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Calcified central venous catheter fibrin sheath: case report and review of the literature
Calcified Central Venous Catheter Fibrin Sheath: case report and review of the literature Aryeh Keehn, Dan Rabinowitz, Steve K Williams, Benjamin H. Taragin PII: DOI: Reference:
S0899-7071(15)00175-8 doi: 10.1016/j.clinimag.2015.07.014 JCT 7870
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
21 May 2015 8 July 2015 15 July 2015
Please cite this article as: Keehn Aryeh, Rabinowitz Dan, Williams Steve K, Taragin Benjamin H., Calcified Central Venous Catheter Fibrin Sheath: case report and review of the literature, Journal of Clinical Imaging (2015), doi: 10.1016/j.clinimag.2015.07.014
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
T
Calcified Central Venous Catheter Fibrin Sheath: case report and review of the literature
SC
RI P
Aryeh Keehn*, Dan Rabinowitz*, Steve K Williams* and Benjamin H. Taragin¥
MA
NU
Department of Surgery* and Radiology¥, Albert Einstein College of Medicine, Bronx, New York, NY, USA
CE
Corresponding author:
PT
ED
Keywords: Central venous catheter, venous cast, complications of central venous catheters Running title: Calcified central venous catheter cast: case report and review of the literature Word count: Manuscript = 1946
AC
Benjamin Taragin MD Department of Radiology The Children’s Hospital at Montefiore Medical Center 111 East 210th Street (Yellow Zone) Room CM 106 Bronx, NY 10467 718-920-4865
ACCEPTED MANUSCRIPT
Introduction
T
Central venous access devices have been used in pediatric patients who require chemotherapy,
RI P
transfusions and blood sampling for an extended period of time. These catheters allow large volumes to be delivered to patients in a short time and also allow for the delivery of medications
SC
that may be irritating to peripheral veins. Long term access to the central venous system may be
NU
achieved by direct venous puncture of the internal jugular, cephalic or subclavian veins with the
MA
tip of the catheter positioned at the right atrium or superior vena cava.1
Removal of chronically implanted central venous access device in the pediatric population can
ED
occur in the operating room, or in the interventional radiology suite depending upon the
PT
institution, age of patient, and complexity of intervention. Potential complications associated with central venous access removal include thromboembolism, hemorrhage and catheter fracture
CE
with retained fragments. A calcified catheter ‘‘cast’’, more commonly referred to as a fibrin
AC
sheath, is a known possible consequence of central venous catheterization that may be mistaken for the presence of a retained catheter fragment. We present a patient with a calcified catheter fibrin sheath in the superior vena cava identified on follow up chest X-ray after removal of an implantable venous access device. Because of its uniform shape and presence of central lucency this was initially felt to be a retained fragment of catheter. However, the operative note clearly stated that the removed catheter was intact and measured to same length as the time insertion. In retrospect, the fibrin sheath can be identified in various stages of formation over 18months which confirmed that this was not a piece of the catheter but rather a cast formed around it.
ACCEPTED MANUSCRIPT Case report A 6 y/o female with acute T cell lymphoblastic leukemia presented to the surgical service for
RI P
T
removal of a Port-a cath after having successfully completed a course of chemotherapy. The patient’s chemotherapy regimen had been prescribed according to the Children’s Oncolgy Group
SC
protocol AALL0232 (vincristine, oral methotrexate, mercaptopurine and prednisone). Eighteen months earlier, the child had insertion of a 5 Fr Infusaport (Kendall Healthcare, Mass) via the
MA
NU
right internal jugular vein to facilitate chemotherapy administration.
On presentation, she was afebrile, with no signs of tenderness or erythema at the catheter site.
ED
Chest X-ray showed the tip of the right sided central venous catheter at the junction between the superior vena cava and the right atrium. The patient was taken to the operating room for catheter
PT
removal. In the operating room, an incision was made over the port site on the right upper chest
CE
wall. The port was easily identified and dissected free from the surrounding tissues, but there was some difficulty in removing the central venous catheter as it appeared to be tethered in the
AC
neck. A second incision was made in the neck at the initial puncture site of the right internal jugular vein. The catheter appeared to be encased in a fibrous sheath within the soft tissues. The catheter was dissected free from the soft tissue fibrous sheath and was removed intact from within the internal jugular vein without appreciation of any intravascular sheath structure.
