. Studies were classified as having low risk of bias if they satisfied all criteria and high risk of bias if they satisfied less than three criteria. The remaining studies were classified as having a moderate risk of bias. Studies were only included for further analysis if they scored high or moderate on relevance and carried a low or moderate risk of bias. Discordances were discussed until consensus was reached.
      Table 1Study assessment.
      Study (year)RelevanceRisk of biasIncluded for analysis
      PatientsOutcome: safetyOutcome: efficacyStandardization of testBlindingSelective reportingComplete data
      Carlson et al (1992)
      • Carlson J.E.
      • Hedlund L.J.
      • Trenkner S.W.
      • Ritenour R.
      • Halvorsen R.A.
      Safety considerations in the power injection of contrast media via central venous catheters during computed tomographic examinations.
      NANo
      Coyle et al (2004)
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      Yes
      Goltz et al (2011)
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      Yes
      Herts et al (2001)
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      Yes
      Lozano et al (2012)
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      NAYes
      Macht et al (2012)
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      NAYes
      Morden et al (2014)
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      NAYes
      Sanelli et al (2004)
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      NAYes
      NA = not applicable
      Relevance
      Patients: ● = patients with a central catheter
      Outcome: safety: ● = data on complications, injection rate and pressure; ○ = data on either complications, injection rate and pressure
      Oucome: efficacy: ● = data on quality of images; ○ = no data on quality of images
      Risk of bias
      Standardization of test: ● = yes;   = no
      Blinding: ● = reviewer of quality of the images was blinded for route of injection; ○ = reviewer was not blinded
      Selective reporting: ● = adequate sample selection; ○ = inadequate sample selection
      Completeness of outcome data: ●<10% missing data; ○>10% missing data

      2.3 Data analysis

      Incidences of complications were extracted from the selected studies were tabulated and presented as percentages. Data on quality of images was extracted where applicable. Numerators and denominators were provided when reported in the articles.

      3. Results

      3.1 Search and selection

      The literature search yielded 484 unique hits. Twenty-three articles were considered eligible for answering the research question after selection based on title and abstract. Seventeen articles were excluded during full text screening because of the following reasons: incorrect domain (n = 1) [
      • Rogalla P.
      • Meiri N.
      • Thoeni R.
      • Goldberg H.
      • Hamm M.
      Safe and easy power injection of contrast material through a central line.
      ], outcome not focusing on safety, efficacy, and complications (n = 1) [
      • Teichgräber U.K.M.
      • Nagel S.N.
      • Kausche S.
      • Enzweiler C.
      Clinical benefit of power-injectable port systems: a prospective observational study.
      ], CVC use in pediatrics (n = 7) [
      • Kaste S.C.
      • Young C.W.
      Safe use of power injectors with central and peripheral venous access devices for pediatric CT.
      ,
      • Kim F.M.
      • Burrows P.E.
      • Hoffe F.A.
      • Chung T.
      Interpreting the results of pediatric central venous cathe- ter studies1.
      ,
      • Moriarty J.M.
      • Kung G.L.
      • Ramos Y.
      • Moghaddam A.N.
      • Ennis D.B.
      • Paul Finn J.
      Injection of gadolinium contrast through pediatric central venous catheters: a safety study.
      ,
      • Rigsby C.K.
      • Gasber E.
      • Seshadri R.
      • Sullivan C.
      • Wyers M.
      • Ben-Ami T.
      Safety and efficacy of pressure-limited power injection of iodinated contrast medium through central in children.
      ,
      • Roche K.J.
      • Genieser N.B.
      • Ambrosino M.M.
      • Roche K.J.
      • Genieser N.B.
      • Ambrosino B.M.M.
      Pediatric hepatic CT: an injection protocol.
      ,
      • Callahan M.J.
      • Servaes S.
      • Lee E.Y.
      • Towbin A.J.
      • Westra S.J.
      • Frush D.P.
      Practice patters for the use of iodinated IV contrast media for pediatric CT studies: a survey of the society for pediatric radiology.
      ,
      • Donnelly L.F.
      • Dickerson J.
      • Racadio J.M.
      Is hand injection of central venous catheters for contrast-enhanced CT safe in children?.
      ], in vitro studies (n = 4) [
      • Rivitz S.M.
      • Drucker E.A.
      Power injection of peripherally inserted central catheters l.
      ,
      • Williamson E.E.
      • Mckinney J.M.
      Assessing the adequacy of peripherally inserted central catheters for power injection of intravenous contrast agents for CT.
      ,
      • Zamos D.T.
      • Emch T.M.
      • Patton H.A.
      • D’Amico F.J.
      • Bansal S.K.
      Injection rate threshold of triple-Lumen central venous catheters: an In vitro study.
      ,
      • Macha D.B.
      • Nelson R.C.
      • Howle L.E.
      • Hollingsworth J.W.
      • Schindera S.T.
      Central venous catheter integrity during mechanical power injection of iodinated contrast medium.
      ], no original article (n = 3) [
      • Plumb A.
      • Murphy G.
      The use of central venous catheters for intravenous contrast injection for CT examinations.
      ,
      • Bonciarelli G.
      • Batacchi S.
      • Biffi R.
      • Buononato M.
      • Damascelli B.
      • Ghibaudo F.
      • Orsi F.
      • Pittiruti M.
      • Scoppettuolo G.
      • Verzè A.
      • Borasi G.
      • de Cicco M.
      • Dosio R.
      • Gazzo P.
      • Maso R.
      • Roman A.
      • Ticha V.
      • Venier G.
      • Blackburn P.
      • Goossens G.A.
      • Santolucito J.B.
      • Stas M.
      • van Boxtel T.
      • Vesely T.M.
      • de Lutio E.
      GAVeCeLT consensus statement on the correct use of totally implantable venous access devices for diagnostic radiology procedures.
      ,
      • Marcy P.Y.
      • Guiffant G.
      • Flaud P.
      Catheter tip displacements at power PICC CT injection.
      ], and not meeting language requirements (n = 1) [
      • Chang D.
      • Kabbasch C.
      • Bovenschulte H.
      • Libicher M.
      • Maintz D.
      • Bangard C.
      Komplikationsrate, Patientenzufriedenheit und klinischer Einsatz nach Implantation eines Port- kathetersystems mit Zulassung zur Hochdruckinfusion.
      ]. During cross referencing, one study was included missed by the initial search [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ]. Eventually, eight studies were eligible for critical appraisal (Table 1) [
      • Carlson J.E.
      • Hedlund L.J.
      • Trenkner S.W.
      • Ritenour R.
      • Halvorsen R.A.
      Safety considerations in the power injection of contrast media via central venous catheters during computed tomographic examinations.
      ,
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ,
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      ,
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      ,
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      ,
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      ,
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      ,
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ].

