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A simple method for removal of polyethylene catheters from the pulmonary artery
A simple method for removal of polyethylene catheters from the pulmonary artery P. C. Barman, M.D., * Syracuse, N. Y.
Embolization of indwelling polyethylene catheters is a serious complication of intravenous therapy. In most cases, it is caused by excessive movement of the patient's arm, which results in the sharp bevel of the needle shearing the catheter. The broken off catheter migrates into the central vascular system and usually lodges itself in the right atrium or the pulmonary artery. Wellmann and associates,' in a review of the literature, reported 13 deaths in 37 cases of polyethylene catheter embolism. The most common complications were infection with endocarditis, thrombus formation in the area of the foreign body, and perforation of the heart. Polyethylene catheters can be removed safely by the percutaneous technique, thereby avoiding the risks and expenses of thoracotomy. Massumi and Ross" and Henley and Ballard" have reported successful percutaneous removal of catheter fragments from the right atrium by means of a snare device. Method A cutdown is performed under local anesthesia in the right antecubital area, and a vein is dissected. A No. 8 Fr., Cournard From the Upstate Medical Center, SUNY, Syracuse, N. Y. Received for publication March 8, 1973. Address for reprints: P. C. Barman, M.D., 925 Seventh North st., No. 19, Liverpool, N. Y. 13088. 'Fellow in Cardiology.
792
catheter is introduced through the vein and passed through the right atrium and right ventricle into the main pulmonary artery under fluoroscopic control. During this time, the patient is being monitored electrocardiographically.as well as hemodynamically to avoid any rhythm problems and to identify the chambers correctly during manipulation of the catheter. A 60 inch long, 4-0 silk or Ethicon thread is used. One end of the thread is tied near the tip of a 0.021 inch guide wire, and both the guide wire and thread are introduced through a Cournard catheter. Under fluoroscopic control, both are passed beyond the tip of the catheter, and a loop is formed by manipulation of the guide wire and thread. The size of the loop can be increased or decreased as desired by manipulation of either one or both (Fig. 1). The loop is passed beyond the distal part of the polyethylene catheter fragment, and attempts are made to snare it into the loop. Afterward, the guide wire is pulled backward into the Cournard catheter, so that the thread keeps the polyethylene catheter firmly secured at the tip. At this point, the Cournard catheter, guide wire, and the thread are pulled out together, with the snared polyethylene catheter anchored at the tip (Fig. 2). Case reports CASE 1. 1. S., a 52-year-old man, was admitted with the diagnosis of diabetic ketoacidosis. An
Volume 65 Number 5
Removal of catheters from pulmonary artery
793
May, 1973
Fig. 2. Polyethylene catheter was snared, and the guide wire with thread was pulled out to secure the fragment tightly at the tip of the Cournard catheter.
Fig. 1, Tip of catheter with the guide wire and thread after polyethylene catheter was taken out. indwelling Intracath catheter was placed in an antecubital vein of the right arm in the emergency room . The initial chest x-ray film was negative, but a follow -up film showed a catheter segment coiled in the right pulmonary artery. A No. 8 Fr. , Cournard catheter was inserted through a cutdown in the right arm and was passed into the right pulmonary artery by manipulation through the right atrium and right ventricle. A 0.021 inch guide wire was tied with a 4-0 silk suture knot, and both were introduced through the catheter. A loop was formed under fluoroscopy, its size being regulated by pulling the silk thread or pushing the guide wire as desired. The loop was passed distal to the coiled polyethylene catheter, and the fragment was snared. Both the guide wire and silk thread were pulled, thereby tightly securing the foreign body at the tip of the Cournard catheter. Then the entire assembly was pulled out . The polyethylene catheter was 15 em. long . CASE 2. S. M., a 48-year-old man admitted with upper gastrointestinal bleeding, required a blood transfusion and intravenous therapy through a medium-sized Intracath catheter. That same evening it was found that the intravenous fluids were not running properly. An examination revealed that the polyethylene tube had migrated into the left pulmonary artery. The patient was taken to the cardiovascular laboratory. A cutdown was performed in the right forearm, and a vein was dissected. Next, a No. 8 Fr., Cournard catheter was introduced and advanced into the left pulmonary artery. With the use of a 0.021 inch guide wire and silk thread loop, the polyethylene
catheter was snared and pulled out . It was 17 em. long. CASE 3. B. H., a 24-year-01d woman, was admitted after sustaining multiple fractures in an automobile accident. A medium-sized Intracath catheter was placed in the left forearm. A few hours later, the entire catheter disappeared into the patient's vein, and an x-ray film revealed that it had migrated into the right pulmonary artery. A cutdown was performed in the right antecubital area, and a No. 8 Fr., Cournard catheter was introduced through one of the large veins. It was passed by being looped through the right ventricle and advanced into the right pulmon ary artery. The foreign body was then snared into the loop made by the 0.021 inch guide wire and silk thread. The recovered catheter was 19 em . long.