Follow up chest radiograph revealed a 3 cm linear density overlying the superior vena cava with an appearance suggesting a residual catheter fragment (Figure 1). Secondary to the uncertainty regarding the possibility of a catheter fragment, the prior imaging on this patient was rereviewed. Previous X-rays demonstrated development of a calcified fibrin sheath around the
ACCEPTED MANUSCRIPT catheter over sequential examinations (figure 2). The consensus amongst the services was that the radiological finding was suggestive of a calcified fibrin sheath which formed
T
circumferentially around the catheter while it was in situ which remained after catheter removal
RI P
and that further investigations or interventions were not necessary. The patient was subsequently discharged, and at one year follow-up post removal, the fibrin sheath has become slightly denser
SC
but has not changed in position. Additionally, the patient remains disease free with no evidence
NU
of superior vena cava obstruction.
MA
Discussion
ED
Placement of a central venous catheter in children introduces several risks while in situ as well as
PT
at the time of removal with reported complication rates of between 0.7 and 23%.2 After catheterization, 42- 100% of central venous catheters are surrounded by a fibrin sleeve which has
CE
been considered a cause of withdrawal occlusion, catheter-related infections and pulmonary
AC
embolism.3 Retained elements, or calcific fibrin sheaths after removal of a central venous catheter or implantable venous devices are less common, with few reports in the literature. 4 5 Despite this, the incidence of retained fibrin sheaths may be more common than previously thought. One study of 147 adults found fibrin sheaths to be present in 13.6% of patients who underwent CT scan after central venous catheter removal, with 45% of those being calcified.6 The radiologic finding of a calcified fibrin sheath from a previously inserted catheter is significant as its appearance may be mistaken for a retained catheter fragment. Knowledge of this finding may prevent unnecessary interventions and are important to identify with regard to future line placement.
ACCEPTED MANUSCRIPT
There have been a few case reports in pediatric literature that describe the retention of broken
T
central venous catheters at the time of insertion or removal. If a catheter appears fixed when
RI P
removal is attempted, the options are to either leave the catheter fragment in situ or to attempt either intravascular removal or open surgical removal. It is recommended that all central venous
SC
catheters be inspected and accurately measured at the time of removal to ensure that its length at
NU
extraction equals the length at insertion. In 2003, Jones et al reported on a series of 132 central line removals in a pediatric population. 7 Of the 132, they reported 3 patients with retained
MA
catheter fragments after a difficult dissection. In these three cases the physicians knew at the time of removal that a fragment had likely been left behind. In the current case, the catheter was felt
ED
to be intact on gross inspection, and its length was similar to that recorded at the time of
PT
insertion. The management of these patients can be more difficult as the actual diagnosis is not
CE
as clear cut.
Various studies have reported on the association between the formation of intravascular sleeves
AC
and all categories of central venous catheter devices. The development of this sheath like covering was reported first in the 1960’s on an autopsy report showing a subclavian vein catheter surrounded by a visible sheath. These sheaths may be completely asymptomatic or can result in catheter occlusion, infusate extravasation, pulmonary embolus at catheter removal, or loss of the access site due to thrombosis.8 The cellular development of this catheter sleeve has been described by Xiang et al.9 During the first week after catheterization a thrombus is formed in the tissues surrounding the catheter as the foreign body activates the coagulation system and becomes coated by plasma proteins such as fibrinogen. Platelets then adhere and aggregate with subsequent activation of the intrinsic coagulation system next. The interaction between vein wall
ACCEPTED MANUSCRIPT and catheter results in denudation of endothelial cells and activation of smooth muscle cells. After roughly 7 days, activated smooth muscle cells migrate from the injured vein wall into the
T
pericatheter thrombus to transform it to a cellular-collagen tissue, covered by a layer of
RI P
endothelial cells resulting in the development of a pericatheter sheath. This pericatheter sheath is composed of a well-organized tissue that cannot be dissolved in the blood stream and is
NU
SC
permanently attached to the vein wall.