      3.2 Study assessment

      Three studies scored high on relevance [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ,
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      ,
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ] and five scored moderate on relevance [
      • Carlson J.E.
      • Hedlund L.J.
      • Trenkner S.W.
      • Ritenour R.
      • Halvorsen R.A.
      Safety considerations in the power injection of contrast media via central venous catheters during computed tomographic examinations.
      ,
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      ,
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      ,
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      ,
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      ]. The risk of bias was low in one study [
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      ], moderate in six studies [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ,
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      ,
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      ,
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      ,
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      ,
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ], and high in one study [
      • Carlson J.E.
      • Hedlund L.J.
      • Trenkner S.W.
      • Ritenour R.
      • Halvorsen R.A.
      Safety considerations in the power injection of contrast media via central venous catheters during computed tomographic examinations.
      ] (Table 1). Carlson et al. [
      • Carlson J.E.
      • Hedlund L.J.
      • Trenkner S.W.
      • Ritenour R.
      • Halvorsen R.A.
      Safety considerations in the power injection of contrast media via central venous catheters during computed tomographic examinations.
      ] evaluated the system pressure in thirteen patients with Port-A-Caths. The pressure measurement was not standardized: five patients’ injection pressures were measured with a pressure gauge that was placed in-line during injection and eight patients’ injection pressures were not. They did not report on the quality of the CT images and only one sentence addressed the absence of complications. The lack of standardization and limited relevance made us decide to exclude this study from data analysis. Finally, seven studies [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ,
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      ,
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      ,
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      ,
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      ,
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      ,
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ] were included for further analysis (Table 2).
      Table 2Results.
      Study (year)nType of studyType of CVCInjection rate and peak injection pressureOutcome: complicationsOutcome: image quality
      Coyle (2004)
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      110PS12 SL 5F PICC 98 DL 5F PICC1–2 mL/s (n = 8), 2 mL/s (n = 89), 2–3 mL/s (n = 9), 4 mL/s (n = 4) SL: 16–79 psi, DL: 40–135 psi.2 (1.8%) ruptured 1 ballooning (DL, 4 mL/s)81 average; 23 above average; 6 below average
      Goltz (2011)
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      141 vs 50 peripheral catheterRS141 TIVAP forearmTIVAP: Max 1.5 mL/s; mean pressure 121.9 ±24.1 psi Peripheral: 3 mL/s, pressure limit 300 psi1 (0.7%) dislocation with rupture3 (2.1%) suspected systemic infection <4 weeks31/44 (70.4%) trigger threshold not reached Significant higher aortic contrast via peripheral catheter
      Herts (2001)
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      174 vs 51 peripheralRCT117 port-type, 41 3L, 10 DL, 6 unknownCVC: 1.5–2 mL/s, pressure cut-off 100 psi Peripheral: 2.5–3 mL/s, pressure cut-off 300 psi1 (0.6%) CVC no longer patent1 positive blood cultureLess contrast enhancement in thoracic aorta, pulmonary artery, liver in CVC group
      Lozano (2012)
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      78PSPower injectable PICC (4–6F, SL/DL)Mean injection rate 4.13 ± 0.855 mL/s (range 3–5); pressure limit 300 psi12/78 (15.4%) dislocation
      Macht (2012)
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      104RSDistal 16G lumen of Arrow multi-lumen (3L, 5L)3L: 4.4 ± 0.5 mL/s; 200.7 ± 17.5 psi5L: 4.6 ± 0.6 mL/s; 194.5 ± 6.5 psiNo complications
      Morden (2014)
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      243 high rate vs. 138 rate increaseRSCT-PICC (4–6F, SL/DL/3L)Injection rates 2–5 mL/s Pressure limit 300 psi20/243 (8.2%) displaced vs. 3/138 (2.2%)
      Sanelli (2004)
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      104PSArrow multi-lumen CVC (n = 89)Percutaneous sheaths IJV (n = 15)3 mL/s (n = 15); 4 mL/s (n = 8); 4 mL/s (n = 79); 5 mL/s (n = 2) Pressure limit 300 psi; 5/43 pressure-limited (306–316 psi)13/60 (21,7%) blood cultures positive during ICU course
