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Indications / Contraindications
Indications
- Recurrent malignant pleural effusion (MPE): most common; lung, breast, mesothelioma, ovarian, lymphoma. Median survival <6 months; typical catheter dwell ~90 days
- Non-expandable lung (trapped lung): IPC strongly preferred — pleurodesis cannot succeed if lung cannot appose the chest wall
- Failed pleurodesis: clinical improvement >95%; spontaneous pleurodesis occurs in 16% of this subset (Thornton JVIR 2010)
- Short life expectancy: IPC preferred over pleurodesis — same-day discharge, no hospitalization for chemical pleurodesis, no 4–5 day inpatient stay
- Non-malignant recurrent effusion (selected cases): hepatic hydrothorax, refractory cardiac failure, chylothorax, inflammatory pleurisy — multidisciplinary decision; align with goals of care
- IPC vs. pleurodesis (expandable lung): TIME2 RCT showed no difference in dyspnea relief; Cochrane review shows higher definitive pleurodesis rate with chemical techniques. Choose IPC when patient prefers outpatient management or has poor performance status
Contraindications
- Active pleural infection / empyema — absolute; drain and treat infection first; do not place tunneled catheter through infected tissue
- Skin infection at planned tunnel or exit site
- Empyema in acute setting — advised against; only case-by-case after full multidisciplinary discussion (source: Anand et al. 2022)
- Loculated effusion not amenable to single catheter drainage
- Coagulopathy: SIR 2019 thresholds for tunneled pleural placement — INR <3.0, platelets >20K; INR <2.0 preferred if subcutaneous tunnel included
- Non-cooperative patient / unable to manage or arrange home drainage
- Chylothorax (relative — IPC drains symptom only; lymphangiography/TDE addresses cause)
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Pre-Procedure Checklist
Review chest X-ray and CT chest — confirm effusion size, distribution, free-flowing vs loculated, lung parenchymal status (trapped vs expandable), diaphragm level
Ultrasound assessment of effusion: depth, largest accessible pocket, presence of septations/loculations
Labs: CBC, INR, platelet count. SIR 2019 thresholds for tunneled pleural placement: INR <3.0, platelets >20K; INR <2.0 preferred when subcutaneous tunnel is included
Anticoagulation: hold oral anticoagulation per SIR guidelines; DOACs hold 24–48h; warfarin hold 5 days
Consent: pleural infection/empyema (4.9% lifetime — multicenter study 1,021 patients; mortality 0.29%), catheter malfunction/occlusion, pneumothorax, re-expansion pulmonary edema, tumor seeding along tunnel (rare), catheter fracture, skin breakdown at exit site, protein/electrolyte loss (cachexia)
Antibiotics: prophylactic antibiotics NOT demonstrated to reduce infection rate for IPC placement — no difference between early and late infections in patients who did and did not receive perioperative antibiotics (Rashid et al. JVIR 2016). Follow institutional protocol; routine prophylaxis not evidence-based for this device
IPC kit: ensure PleurX 15.5 Fr kit OR Rocket/Aspira/Asept kit available (15–16 Fr, valved catheter); drainage vacuum bottles and gravity bags for home use; confirm patient/caregiver trained before discharge
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Relevant Anatomy
Pleural Space Access
- Enter 4th–8th intercostal space; posterior axillary line to midaxillary line preferred; avoids upper axillary vessels (avoid medial to midaxillary line in upper spaces — risk to mediastinal structures); avoid lower than 8th ICS — diaphragm injury risk
- Rib anatomy: enter ABOVE the superior rib margin — avoid the neurovascular bundle (nerve, vein, artery) that runs along inferior margin of each rib
Tunnel Track
- Subcutaneous tunnel 5–8 cm length, directed cephalad from chest wall incision to skin exit site; “breaks” the straight path from pleura to exit, reducing infection risk
- Cuff position: velour cuff must be 1–2 cm inside tunnel from exit site — not outside the skin
- Key measurements: US distance from skin to fluid; avoid visceral pleura in non-expandable lung cases
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Technique
Default RadCall approach · share your own below
Supplies
Ultrasound machine + sterile probe cover
PleurX 15.5 Fr IPC kit
Marking pen
ChloraPrep/chlorhexidine prep
Sterile drapes
1% lidocaine with epinephrine
Scalpel (15 blade)
Tunneling trocar (included in kit)
2-0 Nylon or Prolene suture
Sterile dressing + foam cuff dressing
Steps
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Position and US Survey
Patient seated or semi-lateral. Ultrasound survey to identify largest safe pocket. Mark two incisions: (A) chest wall entry site (between ribs, 4th–8th ICS, posterior/mid-axillary line) and (B) tunnel exit site (5–8 cm cephalad to entry site, in a comfortable location for patient home drainage — usually anterior chest or flank depending on laterality).
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Prep and Drape
Prep entire lateral chest wall including both planned incision sites. Sterile drape.
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Local Anesthesia
Infiltrate 1% lidocaine with epinephrine at both incision sites and throughout planned tunnel track. Allow 3–5 minutes for full effect.