Thrombotic events in cancer patients are probably multifactorial and complicated by the use of
MA
anti-neoplastic drugs such as Vincristine used in our patient.10 These drugs may be harmful to endothelial cells by exposing the subendothelial matrix or inducing the expression of adhesion
ED
molecules on endothelial cell surfaces increasing the reactivity of these cells to platelets
PT
potentially increasing the risk of coagulation. Cytosine arabinoside, Adriamycin and Vincristine have the greatest effect in eliciting thrombin generation. Despite this, fibrin sheath formation is
CE
more common in those catheters used for infusing parenteral nutrition, rather than those used for
AC
monitoring central venous pressures or infusion of medications. 11 The finding of a radiopaque density in the superior vena cava after venous access device removal may also be due to calcification of the pericatheter sheath over time. This calcification results from the abnormal deposition of calcium phosphate crystals and is conceivably similar to the pathogenesis of atherosclerotic calcification.
The ability to discern a fibrin/calcified sheath from a retained fragment is imperative in avoiding invasive procedures. Simple measures can be taken in distinguishing the two entities such as measuring the catheter pre and post operatively, as well as careful description of cast formation
ACCEPTED MANUSCRIPT on pre-removal radiographs. If the retained fibrin sheath is located within a cardiac chamber echocardiography can help in confirming the diagnosis. 12 Parenthetically, the formation of these
T
casts, in our experience, also forebodes difficulty in intra-operative removal. If patients require
RI P
these types of catheters on a long term basis such as for dialysis it is recommended that they be prophylactically exchanged earlier to avoid the formation of fibrin sheaths and adherence to
SC
vessels walls. Classically, CT scan does not offer much more diagnostic information than a plain
NU
radiograph. However, a second case of a catheter cast at this institution, did demonstrate findings that we felt were pertinent to this discussion as well as helpful in diagnosis. A chest radiograph
MA
performed for routine follow up on a 12 year old who recently finished chemotherapy revealed a linear density post removal of an intact indwelling central port (Figure 3). Despite our
ED
interpretation that this likely represented a retained cast, as per the insistence of the patient’s
PT
primary team a limited CT with intravenous contrast was performed to confirm the diagnosis. On review of the CT scan, contrast material was seen passing through the lumen of the cast
CE
(figure 4). It was thought that a retained foreign body would not have permitted contrast to fill
AC
the lumen. It is noteworthy to mention that contrast material can sometimes limit evaluations in less obvious cases as it can be isodense to a calcified sheath. It is important both to be aware of this possible limitation, and to use narrow windows to help differentiate calcium from contrast.
In 2012, van Bastelaar reported on a 19 year old female that presented with fever after the removal of a central venous catheter that had been present for over 3 years. 13 Although plain films were non diagnostic, a subsequent CT scan revealed a hyperdense structure in her left innominate vein thought to be a retained fragment. Since the fragment was not apparent on plain film further workup with three-dimensional image reconstruction was undertaken and results
ACCEPTED MANUSCRIPT showed thrombus with calcification. In response to this case and those similar to it, May et al recently reported a newly engineered micropattern that is imprinted on catheters that reduce
T
platelet adhesion and fibrin sheath formation by up to 86%. 14 Additionally, the micropattern
RI P
reduced S. aureus and S. epidermidis colonization by 70% and 71% when compared to unpatterned controls. This technology may be useful in preventing catheter associated blood
NU
SC
infections as well as sequelae related to fibrin sheath formation.
MA
Conclusion
This case represents an interesting management sequence of a pediatric calcified fibrin sheath
ED
with the use of diagnostic imaging. As noted in previous reports, it is recommended that central
PT
venous catheters be removed as soon as possible after treatment is completed given the potential morbidity associated with thrombus formation. Preoperative radiographic evaluation of chronic
CE
indwelling catheters should include any description of cast formation which could complicate
AC
removal and potentially create confusion on follow up studies. Awareness of calcified fibrin sheaths may avoid unnecessary procedures and guide future line placement should they be needed.
ACCEPTED MANUSCRIPT
Figure 1
RI P
T
Post-catheter removal plain film reveals a 2cm opacity suspicious for a retained catheter fragment.
SC
Figure 2
MA
NU
A: Plain film at 3 months post catheter placement. B: Plain film at 12 months post catheter placement. The catheter has migrated revealing the formation of the catheter cast at the distal end as marked by the arrow.