      Legend: CVC = central venous catheter, PS = prospective study, SL = single lumen, F = French, PICC = peripherally inserted central catheter, DL = double lumen, RS = retrospective study, TIVAP = totally implantable venous access port, RCT = randomized controlled trial, 3L = triple-lumen, G = gauge, 5L = quintuple-lumen, IJV = inferior jugular vein, ICU = intensive care unit

      3.3 Data analysis − safety

      The study characteristics and main results are presented in Table 2. Coyle et al. [
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ] found two (2/110; 1.8%) externally ruptured PICCs while injected at a rate of 2 mL/sec. However, the ruptures were caused by mechanic obstructions; i.e. one of the ruptured PICCs was clamped, the other kinked at the venous entry site. Another PICC ballooned without rupturing and further injected was stopped. Goltz et al. [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ] evaluated power injections in 141 patients with totally implantable venous access ports (TIVAPs) in their forearm. One (1/141; 0.7%) TIVAP’s tip was dislocated in the brachiocephalic vein and revealed a catheter rupture during an interventional retrieval attempt. Three (3/141; 2.1%) TIVAPs were removed due to suspected systemic infection within four weeks after power injection, which was confirmed with positive cultures in one case. Herts et al. randomized 225 patients, after reassignment because of inability to obtain access, in a central venous access group (n = 174) and a peripheral venous access group (n = 51). No significant differences in early, delayed, and late complications were found. In the central venous access group, one (1/174; 0.6%) patient reported that her device was no longer patent, while being successfully used for chemotherapy after contrast injection. In one (1/174; 0.6%) patient an infection was reported. Two studies implemented a strict safety protocol, in which they verified the correct position of the CVC in the superior vena cava (SVC) on scout view before contrast injection, checked for adequate blood return, and checked the patency of the catheter afterwards. They did not report complications relating to the injection using the CVC [
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      ,
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      ]. Although one of these studies reported 13/60 (21.7%) patients with positive blood cultures during admittance on the intensive care unit, they reported that this may not necessarily be due to the contrast injection using the CVC [
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      ]. These thirteen patients received multiple drug therapies through the same CVC and the positive blood culture rate is consistent with previously published reports in literature [
      • Beutz M.
      • Sherman G.
      • Mayfield J.
      • Fraser V.J.
      • Kollef M.H.
      Clinical utility of blood cultures drawn from central vein catheters and peripheral venipuncture in critically ill medical patients*.
      ,
      • Charalambous C.
      • Swoboda S.M.
      • Dick J.
      • Perl T.
      • Lipsett P.A.
      Risk factors and clinical impact of central line infections in the surgical intensive care unit.
      ]. Lozano et al. [
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      ] evaluated the frequency of displacement of power injectable PICC (PIPICC) after contrast injection. Correct catheter position was defined as cephalic to or caudal to the right tracheobronchial angle. A total of 12/78 (15.4%) PIPICC tips changed in position after injection of contrast medium. Seven displaced toward the brachiocephalic veins. They found that PIPICCs positioned in the proximal SVC (cephalic to tracheobronchial angle) before contrast administration had a higher risk of displacement compared to catheters positioned in the distal SVC (caudal to tracheobronchial angle) before contrast administration (5/8 (62.5%) vs. 7/69 (10.1%)). Distal location in the SVC decreased this risk by 89% (RR 0.11 [CI 0.026-0.487], p = 0.006). Displacement of central catheters in non-central positions like the brachiocephalic vein is associated with an increased risk of thrombosis and the authors recommend checking the position of the CVC after power injection[
      • Qiu X.-X.
      • Guo Y.
      • Fan H.-B.
      • Shao J.
      • Zhang X.-B.
      Incidence, risk factors and clinical outcomes of peripherally inserted central catheter spontaneous dislodgment in oncology patients: a prospective cohort study.
      ]. Morden et al. [
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      ] evaluated a rate increase technique of the saline flush after contrast injection via CT-injectable PICCs (CT-PICC), in which they started with a saline flush at 2 mL/s and progressively increased to the rate of contrast injection. With this technique, they found a lower incidence of CT-PICC tip displacement (20/243 (8.2%) without rate increase technique vs. 3/138 (2.2%) with rate increase technique).