Discussion
This method of using a 0.021 inch guide wire with a 4-0 silk suture material tied on the proximal end to form a loop is quite simple and provides an easy means of manipulating the size of the loop . I believe this method offers more control in manipulating the catheter and the loop than do the other techniques which have been mentioned before in the literature.>" The loop is simply passed beyond the catheter part, and the fragment is snared. In all 3 cases, the foreign body was removed after 4 or 5 passes with the loop. The procedure took an average of 30 minutes from cutdown to skin closure . I have used No. 7.1 Fr. polyethylene catheters with a
794
The Journal 01 Thoracic and Cardiovascular Surgery
Barman
bigger inside diameter since the above cases were managed, and I now recommend the use of 0.021 inch guide wire with a 4-0 silk thread loop.
2
Summary Embolization of an indwelling polyethylene catheter is a well-known serious complication of intravenous therapy. In this paper, I described a new method of removing a catheter part from the pulmonary artery using a guide wire and silk suture material as a snare. The method is simple and safe and utilizes equipment which is readily available in cardiac catheterization laboratories. REFERENCES Wellmann, K. F., Reinhard, A., and Salazar, E. P.: Polyethylene Catheter Embolism. Re-
3 4
5
view of the Literature and Report of a Case With Associated Fatal Tricuspid and Systemic Candidiasis, Circulation 37: 380, 1968. Massumi, R. A., and Ross, A. M.: Atraumatic, Nonsurgical Technique for Removal of Broken Catheters From Cardiac Cavities, N. Engl. J. Med. 277: 195, 1967. Henley, F. T., and Ballard, J. W.: Percutaneous Removal of Flexible Foreign Body From the Heart, Radiology 92: 176, 1969. Curry, J. L.: Recovery of Detached Intravascular Catheter or Guide Wire Fragments. A Proposed Method, Am. J. Roentgenol, Radium Ther. Nuc!. Med. 105: 894, 1969. Miller, R. E., Cockerill, E. M., and Helbig, H.: Percutaneous Removal of Catheter Emboli From the Pulmonary Arteries, Radiology 94: lSI, 1970.
Embolization of indwelling polyethylene catheters is a serious complication of intravenous therapy. In most cases, it is caused by excessive movement of the patient's arm, which results in the sharp bevel of the needle shearing the catheter. The broken off catheter migrates into the central vascular system and usually lodges itself in the right atrium or the pulmonary artery. Wellmann and associates,' in a review of the literature, reported 13 deaths in 37 cases of polyethylene catheter embolism. The most common complications were infection with endocarditis, thrombus formation in the area of the foreign body, and perforation of the heart. Polyethylene catheters can be removed safely by the percutaneous technique, thereby avoiding the risks and expenses of thoracotomy. Massumi and Ross" and Henley and Ballard" have reported successful percutaneous removal of catheter fragments from the right atrium by means of a snare device. Method A cutdown is performed under local anesthesia in the right antecubital area, and a vein is dissected. A No. 8 Fr., Cournard From the Upstate Medical Center, SUNY, Syracuse, N. Y. Received for publication March 8, 1973. Address for reprints: P. C. Barman, M.D., 925 Seventh North st., No. 19, Liverpool, N. Y. 13088. 'Fellow in Cardiology.
792
catheter is introduced through the vein and passed through the right atrium and right ventricle into the main pulmonary artery under fluoroscopic control. During this time, the patient is being monitored electrocardiographically.as well as hemodynamically to avoid any rhythm problems and to identify the chambers correctly during manipulation of the catheter. A 60 inch long, 4-0 silk or Ethicon thread is used. One end of the thread is tied near the tip of a 0.021 inch guide wire, and both the guide wire and thread are introduced through a Cournard catheter. Under fluoroscopic control, both are passed beyond the tip of the catheter, and a loop is formed by manipulation of the guide wire and thread. The size of the loop can be increased or decreased as desired by manipulation of either one or both (Fig. 1). The loop is passed beyond the distal part of the polyethylene catheter fragment, and attempts are made to snare it into the loop. Afterward, the guide wire is pulled backward into the Cournard catheter, so that the thread keeps the polyethylene catheter firmly secured at the tip. At this point, the Cournard catheter, guide wire, and the thread are pulled out together, with the snared polyethylene catheter anchored at the tip (Fig. 2). Case reports CASE 1. 1. S., a 52-year-old man, was admitted with the diagnosis of diabetic ketoacidosis. An
Volume 65 Number 5
Removal of catheters from pulmonary artery
793
May, 1973
Fig. 2. Polyethylene catheter was snared, and the guide wire with thread was pulled out to secure the fragment tightly at the tip of the Cournard catheter.