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Chest Wall Incision and Pleural Access
5 mm incision at site A (chest wall entry). Blunt dissection to rib. Enter pleural space with Seldinger needle under US guidance, aspirating to confirm fluid return. Advance guidewire. Dilate with serial dilators.
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Peel-Away Introducer
Insert peel-away 15.5 Fr sheath into pleural space over guidewire. Remove wire and inner dilator. Confirm fluid flows freely through sheath.
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Tunnel Creation
5 mm incision at site B (exit site). Insert tunneling trocar from site B, tunnel subcutaneously toward site A. Withdraw trocar as catheter is threaded through tunnel (catheter pulled from B exit → through tunnel → to chest wall entry site A). Cuff should be positioned 1–2 cm inside tunnel from exit site B — not outside the skin.
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Insert Catheter into Pleural Space
Advance distal catheter through peel-away sheath into pleural space. Peel away and remove sheath. Ensure 10–15 cm of catheter inside pleural space.
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Secure Catheter
Suture catheter to skin at entry site A. Apply foam cuff dressing around exit site B.
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Initial Drainage
Attach PleurX drainage bottle. Drain 1000–1500 mL initially. Stop if: cough, chest pain, or re-expansion pulmonary edema (wheeze, desaturation).
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Chest X-Ray
Immediately post-procedure to confirm catheter position and absence of pneumothorax.
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Troubleshooting
Problem
Unable to advance wire or catheter into pleural space
Likely cause: Fibrinous debris blocking needle, visceral pleura adherent (trapped lung), needle not within fluid
Next step: Rotate needle. Confirm US real-time that needle tip is within fluid. If fluid returns but wire won’t advance: try repositioning patient. For truly entrapped lung: use largest available pocket; smaller catheter may be needed. Fluoroscopy helps confirm wire looping freely in pleural space (posteriorly and superiorly).
Problem
Catheter stops draining — low/no output despite known effusion
Likely cause: Fibrin occlusion of catheter fenestrations (most common), catheter kinking, lung expanded to tip, loculation emptied
Step 1: Flush catheter with 20 mL saline. Step 2 (fibrin occlusion): Instill tPA (alteplase 4 mg in 20 mL NS) via catheter; clamp 1 hour; aspirate. Safe and effective for restoring function of obstructed tunneled pleural catheters (Wilshire, Ann Am Thorac Soc 2015). Step 3 (persistent): Chest X-ray to confirm catheter position and lung status. If kinked: image-guided repositioning. If truly failed: catheter replacement at different site.
Problem
Drainage stops at 500–800 mL / cough and chest tightness during drainage
Likely cause: Re-expansion pulmonary edema or trapped lung with negative pressure build-up
Next step: Stop drainage immediately. Chest X-ray. Usually self-limiting. If re-expansion pulmonary edema: O₂, monitor, admit if significant. Rule: <20 cm H₂O pressure during drainage; stop if cough or discomfort develops; max 1,000–1,500 mL per session. Never vacuum-drain a trapped lung rapidly.
Problem
Exit site infection / fever / purulent effusion
Infection rate: 4.9% (multicenter study, n=1,021). Most common organism: Staphylococcus aureus. Mortality from IPC-related infection: 0.29%.
Exit site cellulitis (superficial): wound culture + oral antibiotics + local wound care. Empyema/pleural infection (fever + purulent drainage or positive culture): hospitalize, IV antibiotics, strong consideration of catheter removal — failed medical management = catheter must come out. Do not leave an infected IPC in place.
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Complications
Immediate
- Pneumothorax (<5%) — obtain post-procedure chest X-ray in all cases
- Re-expansion pulmonary edema — drainage too rapid; limit to 1000–1500 mL per session
- Hemothorax — intercostal vessel injury (rare); ensure needle passes ABOVE superior rib margin
- Vasovagal reaction during procedure — lay patient flat, IV fluids
Delayed
- Pleural infection/empyema (4.9% multicenter, n=1,021; mortality 0.29%) — most serious; IV antibiotics; catheter removal for failed medical management
- Catheter occlusion/fibrin — tPA (alteplase 4 mg in 20 mL NS, dwell 1h) confirmed safe and effective (Wilshire 2015)
- Protein/electrolyte loss (cachexia) — ongoing drainage removes pleural protein; monitor nutritional and electrolyte status in prolonged dwell cases
- Tumor seeding along tract — rare; mesothelioma carries elevated risk
- Catheter fracture — rare; requires removal
- Skin breakdown at cuff site — cuff must be 1–2 cm inside tunnel, not extruded
- Spontaneous pleurodesis (~45% overall; 47% with daily drainage) — remove catheter when <150 mL × 3 consecutive drainage sessions
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Post-Procedure Care
Immediate Monitoring
