CENTRAL VENOUS ACCESS DEVICES

What are Central Venous Access Devices (CVADs)?

• Central venous access devices (CVAD) are small, flexible tubes placed in large veins for people who require frequent access to the bloodstream.
• These devices typically remain in place for long periods: weeks, months, or even longer.
• There are several different types of catheters such as tunneled catheters (Groshong, Powerline, dialysis/pheresis), non-tunneled catheters such as Peripheral Inserted Central Catheters (PICCs) and implantable ports.

Catheters vs. Ports

• Catheters exit directly from the skin, ports are placed completely below the skin.
• With a port, a raised disk about the size of a quarter is felt underneath the skin. Blood is drawn or medication is delivered by placing a tiny needle through the overlying skin into the port

What are the benefits of CVADs?

• Allow medications to be delivered directly into larger veins
• Less likely to clot
• Can be left in for long periods.
• Allow frequent access to the veins without deep needle stick

• Can reduce the risk of inflammation and scarring that can occur in a vein after multiple needle sticks or from administration of strong medications into small veins.

• Increases comfort and reduces anxiety for people who require frequent venous access

What are CVADs used for?

• Administration of medications like antibiotics, chemotherapy drugs, other IV drugs
• Administration of fluids and nutritional compounds (hyperalimentation)
• Transfusion of blood products
• Multiple blood draws for diagnostic testing

Where are CVADs placed?

Placement is usually in one of the large veins of the arm, chest or neck, although placement can also be in the groin, if necessary.

Preparing for the Procedure

If you are having a PICC placed, you may eat the morning of your procedure and take all your scheduled medications.

If you are having a tunneled catheter, then you will need to not eat after the midnight before your procedure. If you are a diabetic and take medications, including insulin then you will need to talk to your healthcare provider about adjusting your dosage.

If you are on Coumadin, you will need to talk to your healthcare provider about adjusting your medication.

During the Procedure

Central Catheters and ports are placed under the guidance of  ultrasound and x-ray to insure that the line is placed properly.

Some catheters are inserted by tunneling under the skin into either the subclavian vein (located beneath the collarbone) or into the internal jugular vein (located in the neck). The part of the catheter where medications are administered or blood is drawn remains outside the skin.

Risks

Problems that can occur during or after placement of a central venous access device include the following:

• Cellulitis - Infection of the skin around the catheter or port
• Pneumothorax – Collapse of the lung because of injury from the needle used to insert the device into the subclavian or jugular veins
• Catheter infection - An actual infection of the device itself inside the vein
• Venous Thrombosis – formation of clot in the vein that was used for CVAD placement.

When to Seek Medical Care

Call or visit a health care provider right away if any of the following symptoms occur:

• Swelling, redness, pain, or tenderness of an arm or the area around the device
• Shortness of breath or chest pain
• Unexplained fever
• Catheter breaks or fluid starts to leak from catheter
• Pain with injection/infusion into the device or if unable to give medication through catheter

After the Procedure

• Avoid heavy exertion or strenuous activity immediately after device placement.
• Change the bandages as directed.
• You will be given discharge instructions once your catheter is placed with detailed information on when to resume any medication that has been stopped and when you will be able to shower.
• Proper home care of a venous access device involves regular irrigation with a drug called heparin to prevent clotting (except with Groshong-type catheters) and attention to a sterile technique to keep the device free of infection.
• The venous access device can be removed when it is no longer needed, such as when the medical problem for which it was inserted has resolved.

Although there are risks associated with central venous access devices, the benefits of these devices usually outweigh the risks. Be aware of the possible complications, recognize the signs and symptoms early, and bring these to the attention of the health care provider. The complications usually can be treated successfully.

INFERIOR VENA CAVA FILTERS

What is an Inferior Vena Cava Filter?

An inferior vena cava (IVC) filter is an umbrella shaped device that blocks the circulation of emboli (clots) in the bloodstream. It is placed in the inferior vena cava, which is a large vein leading from the lower body to the heart.  

Why do I need an IVC Filter?

