Playing it safe: How peripherally inserted catheters can be a safer alternative
Iker Principe, Cikautxo, offers his expertise for manufacturing anti-thrombogenic catheters:
Central venous catheter (CVC) use is a common practice in the critical care system but many patients have associated multiple risk factors for venous thromboembolism. CVC insertion has inherently associated a seldom but the realistic risk of catheter-caused thrombosis and, due to its point of insertion, is certainly uncomfortable for the patient. For non-irritant treatments and longer periods of insertion there is another more comfortable and safer alternative for the patients – peripherally inserted catheters.
Peripherally inserted catheters
Peripherally inserted central catheters (PICCs) are used to obtain central venous access in patients undergoing treatment in acute care facilities, home health agencies, cancer centers and skilled nursing care in a variety of settings. In comparison with CVCs, PICC insertions are less invasive with decreased complication risk and the PICC, being also less uncomfortable for the patient, can remain indwelling for a longer duration than other acute central access devices.
PICC typical indications are longterm chemotherapy, hyper-alimentation, antibiotic therapy, repeated infusion of blood or blood products, venous blood sampling, reduced number of needle punctures to skin and measurement of central venous pressure among others.
The PICC is usually placed today using an ultrasound technology to visualise a deep, large vessel in the upper arm and it is inserted by a specially trained and certified PICC nurse specialist or by an interventional radiologist. Ultrasound placement has been demonstrated to reduce the number of punctures per patient during insertion and is of greatest importance with those patients that are most difficult to insert (eg obese patients). The entire procedure can be done in a patient’s room decreasing discomfort, transportation and inefficiencies of other usual care procedures.
Based in this advantage of the peripheral insertion, a new family of catheters is appearing as an alternative to PICCs in those cases where the tip of the catheter can remain peripheral and does not need to go central: the midline catheters.
A midline catheter positions the tip of the catheter in the clavicular vein area (usually the axillary or subclavian veins) and for this reason are not considered class III Medical Devices, opening the possibilities of insertion to a wider range profile of medical qualified human resources. This advantage opens an excellent cost saving opportunity for hospital management. Today different varieties of midlines are being launched in the market, like the mid-clavicular, the short-midlines, the mini-midlines, others.
Thrombosis risk
With a clear trend towards an increased use of peripherally inserted catheters, the incidence of catheter-related thromboembolism diseases is likely to increase further.
There are several risk factors for the development of catheter related thrombosis. They can, broadly speaking, be categorised as risks relating to three factors: the catheter itself (for example, the catheter to vein ratio is critical), the insertion process and the patient factors. It is useful to remember, in this context, how these factors relate to Virchow’s triad of endothelial damage, stasis and hypercoagulability, described as the components involved in a thrombus formation. As a consequence, venous thrombosis has to be regarded as a multifactorial disease. In addition, in a substantial proportion of thrombosis patients, their risk factor of thrombosis is not easily detectable.
Thrombotic complications associated with the use of venous catheters lead to distressing patient symptoms, catheter dysfunction, increased risk of infections, long-term central venous stenosis, and considerable additional costs for the healthcare system.
Anti-thrombogenic catheter solutions
Symptomatic catheter-related thrombosis is treated with anticoagulation, generally without removing the catheter. The intensity and duration of anticoagulation depend on the extent of thrombosis, risk of bleeding, and need for continued use of a catheter. To date, the clinical benefit of prophylactic doses of anticoagulant has been somehow disappointing.
Some European catheter manufacturers are therefore offering power-injectable and effective PICC and Midline anti-thrombogenic catheters in the European market: it is the case of Cikautxo Medical, a Basque company specialist in silicone and thermoplastic catheter manufacturing in combination with value added solutions proposals. Its CEO, Iker Principe says: “Our customers, the big catheter branded manufacturers, can select, among other solutions, our anti-thrombogenic vascular access devices based in a covalently bonded heparin attack obtained after a sequence of different surface modifications of the original material of the catheter, which avoids clot generation not only in the catheter surface itself but also on the surface of the blood vessel”.