Figure 3
AC
Figure 4
CE
PT
ED
Post-catheter removal X-Ray showcasing a 3 cm linear opacity in the region of the superior vena cava thought to be a possible retained catheter fragment.
Axial CT with contrast demonstrates contrast flowing through the catheter cast.
AC
Fig. 1
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
AC
Fig. 2
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
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Fig. 3
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PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
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Fig. 4
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PT
ED
MA
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SC
RI P
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ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT References
1
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T
Stellato TA, Gauderer MW, Cohen AM. Direct central vein puncture for silicone rubber catheter insertion. An alternative technique for Broviac catheter placement. Surgery. 1981 Nov;90(5):896-9. 2
SC
Askegard-Giesmann JR, Caniano DA, Kenney BD. Rare but serious complications of central line insertion.Semin Pediatr Surg. 2009;18(2):73–83. 3
NU
Xiang D Z, Verbeken E K, Lommel A T Van, Stas M, De Wever I. Composition and formation of the sleeve enveloping a central venous catheter. J Vasc Surg. 1998;28(2):260–271. 4
MA
Sabbaghian MS, Rivera R, Ginsburg HB, Nadler EP. Calcified catheter “cast” masquerading as a retained catheter fragment after removal of an implanted venous access device. Pediatr Surg Int.2007;23(9):927–930. 5
ED
James van Bastelaar, Caroline H C Janssen, Eveline de Bont, Nicole M Blijlevens, Robertine van Baren. Densities in the left innominate vein after removal of an implantable venous device: a case report. J Med Case Rep. 2012; 6: 180. 6
PT
Capitanini A, Ricci E, Frosini P, Cupisti A. Massively calcified intravascular cast after removal of a tunneled central vein catheter for hemodialysis. J Vasc Access. 2013 Apr-Jun;14(2):196-8. 7
8
CE
Jones SA, Giacomantonio M. A complication associated with central line removal in the pediatric population: retained fixed catheter fragments. J Pediatr Surg. 2003;38(4):594-6.
9
AC
Forauer AR, Theoharis CG, Dasika NL. Jugular vein catheter placement: histologic features and development of catheter-related (fibrin) sheaths in a swine model. Radiology. 2006;12:427– 434. Xiang D Z, Verbeken E K, Lommel A T Van, Stas M, De Wever I. Composition and formation of the sleeve enveloping a central venous catheter. J Vasc Surg. 1998;28(2):260–271. 10
Paredes N, Xu L, Berry LR, Chan AK. The effects of chemotherapeutic agents on the regulation of thrombin on cell surfaces. Br J Haematol. 2003 Jan;120(2):315-24. 9
Capitanini A, Ricci E, Frosini P, Cupisti A. Massively calcified intravascular cast after removal of a tunneled central vein catheter for hemodialysis. J Vasc Access. 2013 Apr-Jun;14(2):196-8. 10
Hughes DB, Ullery BW, Spigland N. Formation of a calcified "cast" in a long-term indwelling central venous catheter: a case report. J Pediatr Surg. 2006 Nov;41(11):1927-9.
ACCEPTED MANUSCRIPT
11
T
Hughes DB, Ullery BW, Spigland N. Formation of a calcified "cast" in a long-term indwelling central venous catheter: a case report. J Pediatr Surg. 2006 Nov;41(11):1927-9.
12
SC
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Ríos-Méndez RE, Giménez P. Intracardiac persistence of pericatheter fibrin sheath in a newborn: case report Arch Argent Pediatr. 2014 Feb;112(1)
13
NU
Van bastelaar J, Janssen CH, De bont E, Blijlevens NM, Van baren R. Densities in the left innominate vein after removal of an implantable venous device: a case report. J Med Case Rep. 2012;6:18 14
AC
CE
PT
ED
MA
Rhea M May, Chelsea M Magin, Ethan E Mann, Michael C Drinker, John C Fraser, Christopher A Siedlecki, Anthony B Brennan, and Shravanthi T Reddy. An engineered micropattern to reduce bacterial colonization, platelet adhesion and fibrin sheath formation for improved biocompatibility of central venous catheters. Clin Transl Med. 2015; 4: 9.
