Teaching Case

Woman with disseminated neoplastic progression (malignant pleural effusion, liver and bone metastases) six years after surgical and adjuvant treatment for pT1cN1 ductal breast carcinoma.
On chemotherapy, she complains of right neck swelling with physical finding of hard-consistency oedema along ispilateral upper extremity. Laboratory changes included leukocytosis, elevated C-reactive protein and D-Dimer (3300 mcg/mL).

Radiographically (Fig. 1), the subcutaneously implanted vascular port appeared correctly positioned via right subclavian central venous access, with the distal catheter located in the superior vena cava (SVC). Known, minimal right-sided pleural effusion was present.
The cervical swelling, unresponsive to empiric antibiotics and anti-inflammatory medications, corresponded to colour Doppler ultrasound (Fig. 2) finding of complete thrombosis of ipsilateral subclavian and internal jugular vein (IJV).
Multidetector CT (Fig. 3) confirmed correctly positioned central catheter in the patent SVC and panoramically visualised the extent of the subclavian and IJV occlusion. Additionally, the minimally thickened hyperenhancing walls of involved veins and inflammatory hyperattenuation of surrounding fat planes suggested septic thrombophlebitis. Lymphadenopathies, cervical abscesses, and septic lung embolisation were not present.
Port removal was initially considered, but was ultimately not performed after the patient clinically improved on intensive antibiotics and low-molecular-weight heparin.

Central venous catheters (CVCs) are widely used to provide temporary or long-term vascular access: among them, implantable vascular access devices (IVAD) or “ports” with a subcutaneous chamber connected to the catheter are indispensable in modern oncology, particularly in the perioperative and adjuvant care settings. IVADs reliably allow for repetitive blood sampling, administration of parenteral nutrition, contrast media, chemotherapy, and other systemic therapies, avoiding vascular wall injury and ultimately improving patients’ quality of life [1-4].
However, central venous access carries potential risks: immediate and early (<30 days) post-procedural problems (such as haematoma, pneumothorax, malpositioning and arrhythmias) are now very uncommon with near-universal use of ultrasound guidance. The major late complications include thrombosis, infections (incidence 0.8-7.5%), mechanical damage (1.8%), and extravasation (1.3%) in descending order of frequency. Overall, thrombosis may occur in 12%-64% of CVCs, with lower risk (1%) associated with IVADs. Thrombosis is more common with subclavian rather than jugular access, multilumen or large-calibre CVCs. Risk is markedly increased in cancer patients on chemotherapy. Thrombosis results from acute or chronic endothelial damage, may be asymptomatic in up to 70% of patients, and may result in catheter dysfunction and ultimately venous stenosis. Closely associated with thrombosis, septic complications include pocket, device and bloodstream infections, most commonly caused by Staphylococcus species, and are less common with IVADs compared to tunnelled and short-term CVCs [3-9].
As in the hereby presented case, imaging plays a key role in detection of CVC-related complications. Albeit with limitations behind the clavicle and at skull base, colour Doppler ultrasound readily acts as first-line investigation to detect distended, non-compressible thrombosed veins with absent flow. Multidetector CT effectively and panoramically visualises the extent of thrombosis with indwelling CVC: signs include venous distention with intraluminal precontrast hyperattenuation corresponding to fresh clot, focal opacification defects at the catheter tip or occlusion of the entire lumen; septic thrombophlebitis is suggested by thickened enhancing vascular walls and oedema of the surrounding soft tissues. Further complications may include pulmonary embolism (reported to occur in 15-25% of cases), lung septic emboli, upper extremity postphlebitic syndrome [10-12].
Treatment of CVC-related thrombophlebitis requires antibiotics and anticoagulation depending on its extent. The decision to remove an IVAD should consider the underlying illness, availability of other access sites, and complications such as tunnel infection and endocarditis. Since catheter removal does not offer benefit after thrombosis has developed, IVADs are preserved in 45-96% of cases, unless refractory thrombosis or contraindications to anticoagulation exist [4, 8, 13].