Fig. 1, Tip of catheter with the guide wire and thread after polyethylene catheter was taken out. indwelling Intracath catheter was placed in an antecubital vein of the right arm in the emergency room . The initial chest x-ray film was negative, but a follow -up film showed a catheter segment coiled in the right pulmonary artery. A No. 8 Fr. , Cournard catheter was inserted through a cutdown in the right arm and was passed into the right pulmonary artery by manipulation through the right atrium and right ventricle. A 0.021 inch guide wire was tied with a 4-0 silk suture knot, and both were introduced through the catheter. A loop was formed under fluoroscopy, its size being regulated by pulling the silk thread or pushing the guide wire as desired. The loop was passed distal to the coiled polyethylene catheter, and the fragment was snared. Both the guide wire and silk thread were pulled, thereby tightly securing the foreign body at the tip of the Cournard catheter. Then the entire assembly was pulled out . The polyethylene catheter was 15 em. long . CASE 2. S. M., a 48-year-old man admitted with upper gastrointestinal bleeding, required a blood transfusion and intravenous therapy through a medium-sized Intracath catheter. That same evening it was found that the intravenous fluids were not running properly. An examination revealed that the polyethylene tube had migrated into the left pulmonary artery. The patient was taken to the cardiovascular laboratory. A cutdown was performed in the right forearm, and a vein was dissected. Next, a No. 8 Fr., Cournard catheter was introduced and advanced into the left pulmonary artery. With the use of a 0.021 inch guide wire and silk thread loop, the polyethylene
catheter was snared and pulled out . It was 17 em. long. CASE 3. B. H., a 24-year-01d woman, was admitted after sustaining multiple fractures in an automobile accident. A medium-sized Intracath catheter was placed in the left forearm. A few hours later, the entire catheter disappeared into the patient's vein, and an x-ray film revealed that it had migrated into the right pulmonary artery. A cutdown was performed in the right antecubital area, and a No. 8 Fr., Cournard catheter was introduced through one of the large veins. It was passed by being looped through the right ventricle and advanced into the right pulmon ary artery. The foreign body was then snared into the loop made by the 0.021 inch guide wire and silk thread. The recovered catheter was 19 em . long.
Discussion
This method of using a 0.021 inch guide wire with a 4-0 silk suture material tied on the proximal end to form a loop is quite simple and provides an easy means of manipulating the size of the loop . I believe this method offers more control in manipulating the catheter and the loop than do the other techniques which have been mentioned before in the literature.>" The loop is simply passed beyond the catheter part, and the fragment is snared. In all 3 cases, the foreign body was removed after 4 or 5 passes with the loop. The procedure took an average of 30 minutes from cutdown to skin closure . I have used No. 7.1 Fr. polyethylene catheters with a
794
The Journal 01 Thoracic and Cardiovascular Surgery
Barman
bigger inside diameter since the above cases were managed, and I now recommend the use of 0.021 inch guide wire with a 4-0 silk thread loop.
2
Summary Embolization of an indwelling polyethylene catheter is a well-known serious complication of intravenous therapy. In this paper, I described a new method of removing a catheter part from the pulmonary artery using a guide wire and silk suture material as a snare. The method is simple and safe and utilizes equipment which is readily available in cardiac catheterization laboratories. REFERENCES Wellmann, K. F., Reinhard, A., and Salazar, E. P.: Polyethylene Catheter Embolism. Re-
3 4
5
view of the Literature and Report of a Case With Associated Fatal Tricuspid and Systemic Candidiasis, Circulation 37: 380, 1968. Massumi, R. A., and Ross, A. M.: Atraumatic, Nonsurgical Technique for Removal of Broken Catheters From Cardiac Cavities, N. Engl. J. Med. 277: 195, 1967. Henley, F. T., and Ballard, J. W.: Percutaneous Removal of Flexible Foreign Body From the Heart, Radiology 92: 176, 1969. Curry, J. L.: Recovery of Detached Intravascular Catheter or Guide Wire Fragments. A Proposed Method, Am. J. Roentgenol, Radium Ther. Nuc!. Med. 105: 894, 1969. Miller, R. E., Cockerill, E. M., and Helbig, H.: Percutaneous Removal of Catheter Emboli From the Pulmonary Arteries, Radiology 94: lSI, 1970.