• Often times, because of certain risk factors clots can form in deep veins in the pelvis or legs. These clots are called Deep Venous Thrombosis (DVT).
• Clot that is in the pelvis or thigh can break off, travel up the IVC and make its way to the lungs. When a clot gets trapped in the lung, it is called a Pulmonary Embolism (PE).
• Usual treatment for preventing a PE is a medication known as an anticoagulant, or “blood thinner.” An IVC filter is often recommended in patients with DVT who cannot use blood thinners because of recent surgery, a stroke caused by bleeding, bleeding in another area of the body, or low platelets due to heparin therapy.
• IVC filters are sometimes placed in patients who are on anticoagulation if they are considered “high-risk” for developing a PE.
• IVC Filters are also placed to help prevent PE in certain surgically procedures such as lung resection - pneumonectomy or gastric bypass.

Before the Procedure

Only a few preparations are needed on the patient’s part before the procedure.

• You must not eat anything by mouth 6 hours before the procedure.
• If you are allergic to IV dye (contrast) or iodine or shellfish please let your doctor know immediately.
• An IV will be placed in your arm to administer fluids and one dose of antibiotic during the procedure.

About the Procedure

IVC filter placement is a minimally invasive procedure and takes about 1-2 hours. The procedure is done by doctors called Interventional Radiologists in the Interventional Radiology Suite.

• To prepare for the procedure, the groin or the neck area is first cleaned with sterile gauze to prevent infection.
• Numbing medication is then injected under the skin to prevent pain. You should not feel any pain other than slight burning sensation when the numbing medication is first administered. If you do feel any pain during the procedure, let the doctor know.
• A small incision is then made in a vessel in the groin or neck to place the catheter containing the filter at the desired site.
• As this is done, x-ray images are taken to help guide the catheter advancement into the blood vessel
• The IVC filter is then deployed from the catheter once it is in proper position.
• The filter will attach to the IVC and stay in place to trap clots traveling up to the lungs.
• Once the filter is in place, the catheter is removed and pressure is applied to the incision site for 5-10 minutes.
• The incision site is then covered with sterile gauze and bandage, which can be removed after 24 hours.

After the Procedure

• Let your nurse know immediately if bleeding or pain develops at the site of incision
• You should lie flat for 2 hours, if your leg was used to place the filter. After the 2 hours, you may get up to go to the bathroom with help.
• If the catheter was placed in your leg, limit bending at the waist for 48 hours.
• To help clear the IV dye from your body; drink plenty of fluids unless your doctor tells you otherwise.

Home Care of the IVC Filter

• Do not drive for 24 hours. You will need to have somebody to drive you home after the procedure.
• Limit your activity after filter placement.  You may resume you usual activity the following day.
• Do not lift heavy objects for 48 hours from the time you leave the hospital.
• You make take a shower or bath the day after your procedure. Do not scrub the incision site.

Possible Complications

IVC filter placement is a low risk procedure and major complications are rare. Possible complications of the procedure include bleeding, infection and clot formation.

• Bleeding - If bleeding occurs from the site, lie down flat on your back. Apply pressure for 10-15 minutes until bleeding stops. Continue to lie flat on your back with your legs straight for another hour. You might feel dizzy if you rise up too quickly. To help prevent this, rise slowly. If the bleeding does not stop, call 911.
• Infection – If you develop any signs of infection, including fever above 100 F, warmth, swelling, redness, or pain, call us immediately.

MALE AND FEMALE INFERTILITY

At GW, Interventional Radiology can treat some of the most common types of infertility in both males and females.  These procedures are done on an outpatient basis under light sedation.  Patients can usually resume their usual activities the next day.

FEMALE FALLOPIAN TUBE RECANALIZATION

You and your partner have been trying to conceive and have been unable to do so.  During your infertility work-up, you have probably undergone many tests and examinations to diagnose the problem and have learned that one or both fallopian tubes are blocked.  Blockage of one or both fallopian tubes is one of the most common causes of female infertility.

Your doctor has referred you to the George Washington University Hospital, Division of Interventional Radiology for a procedure called Fallopian Tube Recanalization.  We are happy to help you and hope this information will answer questions you may have about the procedure.

Before The Procedure

Our physicians and nurse practitioner will see you in clinic for a consultation.  If you decide that Fallopian Tube Recanalization is the right option for you, we will schedule your procedure.  Your procedure will be scheduled just prior to the ovulation phase of your menstrual cycle.  When you come to clinic, we will need to know how long your menstrual cycles have been for the last 3-6 months so we can more accurately predict the ovulation phase of your cycle. 

