Fibrin sheath

Complications from IP therapy may be related to catheter fnnc-tion, infection, or bowel problems. Mechanical obstrnction to flnid inflow has been reported in approximately 5% of patients. Most commonly, this results from fibrin sheath formation around the catheter tip. In some cases, peritoneal adhesions obstruct fluid entry into the abdominal cavity, causing uneven distribution of the chemotherapentic agent. Infections complications, such as superficial cellulitis around the catheter entry site, deep tissue infections, and peritonitis, are the most prevalent IP-related comphcations and are reported in approximately 10% of patients. Bowel-related comphcations (approximately 3% incidence) inclnde obstruction. Ecus, and perforation. IP administration may also resnlt in a false CA-125 elevation. ... 

Thrombotic complications are common with catheter use. The development of a fibrin sheath is a near universal occurrence on intravascular devices such as central venous (Hoshal et al., 1971) and hemodialysis catheters, and can have a profound effect upon blood flow in the device (Trerotola, 2000). This sheath can be removed either by stripping (Rockall et al., 1997 Crain et al., 1996) or fibrinolytic medical therapy (Twardowski et al., 1998), or the catheter can be replaced to restore adequate flow performance. Recent randomized controlled clinical trials have revealed improved long-term outcomes with catheter exchange versus fibrin sheath stripping (Merport, 2000), while no outcome differences were realized in patients randomized to either fibrin sheath stripping or thrombolytic therapy (Gray, 2000). 

Gray, R. J., Levitin, A., Buck, D., Brown, L. C., Sparling, Y. H., Jablonski, K. A., Fessahaye, A., and Gupta, A. K., Percutaneous fibrin sheath stripping versus transcatheter urokinase infusion for malfunctioning well-positioned tunneled central venous dialysis catheters A prospective, randomized triaL /- Vase. Interv. Radiol., 2000 11(9) 1121-1129. 

Several authors have reported their experience with thrombolytic infusions lasting 3-12 h for the treatment of fibrin sheaths. Clinical success ranged... 

Fig.6.15. Fibrin sheath stripping. Loop snare around a catheter during a stripping maneuver. (Published with permission of Lippincott, Williams and Wilkins)...

Fig. 6.16a-c. Balloon disruption of the fibrin sheath, a Injection following catheter removal demonstrating a long fibrin sheath, b Balloon disruption, c Repeat contrast injection shows no sheath and good flow. (Published with permission of W. B. Saunders Co.)... 

Brady PS, Spence LD, Levitin A, Mickolich CT, Dolmatch BL (1999) Efficacy of percutaneous fibrin sheath stripping in restoring patency of tunneled hemodialysis catheters. AJR Am J Roentgenol 173 1023-1027... 

Haskal ZJ, Leen VH, Thomas-Hawkins C, Shlansky-Goldberg RD, Baum RA, Soulen MC (1996) Transvenous removal of fibrin sheaths from tunneled hemodialysis catheters. J Vase Interv Radiol 7 513-517... 

Savader SJ, Haikal LC, Ehrman KO, Porter DJ, Oteham AC (2000) Hemodialysis catheter-associated fibrin sheaths treatment with a low-dose rt-PA infusion. J Vase Interv Radiol 11 1131-1136... 

Mehall JR, Saltzman DA, Jackson RJ, et al. Fibrin sheath enhances central venous catheter infection. Crit Care Med April 2002 30(4) 908-12. 

Medical and nursing staff dealing with central venous catheters (CVC) should be aware of specific risk factors and safety hazards associated with this access type (damage of the vessels and/or surrounding tissue at CVC insertion, fibrin sheath formation, leak of the anticoagulation lock solution into the vascular system, etc.). 

Research and development in CVC design is focused on prevention of CVC fibrin sheath formation, thrombosis and infection. With lack of sufficiently large studies, true benefits of the innovations should, however, be carefully assessed. 

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