      3.4 Data analysis − efficacy

      Goltz et al. [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ] found a significantly lower arterial contrast density in patients with TIVAPs compared with classic peripheral cannula, resulting in limited image quality. In 31/44 (70.4%) examinations, manual initialization was necessary, while initial arterial bolus tracking was performed, because the trigger threshold had not been reached in time. This might be the result of the lower flow rate of 1.5 mL/s through TIVAPs. Triggering with automatic scan initiation resulted in significantly higher contrast in the aorta compared to manual scan initiation (163 HU vs 144 HU, p = 0.039), concluding automatic scan initiation should be aimed at. In Herts et al., two reviewers who were blinded for route of injection measured the enhancement of the large vessels. The level of enhancement of the thoracic aorta, pulmonary artery, and liver vasculature was significantly less dense in the central venous access group compared to the peripheral venous access group [
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      ]. No significant difference was seen in the enhancement of the abdominal aorta. In Coyle et al. CT images were assessed subjectively by the radiologist supervising the CT examination, which resulted in categorizing the quality of CT images as average in 81/110 (74%) of cases and above average in 23/110 (21%) of cases.

      4. Discussion

      The most reported complication of contrast injection through a CVC was rupture of the CVC, with incidences ranging from 0% to 1.8% due to mechanical obstructions. Late complications as suspected infection of CVCs were observed in 0.6% to 2.1% of cases. These suspected infections may very well not be the result of using the CVC for contrast injection, as the CVCs are frequently used for administration of other agents. The incidence of suspected infections did not differ from other previously reported incidences of catheter infections [
      • Beutz M.
      • Sherman G.
      • Mayfield J.
      • Fraser V.J.
      • Kollef M.H.
      Clinical utility of blood cultures drawn from central vein catheters and peripheral venipuncture in critically ill medical patients*.
      ,
      • Charalambous C.
      • Swoboda S.M.
      • Dick J.
      • Perl T.
      • Lipsett P.A.
      Risk factors and clinical impact of central line infections in the surgical intensive care unit.
      ]. When assessing CVC displacement, the incidence ranged from 2.2% to 15.4%. Catheter displacement carries a higher risk for thrombosis of CVC [
      • Qiu X.-X.
      • Guo Y.
      • Fan H.-B.
      • Shao J.
      • Zhang X.-B.
      Incidence, risk factors and clinical outcomes of peripherally inserted central catheter spontaneous dislodgment in oncology patients: a prospective cohort study.
      ]. None of the studies reported thrombosis, which may have been the result of following a strict protocol, including checking the localization of CVC before and after scanning. Catheter displacement can be reduced when saline is flushed with the rate increase technique [
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      ].
      Data on efficacy was inconsistent. Power injection via TIVAPs at a flow rate of 1.5 mL/s leads to inadequate arterial contrast density, which is mandatory if pulmonary embolism or liver metastasis are suspected [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ]. Flowrates of 1.5 mL/s may be too slow for adequate aortic contrast density. Additionally, bolus tracking was not successful in 70.4% of the scans, with no good explanation why bolus tracking failed. Vascular enhancement of the pulmonary artery and thoracic aorta were inadequate when injecting through the Bardport and triple-lumen Hickman catheters as well[
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      ]. One study reported satisfactory quality of scans [
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ]. This discrepancy may be explained by the difference in scoring of quality. The latter study subjectively reported quality of scans, with no mention of Hounsfield units measured [