If you decide on the procedure, you will be given a prescription for an antibiotic, usually doxycycline.  This will help prevent infection.  You will need to take it two days before the procedure, the day of and two days after the procedure.

We recommend that you do not eat anything after midnight the day before the procedure.  This is because we will be giving you light sedation during the procedure.  You may take your usual medications with a sip of water in the morning.  If you are on medication, please bring your medication list with you the day of your consultation and any imaging studies such as prior hysterosalpingograms (HSG). You will also need to have someone drive you home the day of the procedure.

The Procedure

Your procedure will be done in Interventional Radiology.  When you arrive at the hospital, you will need to go to Registration on the 1^st floor of the hospital.  After registration, you will come to the 2^nd floor Surgical Waiting Room.  From there, you will go to the Recovery Room to change into a hospital gown and to have an IV placed so we can give you medication before, during and after your procedure.  You may want to leave any personal belongings such as wallet, purse or jewelry with your family or partner. 

You will then be moved to the Interventional Radiology suites.  There, the physicians performing your procedure will answer any questions you have and ask you to sign a consent form that says you understand the procedure and agree to have it performed.

Then, the technologists and nurses will prepare you for the procedure which will be performed in the Interventional Radiology suite.  You will be asked to lie on a long x-ray table with a large camera above you.  This will allow the physicians to take images.  You will place your legs apart as you would for a gynecological exam.  A sterile drape will be placed across your legs. You will be given IV medications before the procedure begins and given sedation and pain relief medications during the procedure.  You may still experience some mild cramping during the procedure.

At this point, the physicians will begin the procedure. A speculum will be inserted to visualize the cervix.  Your cervix will then be then be cleaned to reduce the risk of infection.  Then, a series of catheters and wires are gently inserted into the uterus and x-ray dye (also known as contrast) is injected to confirm the presence of blocked fallopian tubes.  The images will project onto a screen in the room.  Then, the physician will manipulate the wires and catheters to attempt to open up the blockage.  Once the procedure is complete, the catheters and wires are removed.  The procedure usually lasts about an hour.

After The Procedure

You will be brought back to the Recovery Room after the procedure where you will be monitored as you wake up from the sedation that was given to you during the procedure. Once there, your family or partner will be allowed to sit with you.  Once you are fully awake, you will be discharged home.  You and your family will have time to discuss the results of the procedure with the physician.  You will be given a set of discharge instructions before you leave.

Most patients experience some degree of cramping similar to menstrual cramps and light spotting after the procedure.  You may want to wear a panty liner during this time.  You may take over the counter pain medication such as Tylenol or Advil.  Nausea from the sedation medication can also occur so we advise you to eat light meals for the rest of the day.  Do not drink alcoholic beverages as they could react with the medications you were given during your procedure.  You should rest for the remainder of the day and resume your usual activities the following day.  We encourage sexual activity after the procedure to increase your chances of pregnancy.

Complications are rare after Fallopian Tube Recanalization however, bleeding, infection, tubal perforation and rarely tubal pregnancy can occur. To help prevent infection, you are to continue the doxycycline for two days after the procedure.  If you experience heavy bleeding, fever greater than 101F, foul spelling vaginal discharge, chills or severe cramping, please call our office immediately. Our contact information is below:

-Monday thru Friday, please call our secretary, Ms. Shundra Dinkins at 202-715-5155. 

-If it is after business hours, on the weekend or a holiday, call the page operator at 202-715-4141 and have them page the Radiology resident on call.

We will do our best to make sure your experience is as comfortable as possible.  Please contact our nurse practitioner Mrs. Amy Harper at 202-715-5129 if you have questions before or after your procedure.

To schedule your consultation, please call our secretary Ms. Shundra Dinkins at 202-715-5155.

MALE VARICOCELE EMBOLIZATION

A varicocele is a varicose vein of the testicle and scrotum that may cause pain, shrinkage of the testicle and fertility problems as it can lead to:

-Decreased sperm count

-Decreased motility of sperm

-Increased number of abnormal sperm

  Varicocele embolization is a non-surgical treatment that may be an option to correct male infertility.  Varicoceles typically occur in men between the ages of 15-35 and among infertile couples, the incidence of varicocele may be as high as 30%. 