- Chest X-ray in recovery confirms catheter position and lung status
- Observe 1–2h post-procedure for pneumothorax symptoms
- Demonstrate drainage procedure to patient and/or caregiver before discharge
- Home drainage supplies: PleurX drainage bottles (3 per week initially), dressing change supplies
When to Call IR/Doctor
- Fever >38°C
- Purulent or unusual-appearing fluid
- Sharp chest pain or new shortness of breath
- Drainage volume change >50% from baseline
- Red or cloudy drainage
Home Drainage Protocol
- Drain up to 1,000–1,500 mL per session; stop if cough or chest tightness develops
- Frequency — ASAP Trial (Wahidi, AJRCCM 2017): daily drainage achieves 47% spontaneous pleurodesis vs 24% every-other-day. Consider daily drainage protocol when pleurodesis is the goal
- Every-other-day is acceptable for symptom control alone with less patient burden
- If <150 mL × 3 consecutive sessions → evaluate for catheter removal (spontaneous pleurodesis achieved)
Accelerating Pleurodesis
- Daily drainage (ASAP data): 47% pleurodesis rate vs 24% every-other-day; shorter mean time to pleurodesis
- Combination therapy (talc + IPC): instillation of talc through IPC achieves ~92% pleurodesis rate with shorter IPC dwell time (Reddy, Chest 2011)
- Spontaneous pleurodesis ~45% overall (systematic review, 943 patients)
- Catheter removal criteria: <150 mL × 3 consecutive sessions + confirmed lung expansion on chest X-ray
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Critical Pearls
✶
Trapped lung vs expandable lung: The most important pre-procedure assessment. Check post-thoracentesis X-ray from any prior drainage — if lung doesn’t fully expand, it’s trapped. Trapped lung → IPC is ideal (pleurodesis won’t work). Expandable lung → IPC or pleurodesis both options.
✶
Cuff position matters: The velour cuff must be 1–2 cm inside the subcutaneous tunnel from the exit site — NOT outside the skin. An extruded or misplaced cuff is the most common technical error and causes early skin breakdown.
✶
Drain slowly for trapped lung: Never vacuum-drain a large chronic effusion rapidly in a patient with suspected trapped lung — large negative pleural pressure causes re-expansion pulmonary edema. Gravity drainage only, 1000 mL max per session.
✶
Empyema is the feared complication: 3–5% lifetime risk. Patients must be counseled about signs: fever, purulent drainage, pain. Any suspected empyema requires hospitalization and IV antibiotics — not outpatient management.
✶
IPC enables spontaneous pleurodesis in ~45%: Daily drainage achieves 47% pleurodesis vs 24% every-other-day (ASAP Trial). Set this expectation upfront — catheter removal after pleurodesis is the best outcome. Combination talc instillation through IPC boosts rate to ~92%.
✶
tPA for catheter occlusion: Instill alteplase 4 mg in 20 mL NS, clamp 1h, aspirate. Confirmed safe and effective for restoring tunneled pleural catheter function (Wilshire, Ann Am Thorac Soc 2015). Do not replace catheter before trying this.
✶
Prophylactic antibiotics are not evidence-based for IPC placement: Multiple studies show no difference in infection rates in patients who did and did not receive perioperative antibiotics. Infection is a device-related risk that occurs throughout the dwell period, not just at insertion.
✶
Failed pleurodesis is not an exclusion: Tunneled catheters after failed chemical pleurodesis achieve clinical improvement in >95% of patients. IPC is viable salvage when pleurodesis has already been attempted.
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References & Resources
Key Guidelines
- BTS Guidelines for Investigation and Management of Malignant Pleural Mesothelioma (2018)
- ERS/ATS Task Force on Malignant Pleural Effusions
- ACCP/SIS Guidelines (2018)
Primary References
- Anand K, Kaufman CS, Quencer KB. Thoracentesis, chest tubes, and tunneled chest drains. Semin Intervent Radiol. 2022;39:348–354. [Source for device selection, complication rates, prophylactic antibiotic data]
- Ha T, Madoff DC, Li D. Symptomatic fluid drainage: tunneled peritoneal and pleural catheters. Semin Intervent Radiol. 2017;34:337–342. [Source for pleurodesis data, combination therapy, cost-effectiveness]
- Davies HE, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis: TIME2 RCT. JAMA. 2012;307:2383–2389.
- Wahidi MM, et al. Randomized trial of pleural fluid drainage frequency — The ASAP Trial. Am J Respir Crit Care Med. 2017;195:1050–1057. [Daily 47% vs every-other-day 24% pleurodesis]
- Fysh ETH, et al. Clinical outcomes of indwelling pleural catheter-related pleural infections. Chest. 2013;144:1597–1602. [Infection rate 4.9%, mortality 0.29%, Staph aureus most common]
- Wilshire CL, et al. Safety and efficacy of fibrinolytic therapy in restoring function of obstructed tunneled pleural catheter. Ann Am Thorac Soc. 2015;12:1317–1322.
- Thornton RH, et al. Tunneled pleural catheters for treatment of recurrent MPE following failed pleurodesis. J Vasc Interv Radiol. 2010;21:696–700.
- Rashid S, et al. Utility of prophylactic antibiotics in tunneled peritoneal and pleural drainage catheters. J Vasc Interv Radiol. 2016;27.