S0899-7071(15)00175-8 doi: 10.1016/j.clinimag.2015.07.014 JCT 7870
To appear in:
Journal of Clinical Imaging
Received date: Revised date: Accepted date:
21 May 2015 8 July 2015 15 July 2015
Please cite this article as: Keehn Aryeh, Rabinowitz Dan, Williams Steve K, Taragin Benjamin H., Calcified Central Venous Catheter Fibrin Sheath: case report and review of the literature, Journal of Clinical Imaging (2015), doi: 10.1016/j.clinimag.2015.07.014
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
T
Calcified Central Venous Catheter Fibrin Sheath: case report and review of the literature
SC
RI P
Aryeh Keehn*, Dan Rabinowitz*, Steve K Williams* and Benjamin H. Taragin¥
MA
NU
Department of Surgery* and Radiology¥, Albert Einstein College of Medicine, Bronx, New York, NY, USA
CE
Corresponding author:
PT
ED
Keywords: Central venous catheter, venous cast, complications of central venous catheters Running title: Calcified central venous catheter cast: case report and review of the literature Word count: Manuscript = 1946
AC
Benjamin Taragin MD Department of Radiology The Children’s Hospital at Montefiore Medical Center 111 East 210th Street (Yellow Zone) Room CM 106 Bronx, NY 10467 718-920-4865
ACCEPTED MANUSCRIPT
Introduction
T
Central venous access devices have been used in pediatric patients who require chemotherapy,
RI P
transfusions and blood sampling for an extended period of time. These catheters allow large volumes to be delivered to patients in a short time and also allow for the delivery of medications
SC
that may be irritating to peripheral veins. Long term access to the central venous system may be
NU
achieved by direct venous puncture of the internal jugular, cephalic or subclavian veins with the
MA
tip of the catheter positioned at the right atrium or superior vena cava.1
Removal of chronically implanted central venous access device in the pediatric population can
ED
occur in the operating room, or in the interventional radiology suite depending upon the
PT
institution, age of patient, and complexity of intervention. Potential complications associated with central venous access removal include thromboembolism, hemorrhage and catheter fracture
CE
with retained fragments. A calcified catheter ‘‘cast’’, more commonly referred to as a fibrin
AC
sheath, is a known possible consequence of central venous catheterization that may be mistaken for the presence of a retained catheter fragment. We present a patient with a calcified catheter fibrin sheath in the superior vena cava identified on follow up chest X-ray after removal of an implantable venous access device. Because of its uniform shape and presence of central lucency this was initially felt to be a retained fragment of catheter. However, the operative note clearly stated that the removed catheter was intact and measured to same length as the time insertion. In retrospect, the fibrin sheath can be identified in various stages of formation over 18months which confirmed that this was not a piece of the catheter but rather a cast formed around it.
ACCEPTED MANUSCRIPT Case report A 6 y/o female with acute T cell lymphoblastic leukemia presented to the surgical service for
RI P
T
removal of a Port-a cath after having successfully completed a course of chemotherapy. The patient’s chemotherapy regimen had been prescribed according to the Children’s Oncolgy Group
SC
protocol AALL0232 (vincristine, oral methotrexate, mercaptopurine and prednisone). Eighteen months earlier, the child had insertion of a 5 Fr Infusaport (Kendall Healthcare, Mass) via the
MA
NU
right internal jugular vein to facilitate chemotherapy administration.
On presentation, she was afebrile, with no signs of tenderness or erythema at the catheter site.
ED
Chest X-ray showed the tip of the right sided central venous catheter at the junction between the superior vena cava and the right atrium. The patient was taken to the operating room for catheter
PT
removal. In the operating room, an incision was made over the port site on the right upper chest
CE
wall. The port was easily identified and dissected free from the surrounding tissues, but there was some difficulty in removing the central venous catheter as it appeared to be tethered in the
AC
neck. A second incision was made in the neck at the initial puncture site of the right internal jugular vein. The catheter appeared to be encased in a fibrous sheath within the soft tissues. The catheter was dissected free from the soft tissue fibrous sheath and was removed intact from within the internal jugular vein without appreciation of any intravascular sheath structure.