Before The Procedure

Our physicians and nurse practitioner will see you in clinic for a consultation.  If you are on medication, please bring your medication list with you the day of your consultation and any imaging studies. If you and your doctor decide that Varicocele Embolization is the right option for you, we will schedule your procedure.  We recommend that you do not eat anything after midnight the day before the procedure.  This is because we will be giving you light sedation during the procedure.  You may take your usual medications with a sip of water in the morning.  You will need to have someone drive you home the day of the procedure.

The Procedure

Your procedure will be done in Interventional Radiology.  When you arrive at the hospital, you will need to go to Registration on the 1^st floor of the hospital.  After registration, you will come to the 2^nd floor Surgical Waiting Room.  From there, you will go to the Recovery Room to change into a hospital gown and to have an IV placed so we can give you medication before, during and after your procedure.  You may want to leave any personal belongings such as wallet, purse or jewelry with your family or partner. 

You will then be moved to the Interventional Radiology suites.  There, the physicians performing your procedure will answer any questions you have and ask you to sign a consent form that says you understand the procedure and agree to have it performed.

Then, the technologists and nurses will prepare you for the procedure which will be performed in the Interventional Radiology suite.  You will be asked to lie on a long x-ray table with a large camera above you.  This will allow the physicians to take images.  You will be given IV medications before the procedure begins and given sedation and pain relief medications during the procedure. 

At this point, the physicians will begin the procedure.  You will be given local anesthesia at the groin.  There, a thin catheter is passed into the femoral vein then to the testicular vein.  They will inject contrast dye to visualize the veins so they will know exactly where to embolize (block) the affected veins.  The Interventional Radiologist will use coils or particles to block blood flow in the vein.  By blocking these veins, blood is re-directed to healthy veins.  The procedure usual takes about 2 hours. 

After The Procedure

You will be brought back to the Recovery Room after the procedure where you will be monitored as you wake up from the sedation that was given to you during the procedure. Once there, your family or partner will be allowed to sit with you.  Once you are fully awake, you will be discharged home.  You and your family will have time to review the findings and results with the physician.  You will be given a set of discharge instructions before you leave.

Complications are rare after Varicocele Embolization but include pain, infection and allergic reaction to medications. Most patients experience some degree of pain after the procedure. You may take over the counter pain medication such as Tylenol or Advil. You may require stronger pain medication such as one with a narcotic.   Nausea from the sedation medication can also occur so we advise you to eat light meals for the rest of the day.  Do not drink alcoholic beverages as they could react with the medications you were given during your procedure.  You should rest for the remainder of the day and resume your usual activities the following day. Our contact information is below:

-Monday thru Friday, please call our secretary, Ms. Shundra Dinkins at 202-715-5155. 

-If it is after business hours, on the weekend or a holiday, call the page operator at 202-715-4141 and have them page the Radiology resident on call.

We will do our best to make sure your experience is as comfortable as possible.  Please contact our nurse practitioner Mrs. Amy Harper at 202-715-5129 if you have questions before or after your procedure.

To schedule your consultation, please call our secretary Ms. Shundra Dinkins at 202-715-5155.

CHRONIC PELVIC PAIN (PELVIC CONGESTION SYNDROME) DUE TO PELVIC VARICES

Up to one-third of women will experience chronic pelvic pain.  Many women may spend a lifetime trying to find out the reason for their pain.  There are numerous causes of pelvic pain.  One cause is due to pelvic varicose veins.  Approximately 15% of women between the ages of 20-45 have varicose veins in the pelvis, however not all have symptoms.  Pelvic varices are similar to varicose veins in the legs.  In each case, the valves in the veins that help to return blood to the heart are damaged.  When these valves are damaged, the blood pools creating increased pressure and causing the veins to bulge.  The diagnosis of pelvic varices is often missed because women lie down for a pelvic exam.  This relieves the pressure on the veins so they no longer bulge with the pooling blood as they do when a women stands.

We understand that living with chronic pelvic pain is difficult.  It not only affects the woman but her relationships with her family and friends as well.  At George Washington University Hospital, we are often able to treat the varices with embolization techniques.  This treatment often improves pain and patient’s quality of life.

