LAUSR

Editor: Bleeding or oozing from the subcutaneous track of tunneled central venous catheters is common. While management options for track bleeding include local compression using manual pressure or a pressure dressing [1], placement of a purse-string suture [2], subcutaneous lidocaine/epinephrine injection [1], intravenous desmopressin administration [1, 3], and correction of coagulopathy or thrombocytopenia, the injection of hemostatic materials into the catheter track may also facilitate bleeding cessation [3]. To this end, injection of microfibrillar collagen—an absorbable bovine derived collagen product—into the subcutaneous track represents a simple and effective means to efficiently achieve track hemostasis, and is described herein using a single example case, highlighting the straightforward technique and potential clinical value. Institutional review board approval is not required for single retrospective case studies at the author’s institution. A 46-year-old man with myelofibrosis was referred to Interventional Radiology (IR) for tunneled central venous catheter placement for stem cell transplantation. At the time of the procedure, the patient was thrombocytopenic (platelet count 24 9 10/lL) and slightly coagulopathic (international normalized ratio 1.3). No pre-procedure transfusion was undertaken. A 12-French triple lumen catheter (Hickman Trifusion; C.R. Bard, Murray Hill NJ) was uneventfully placed via the right internal jugular vein using standard technique. Four days later, IR was contacted by the patient’s primary medical service due to persistent slow daily bleeding from the tunneled catheter exit site resulting in blood soaked dressings since the time of catheter placement. The bleeding was recalcitrant to pressure dressing and platelet transfusion, after which the patient remained thrombocytopenic (platelet count 24 9 10/lL). In the IR procedure holding area, the patient’s right neck and chest were sterilely prepped and draped. Visual inspection of the tunneled catheter exit site confirmed active track oozing (Fig. 1). Microfibrillar collagen paste (Avitene; C.R. Bard) was prepared by mixing the dry product with 6 mL of normal saline. The wet paste was then loaded by hand into a syringe equipped with a 14-gauge angiocath (Fig. 2). The microfibrillar collagen paste was subsequently injected into the tunneled catheter track (Figs. 3 and 4), taking care to apply manual compression to the right internal jugular vein access site during administration to avoid intravascular transit of the material. Track hemostasis was confirmed by visual observation for 10 min. Though the microfibrillar collagen paste alone prompted hemostasis, a purse-string suture was also placed at the catheter exit site as a second supportive hemostatic measure (Fig. 5). The site was then sterilely dressed, and the patient was transported to his medical room. He experienced no further track bleeding over the subsequent 2-week hospital course prior to discharge, despite continued thrombocytopenia (platelet count nadir 9 9 10/lL). While most often self-limited, persistent tunneled catheter track bleeding can at best be a nuisance and at worst an adverse event requiring clinical intervention [4]. Hemostatic agents used to address bleeding tunneled central venous catheter tracks have included gelatin sponge & Ron C. Gaba [email protected]