New technique for fixation of Broviac catheters☆

Materials and methods 

Through a transverse neck incision, the internal or external jugular vein is isolated between 2 vascular slings. The exit wound is made lateral and superior to the ipsilateral nipple. A metal tunneller then is passed through the exit wound to emerge through the neck wound.

The catheter and 3-0 Polyglactin tie are passed through the eye of the tunneller, and the tie is secured (Fig 1).

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Fig. 1. Diagram shows 3-0 polyglactin tie and Broviac ready to be pulled through the subcutaneous tunnel. The eye of the tunneller is made much wider in the diagram, for clarity.

Just before the cuff is pulled into the subcutaneous tunnel through the exit wound, the lower end of the 3-0 Polyglactin tie is tied securely around the catheter, just external to the cuff. Then by pulling on the catheter and tie from the top end, the cuff is positioned 2 to 3 cm above the exit wound (Fig 2).

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Fig. 2. Diagram shows lower end of 3-0 polyglactin tied around the inferior margin of the cuff, and the cuff positioned 2 to 3 cm above the exit wound.

The catheter is inserted into the vein and positioned appropriately. A 3-0 Polyglactin suture is used to approximate the 2 heads of sternocleidomastoid muscle. The upper end of the internal anchoring suture us tied to this anchoring suture without any slackness or tension (Fig 3).

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Fig. 3. Internal fixation tie in position.

Results 

We have placed this suture, together with the traditional exit wound anchoring suture, in 80 consecutive Broviac catheters over a period of 14 months. Fifty-one of these children were boys and 29 girls. The average age at insertion was 6 years (range, 15 days to 15 years). Twenty-four children were younger than 2 years. The reasons for inserting the Broviac catheters included malignancies (n = 70), Hurler's syndrome and bone marrow transplant (n = 2), short gut syndrome (n = 2), pseudomonas pericarditis (n = 1), superior mesenteric artery syndrome (n = 1), gastroschisis (n = 1), severe burns (n = 1), and chronic granulomatous disease (n = 1).

Four children had postoperative wound infections (5.7%). Two of these catheters were removed because of pseudomonas colonisation (one child with burns and a 3-year-old child with acute lymphoblastic leukaemia and severe neutropenia). Two other catheters needed changing because of blockage. There were no accidental dislodgements.

Discussion 

Under ideal conditions it takes 4 to 6 weeks for the in growth of fibrous tissue into the Dacron cuff in Broviac and Hickman catheters. Although anchoring sutures at the exit site, dressings, and careful nursing all help in holding the catheter in place, a significant number of catheters are displaced during this initial period. In our experience, this is more common in the 0 to 2 year olds, possibly because of the shorter subcutaneous tunnel and increased patient movement.

With our technique, a strategically placed Polyglactin tie provides internal fixation and prevents outward dislodgement of the cuff. Because Polyglactin is absorbed over a period of 60 to 90 days, this tie provides anchoring until the fibrous growth into the cuff is complete. This technique adds only 3 minutes, on average, to the procedure and is very simple to learn. It requires no extra incisions, no instrumentation of the tunnel, and no need for specialised catheters. There has been no additional difficulty removing the catheters from 35 of these children. The remaining 41 catheters still were in use at the time of writing. This was not a randomised trial. There is a need for a prospective randomised trial to compare this internal fixation suture as the sole method of anchoring with the combined internal and exit wound anchoring suture. This trial is underway in our centre.