Risk Factors

• Two or more pregnancies
• Varicose leg veins
• Polycystic ovaries

Symptoms

Chronic pelvic pain is defined as “non-cyclic” pain lasting greater than six months.  Pain is usually described as a persistent dull ache in the lower abdomen and back.  Pain can be increased following intercourse, with menstrual cycle, during pregnancy, when standing or being tired such as at the end of the day. 

Diagnosis

Diagnosis is often difficult because pelvic varices are not visible externally and many imaging studies do not demonstrate them because the women lie down for the studies.  However, these imaging modalities are very helpful in ruling out other sources of pelvic pain including pelvic pathology (such as tumors).  Imaging may include ultrasound (either pelvic or transvaginal) or MRI.

Treatment

Our physicians and nurse practitioner will see you in clinic for a consultation.  If you decide that Embolization of Pelvic Varices is the right option for you, we will schedule your procedure.  We recommend that you do not eat anything after midnight the day before the procedure.  This is because we will be giving you light sedation during the procedure.  You may take your usual medications with a sip of water in the morning.  If you are on medication, please bring your medication list with you the day of your consultation and any imaging studies. You will also need to have someone to drive you home the day of the procedure.

The Procedure

Your procedure will be done in Interventional Radiology.  When you arrive at the hospital, you will need to go to Registration on the 1^st floor of the hospital.  After registration, you will come to the 2^nd floor Surgical Waiting Room.  From there, you will go to the Recovery Room to change into a hospital gown and to have an IV placed so we can give you medication before, during and after your procedure.  You may want to leave any personal belongings such as wallet, purse or jewelry with your family or partner. 

You will then be moved to the Interventional Radiology suites.  There, the physicians performing your procedure will answer any questions you have and ask you to sign a consent form that says you understand the procedure and agree to have it performed.

Then, the technologists and nurses will prepare you for the procedure.  You will move on to a long x-ray table with a large camera above you.  This will allow the physicians to take images.  A sterile drape will be placed across your legs. You will be given IV medications before the procedure begins and given sedation and pain relief medications during the procedure.  You may still experience some mild cramping during the procedure.

At this point, the physicians will begin the procedure. Local anesthetic will be given in the groin in the area of the vein.  Then, a small catheter will be placed.  Through this catheter, contrast material will be given to see the veins.  Once the physicians identify the varices, embolic material will be given to shut off the blood flow to the varices.  The catheter is then removed and a small bandage is placed over the area. 

After the Procedure

You will be brought back to the Recovery Room after the procedure to allow you to wake up.  Once there, your family or partner will be allowed to sit with you.  Once you are fully awake, you will be discharged home.  You and your family will have time to review the findings and results with the physician.  You will be given a set of discharge instructions before you leave.

Most patients experience some degree of cramping similar to menstrual cramps after the procedure.  You may take over the counter pain medication such as Tylenol or Advil.  Nausea from the sedation medication can also occur so we advise you to eat light meals for the rest of the day.  Do not drink alcoholic beverages as they could react with the medications you were given during your procedure.  You should rest for the remainder of the day and resume your usual activities the following day.

Complications are rare after but include bleeding, infection, damage to the veins or other structures and rarely, embolic material going to other areas.  If you experience bleeding, fever greater than 101F, foul smelling vaginal discharge, chills or severe cramping, please call our office immediately. Monday thru Friday, please call our secretary, Ms. Shundra Dinkins at 202-715-5155.  If it is after business hours, on the weekend or a holiday, call the page operator at 202-715-4141 and have them page the Radiology resident on call.

We will do our best to make sure your experience is as comfortable as possible.  Please call our nurse practitioner Mrs. Amy Harper at 202-715-5129 if you have questions before or after your procedure.

Our Physicians

Anthony Venbrux, M.D.

Professor of Radiology and Surgery
Director, Cardiovascular and Interventional Radiology   

Elizabeth Ignacio, M.D.

Assistant Professor of Radiology

Shawn Sarin, M.D.

Assistant Professor of Radiology

For additional inquiries or questions please contact us at 202-715-5155 or visit Department of Interventional Radiology online at http://www.gwdocs.com.