Follow up chest radiograph revealed a 3 cm linear density overlying the superior vena cava with an appearance suggesting a residual catheter fragment (Figure 1). Secondary to the uncertainty regarding the possibility of a catheter fragment, the prior imaging on this patient was rereviewed. Previous X-rays demonstrated development of a calcified fibrin sheath around the
ACCEPTED MANUSCRIPT catheter over sequential examinations (figure 2). The consensus amongst the services was that the radiological finding was suggestive of a calcified fibrin sheath which formed
T
circumferentially around the catheter while it was in situ which remained after catheter removal
RI P
and that further investigations or interventions were not necessary. The patient was subsequently discharged, and at one year follow-up post removal, the fibrin sheath has become slightly denser
SC
but has not changed in position. Additionally, the patient remains disease free with no evidence
NU
of superior vena cava obstruction.
MA
Discussion
ED
Placement of a central venous catheter in children introduces several risks while in situ as well as
PT
at the time of removal with reported complication rates of between 0.7 and 23%.2 After catheterization, 42- 100% of central venous catheters are surrounded by a fibrin sleeve which has
CE
been considered a cause of withdrawal occlusion, catheter-related infections and pulmonary
AC
embolism.3 Retained elements, or calcific fibrin sheaths after removal of a central venous catheter or implantable venous devices are less common, with few reports in the literature. 4 5 Despite this, the incidence of retained fibrin sheaths may be more common than previously thought. One study of 147 adults found fibrin sheaths to be present in 13.6% of patients who underwent CT scan after central venous catheter removal, with 45% of those being calcified.6 The radiologic finding of a calcified fibrin sheath from a previously inserted catheter is significant as its appearance may be mistaken for a retained catheter fragment. Knowledge of this finding may prevent unnecessary interventions and are important to identify with regard to future line placement.
ACCEPTED MANUSCRIPT
There have been a few case reports in pediatric literature that describe the retention of broken
T
central venous catheters at the time of insertion or removal. If a catheter appears fixed when
RI P
removal is attempted, the options are to either leave the catheter fragment in situ or to attempt either intravascular removal or open surgical removal. It is recommended that all central venous
SC
catheters be inspected and accurately measured at the time of removal to ensure that its length at
NU
extraction equals the length at insertion. In 2003, Jones et al reported on a series of 132 central line removals in a pediatric population. 7 Of the 132, they reported 3 patients with retained
MA
catheter fragments after a difficult dissection. In these three cases the physicians knew at the time of removal that a fragment had likely been left behind. In the current case, the catheter was felt
ED
to be intact on gross inspection, and its length was similar to that recorded at the time of
PT
insertion. The management of these patients can be more difficult as the actual diagnosis is not
CE
as clear cut.
Various studies have reported on the association between the formation of intravascular sleeves
AC
and all categories of central venous catheter devices. The development of this sheath like covering was reported first in the 1960’s on an autopsy report showing a subclavian vein catheter surrounded by a visible sheath. These sheaths may be completely asymptomatic or can result in catheter occlusion, infusate extravasation, pulmonary embolus at catheter removal, or loss of the access site due to thrombosis.8 The cellular development of this catheter sleeve has been described by Xiang et al.9 During the first week after catheterization a thrombus is formed in the tissues surrounding the catheter as the foreign body activates the coagulation system and becomes coated by plasma proteins such as fibrinogen. Platelets then adhere and aggregate with subsequent activation of the intrinsic coagulation system next. The interaction between vein wall
ACCEPTED MANUSCRIPT and catheter results in denudation of endothelial cells and activation of smooth muscle cells. After roughly 7 days, activated smooth muscle cells migrate from the injured vein wall into the
T
pericatheter thrombus to transform it to a cellular-collagen tissue, covered by a layer of
RI P
endothelial cells resulting in the development of a pericatheter sheath. This pericatheter sheath is composed of a well-organized tissue that cannot be dissolved in the blood stream and is
NU
SC
permanently attached to the vein wall.
Thrombotic events in cancer patients are probably multifactorial and complicated by the use of
MA
anti-neoplastic drugs such as Vincristine used in our patient.10 These drugs may be harmful to endothelial cells by exposing the subendothelial matrix or inducing the expression of adhesion
ED
molecules on endothelial cell surfaces increasing the reactivity of these cells to platelets
PT
potentially increasing the risk of coagulation. Cytosine arabinoside, Adriamycin and Vincristine have the greatest effect in eliciting thrombin generation. Despite this, fibrin sheath formation is
CE
more common in those catheters used for infusing parenteral nutrition, rather than those used for
AC
monitoring central venous pressures or infusion of medications. 11 The finding of a radiopaque density in the superior vena cava after venous access device removal may also be due to calcification of the pericatheter sheath over time. This calcification results from the abnormal deposition of calcium phosphate crystals and is conceivably similar to the pathogenesis of atherosclerotic calcification.