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ]. This may indicate that while injection of contrast media via CVCs leads to decreased contrast enhancement, it does not necessarily results in diagnostic accuracy. The need for vascular enhancement (i.e. with pulmonary embolism) should be evaluated for determining whether or not to use CVCs as access for contrast media. On the other hand, all three studies’ flowrates barely exceeded 3 mL/sec [
      • Goltz J.P.
      • Machann W.
      • Noack C.
      • Hahn D.
      • Kickuth R.
      Feasibility of power contrast injections and bolus triggering during CT scans in oncologic patients with totally implantable venous access ports of the forearm.
      ,
      • Herts B.
      • O’Malley C.M.
      • Wirth S.L.
      • Lieber M.L.
      • Pohlman B.
      Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.
      ,
      • Coyle D.
      • Bloomgarden D.
      • Beres R.
      • Patel S.
      • Sane S.
      • Hurst E.
      Power injection of contrast media via peripherally inserted central catheters for CT.
      ], in contrast to the other four studies who used median flowrates of 4 mL/sec [
      • Macht S.
      • Beseoglu K.
      • Eicker S.
      • Rybacki K.
      • Braun S.
      • Mathys C.
      • Antoch G.
      • Turowski B.
      Safety and feasibility in highly concentrated contrast material power injections for CT-perfusion studies of the brain using central venous catheters.
      ,
      • Sanelli P.C.
      • Deshmukh M.
      • Ougorets I.
      • Caiati R.
      • Heier L.A.
      Safety and feasibility of using a central venous catheter for rapid contrast injection rates.
      ,
      • Sosa Lozano L.A.
      • Marn C.
      • Goodman L.R.
      Power injectable peripherally inserted central venous catheter lines frequently flip after power injection of contrast.
      ,
      • Morden P.
      • Sokhandon F.
      • Miller L.
      • Savin M.
      • Kirsch M.
      • Farah M.
      • Silbergleit R.
      The role of Saline flush injection rate in displacement of CT-Injectable peripherally inserted central catheter tip during power injection of contrast material.
      ]. The quality of scans when using higher flowrates remains underexposed.
      The different types of CVC, warming of contrast media, injection rates, and pressure cut-offs limits us in making a generalized advice on the applicability of CVC for contrast injection. Patient-related factors need to be taken into consideration as well. Patient body size and cardiac output affect contrast enhancement [
      • Bae K.T.
      Intravenous contrast medium administration and scan timing at CT: considerations and approaches.
      ]. Contrast enhancement will be lower in larger patients. Similarly, in patients with decreased cardiac output, the contrast material bolus arrival and clearance will be delayed, resulting in delayed but stronger peak arterial and parenchymal enhancement [
      • Bae K.T.
      Intravenous contrast medium administration and scan timing at CT: considerations and approaches.
      ]. When timing is critical, a bolus-tracking technique should be used.
      An important limitation of this review is the differing in types of CVC, contrast and injection rates used in the included studies. Another limitation is the possibility of publication bias in our original literature. However, we tried to reduce other limitations by using strict and predefined criteria for the inclusion of studies to be able to draw conclusions from available literature.

      5. Conclusion

      Contrast injection via CVCs is a safe alternative to peripheral injection if a strict protocol is followed. Implementing a safety protocol before power injecting via CVC is advisable. This safety protocol should include aspirating blood before injecting contrast media, localizing the CVC before and after injection, making sure no kinking of the CVC and attached lines occurs, using sterile syringes, and making sure the CVC is patent after scanning. The quality of scans varies and remains not sufficiently investigated in scans with higher flow rates.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Conflict of interest

      The authors declare no conflict of interest.

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