PICC ucu malpozisyonu ve kateter ilişkili komplikasyonlar

Özet

PICC, üst ekstremite veninden ilerletilen ve uzun süreli damar erişimi gereken hastalarda kullanılan santral kateterdir. Kateter ucunun santral hedef dışında kalması, damar duvarına temas etmesi veya kateter çevresinde trombüs oluşumu, tıkanıklık, tromboz ve enfeksiyon risklerini artırır. Bilgisayarlı tomografi, kateterin seyrini ve damar anatomisini göstererek; kontrastlı incelemeler trombüs, oklüzyon ve ekstravazasyon gibi eşlik eden bulguların tespitine yardımcı olur. Kateter kırığının veya damar dışı uzanımının gecikmeli tanısı, damar perforasyonu, kardiyak tamponad veya pulmoner emboli gibi ciddi komplikasyonlara yol açabilir.

Faz ve pencere

Kontrastsız tanısal

Kontrastsız görüntülemede kateterin radyoopak gövdesi, kıvrımı, süreksizliği ve ucunun genel konumu izlenir; ancak venöz trombüsün değerlendirilmesi için kontrastlı inceleme gereklidir.

Gecikmiş tanısal

Gecikmiş venöz fazda, kateter komşuluğunda görülen trombüs, yapışık dolum defekti veya damar dışı kontrast birikimi, damar duvarı yaralanması veya ekstravazasyonu şüphesini doğurur.

Önerilen pencereler: Mediasten (G 350 / M 50), Yumuşak doku (G 400 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Üst ekstremite veninden ilerleyerek brakiosefalik ven veya vena kava superior dışında bir segmente yerleşen kateterin malpozisyonu düşündürülür.
• Kateter ucunun beklenen santral hedef olan vena kava superiorun alt üçte biri/kavatrial bileşke bölgesi dışında kalması; juguler, karşı brakiosefalik veya daha periferik vene dönmesi malpozisyonu düşündürür. Kateter ucunun optimal konumu, yerleştirme protokolü ve ölçüm kriterlerine bağlı olarak değişebilir; genellikle kavatrial bileşke civarı kabul edilir.
• Kateterin seyrine paralel uzanan, lümeni çevreleyen ya da kateter ucunda sonlanan kontrast dolum defekti; eşlik eden ven genişlemesi akut trombozu destekleyebilir.
• Vena kava superior veya brakiosefalik ven çapında azalma ile birlikte göğüs duvarı, mediastinal ya da azygos kollaterallerinin belirginleşmesi.
• Kateterde ani sonlanma veya kopuk parça izlenmesi, parçanın sağ kalp boşluklarına veya pulmoner arterlere göç etmiş olabileceğini gösterir.
• Damar sınırı dışında ilerleyen kateter ucu veya damar çevresinde kontrast birikimi ekstravasküler konum/kaçak şüphesini doğurur.

Normalde

Normal konfigürasyonda üst kol veninden gelen PICC aksiller ve subklavyen venlerden brakiosefalik vene, oradan vena kava superiora kesintisiz izlenir; ucu genellikle SVC’nin alt üçte biri/kavatrial bileşke bölgesindedir. Taze kanama veya kronik obstrüksiyon olmayan normal vakalarda, kateter seyrinde belirgin dolum defekti veya genişlemiş kollateral venöz ağ gözlenmez.

Ayırıcı tanı

Kateter komşuluğunda görülen heterojen opaklaşma veya dış cihaz artefaktları, gerçek bir dolum defektini taklit edebilir; çok fazlı ve multiplanar görüntülerdeki davranışı ile doğrulanmalıdır.

Akut kateter ilişkili trombüs

duvara tutunan dolum defekti venöz fazda sürer ve damarı genişletebilir.

Kronik santral ven stenozu, uzun segment daralma ve geniş kollateralle karakterizedir; akut tromboz ise fokal dolum defekti ile öne çıkar.

Kateterde süreksizlik veya ani sonlanma gibi yapısal bozulmalar, parça göçü veya perforasyon riskini gösterir ve acil müdahale gerektirebilir.

Ekstravasküler kateter

kateter damar lümenini terk eder; çevre yumuşak dokuda hematom veya kontrast kaçağı eşlik edebilir.

Tuzaklar

• Sadece aksiyel kesit, kateterin juguler vene dönmesini kısa bir damar kesiti gibi gösterebilir; koronal/sagittal rekonstrüksiyonda kateteri giriş yerinden ucuna kadar izle.
• Venöz geçişteki gecikmeler veya opaklaşma yetersizliği kateter komşuluğunda yalancı dolum defekti gibi görünüşlere yol açabilir; çok fazlı ve multiplanar görüntülerle doğrulanmalıdır.
• Metal kateter nedeniyle oluşan artefaktlar ince trombüsleri gizleyebilir; artefaktan uzak kesitler ve damar duvarı ile ilişkili dolum eksiklikleri ayrıca değerlendirilmelidir.
• Önceki görüntü olmadan ucu yalnız kalp siluetine göre sınıflamak yanıltabilir; kateterin damar içi devamlılığını ve gerçek ucunu multiplanar düzlemde doğrula.

Kendini dene

1. PICC, brakiosefalik ven birleşimine ulaştıktan sonra kraniyale dönerek juguler vende sonlanıyor. En uygun tanım?

   • Beklenen santral seyir
   • Juguler ven malpozisyonu
   • Kateter ucu kırığı
   • Ekstravasküler uzanım
   Cevabı göster

   Juguler ven malpozisyonu. Kateterin santrale devam etmesi gerekirken juguler vene dönmesi malpozisyonu gösterir. Kırıkta metalik devamlılık kesilir; ekstravasküler uzanımda kateter damar sınırının dışına çıkar.

2. PICC komşuluğundaki SVC'de görülen dolum defekti ve damar duvarı yanındaki hiperdens alan en çok neyi düşündürür?

   • Kontrast karışım artefaktı
   • Kateter ilişkili trombüs ve perforasyon
   • Kronik ven stenozu
   • Mekanik kateter kırığı
   Cevabı göster

   Kateter ilişkili trombüs ve perforasyon. Kaynaklarda, kateter ucu yakınındaki dolum defekti ve perikardiyal efüzyon/ekstravazasyon, kateter ilişkili trombüs ve damar duyarlılığına işaret eder.

Bu konunun yer aldığı turlar

• Tüpler, kateterler ve cihazların BT'de değerlendirilmesi

İlgili konular

• Santral venöz kateter ucu malpozisyonu
• Kateter ilişkili venöz tromboz ve fibrin kılıfı

Kaynaklar

Bu sayfadaki 35 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 16 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez. İçerik yapay zekâ destekli bir süreçle güncel literatüre göre cümle cümle kaynaklarla karşılaştırıldı, ancak uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.