The ability to discern a fibrin/calcified sheath from a retained fragment is imperative in avoiding invasive procedures. Simple measures can be taken in distinguishing the two entities such as measuring the catheter pre and post operatively, as well as careful description of cast formation
ACCEPTED MANUSCRIPT on pre-removal radiographs. If the retained fibrin sheath is located within a cardiac chamber echocardiography can help in confirming the diagnosis. 12 Parenthetically, the formation of these
T
casts, in our experience, also forebodes difficulty in intra-operative removal. If patients require
RI P
these types of catheters on a long term basis such as for dialysis it is recommended that they be prophylactically exchanged earlier to avoid the formation of fibrin sheaths and adherence to
SC
vessels walls. Classically, CT scan does not offer much more diagnostic information than a plain
NU
radiograph. However, a second case of a catheter cast at this institution, did demonstrate findings that we felt were pertinent to this discussion as well as helpful in diagnosis. A chest radiograph
MA
performed for routine follow up on a 12 year old who recently finished chemotherapy revealed a linear density post removal of an intact indwelling central port (Figure 3). Despite our
ED
interpretation that this likely represented a retained cast, as per the insistence of the patient’s
PT
primary team a limited CT with intravenous contrast was performed to confirm the diagnosis. On review of the CT scan, contrast material was seen passing through the lumen of the cast
CE
(figure 4). It was thought that a retained foreign body would not have permitted contrast to fill
AC
the lumen. It is noteworthy to mention that contrast material can sometimes limit evaluations in less obvious cases as it can be isodense to a calcified sheath. It is important both to be aware of this possible limitation, and to use narrow windows to help differentiate calcium from contrast.
In 2012, van Bastelaar reported on a 19 year old female that presented with fever after the removal of a central venous catheter that had been present for over 3 years. 13 Although plain films were non diagnostic, a subsequent CT scan revealed a hyperdense structure in her left innominate vein thought to be a retained fragment. Since the fragment was not apparent on plain film further workup with three-dimensional image reconstruction was undertaken and results
ACCEPTED MANUSCRIPT showed thrombus with calcification. In response to this case and those similar to it, May et al recently reported a newly engineered micropattern that is imprinted on catheters that reduce
T
platelet adhesion and fibrin sheath formation by up to 86%. 14 Additionally, the micropattern
RI P
reduced S. aureus and S. epidermidis colonization by 70% and 71% when compared to unpatterned controls. This technology may be useful in preventing catheter associated blood
NU
SC
infections as well as sequelae related to fibrin sheath formation.
MA
Conclusion
This case represents an interesting management sequence of a pediatric calcified fibrin sheath
ED
with the use of diagnostic imaging. As noted in previous reports, it is recommended that central
PT
venous catheters be removed as soon as possible after treatment is completed given the potential morbidity associated with thrombus formation. Preoperative radiographic evaluation of chronic
CE
indwelling catheters should include any description of cast formation which could complicate
AC
removal and potentially create confusion on follow up studies. Awareness of calcified fibrin sheaths may avoid unnecessary procedures and guide future line placement should they be needed.
ACCEPTED MANUSCRIPT
Figure 1
RI P
T
Post-catheter removal plain film reveals a 2cm opacity suspicious for a retained catheter fragment.
SC
Figure 2
MA
NU
A: Plain film at 3 months post catheter placement. B: Plain film at 12 months post catheter placement. The catheter has migrated revealing the formation of the catheter cast at the distal end as marked by the arrow.
Figure 3
AC
Figure 4
CE
PT
ED
Post-catheter removal X-Ray showcasing a 3 cm linear opacity in the region of the superior vena cava thought to be a possible retained catheter fragment.
Axial CT with contrast demonstrates contrast flowing through the catheter cast.
AC
Fig. 1
CE
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SC
RI P
T
ACCEPTED MANUSCRIPT
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Fig. 2
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Fig. 3
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Fig. 4
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ACCEPTED MANUSCRIPT References
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