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Difficult extraction of long-term central venous catheters in children—case report
Journal of Pediatric Surgery (2010) 45, 1720–1723
www.elsevier.com/locate/jpedsurg
Difficult extraction of long-term central venous catheters in children—case report Ilan Maizlina,⁎, Heather Carpentier a , David Bliss b a
School of Medicine, Oregon Health & Science University, Portland, OR 97034, USA Oregon Health & Science University, Portland, OR 97034, USA
b
Received 7 October 2009; revised 15 May 2010; accepted 17 May 2010
Key words: Central venous catheter; Removal; Surgical complications; Port-a-Cath; Hickman line; Broviac line
Abstract Although many publications address the complications associated with insertion of long-term, indwelling central venous catheters, there are only scattered reports of problems related to their removal. We report 4 cases of pediatric patients in whom the lines could not be pulled from the vein by standard methods, requiring 2 intraperiosteal clavicle resections with venorrhaphy, 1 femoral vein exploration and reconstruction, and 1 jugular venorrhaphy. Despite their relative biocompatibility, long-term silicone lines may become fixed in the vein. The rare and unpredictable occurrence of this problem may present the surgeon with unexpected intraoperative dilemmas. Before attempting localized extraction, surgeons should consider what venue, equipment, and anesthesia support may be required to successfully remove these catheters. © 2010 Published by Elsevier Inc.
Central venous catheters (CVCs) have become a common tool in the treatment of chronic pediatric conditions. They provide durable and atraumatic venous access for blood sampling and administration of medications, blood components, and parenteral nutrition [1,2]. Routes of access include a subclavian; an internal jugular; an external jugular; a femoral; and, more rarely, a saphenous, a cephalic, or a facial vein [3]. Although many publications address the complications associated with insertion and in situ presence of longterm, indwelling CVCs [3,4], there are only scattered reports of problems related to their removal [2,5,6]. We detail a retrospective review of 4 such events in pediatric patients and compare their details to the general pediatric population with successfully removed CVCs.
⁎ Corresponding author. Tel.: +1 503 515 6006; fax: +1 503 635 5307. E-mail address: [email protected] (I. Maizlin). 0022-3468/$ – see front matter © 2010 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2010.05.026
1. Cases Between January 2001 and July 2008, 1019 patients underwent removal of CVCs in 2 regional children's hospitals. All procedures were performed by a single academic pediatric surgical group serving both institutions. All catheter types were silicone based and either entirely indwelling (Port) or cuffed, partially external (Hickman, Broviac). The patients ranged in age from newborn to 18 years and required the central line for a wide range of conditions, including oncologic, hematologic, infectious, gastrointestinal, and other disorders. Of the 1019 patients, 4 patients were identified as requiring more extensive procedures for catheter removal. Characteristics of these children and the overall population are shown in Table 1. Vein site was originally determined by the operating surgeon, based upon individual preference or experience,
Extraction of long-term central venous catheters in children
1721
Table 1
Patient and catheter characteristics
Patient/ gender
Primary diagnosis
Age Time in Type/method placed place of placement
Structural material
Size
Vein
Patient 1/F
ALL
8y
3y
Port/percutaneous
6.0F
Left subclavian
Patient 2/F
ALL
2y
3y
Port/percutaneous
3y
5y
Port/percutaneous
7 mo
17 mo
PowerPort/ percutaneous Approx 1/3 Ports and 2/3 Hickman, Broviac
Silicon based Silicon based Silicon based Silicon based Silicon based
Patient 3/F
Sickle cell anemia Patient 4/M Wilms tumor, intersex General pediatric Equal among population gastrointestinal, infectious, oncologic, and hematologic disorders
b1 wk 1 mo to 18 y to 3 y
Removal procedure
Removal of clavicle 5.4F Left subclavian Removal of clavicle 5.8F Left femoral Femoral venorrhaphy 5.8F Left internal Jugular jugular venorrhaphy Local dissection 5.0F to Subclavian, 7.0F internal jugular, followed by external jugular, simple traction femoral
Patient, line, and procedure data of the 4 patients requiring more extensive extraction procedures and correlating data of general pediatric population.
patient and family preferences, and available sites. No perioperative complications were reported during any of the 4 percutaneous placement procedures of the single-lumen silicon-based catheters. The CVCs remained in situ for a period of 17 months to 5 years, with 3 of the patients reporting minor complications while using the catheters. One patient (patient 1) experienced bacterial sepsis, which resolved with a 7-day antibiotic regimen. Another (patient 4) was readmitted on several occasions for febrile neutropenia, though without any documented bacteremias. Patient 3 presented with catheter thrombosis, secondary to parental noncompliance with care recommendations. In all patients, the removal procedure was elective, owing either to completion of therapy (patients 1, 2, and 4) or to dysfunction of catheter secondary to complete thrombosis (patient 3). In all cases, the standard “simple traction” method of removal was first attempted, in which the subcutaneous reservoirs are removed by reopening the prior incision, dissecting the port free of surrounding tissue,
and pulling the catheter from the vessel. This approach is the published standard of practice [2,5,6] and is the method that was used in all cases of uncomplicated extractions. In all 4 cases of extraction complications, an intraoperative finding of catheter fixation to the vessel wall was noted, owing to calcification (patients 1 and 2), to thrombosis (patient 3), or to extensive scarring (patient 4). Consequently, 2 of the patients (patients 1 and 2) underwent infraclavicular incision and intraperiosteal resection of the clavicle, lysis of calcifications surrounding the catheter and fusing it to the vessel wall, catheter extraction, and subclavian venorrhaphy. In patient 3, a dissection of the reservoir followed by superficial groin dissection failed to release the catheter. This required deeper dissection with ultrasonographic examination of the femoral and iliac vein, revealing partial venous thrombosis with entrapment of the catheter. After isolation of the femoral vein, an extensive venotomy to release the catheter from adhesions to the vein wall and vein reconstruction were performed. Patient 4 required a second incision over the left neck entry
Fig. 1 Serial chest radiographs of patient 1, demonstrating claviculectomy and regrowth of the left clavicle. A, Chest radiograph before central line removal (arrow = central line as it passes under the left clavicle). B, Chest radiograph immediately following central line removal via left partial claviculectomy (arrow = site of claviculectomy). C, Chest radiograph 2 years following central line removal (arrow = regrowth of left clavicle).
1722 point and dissection to the level of the left internal jugular vein. Extensive scarring was noted at the level of the vessel. Once the scar was lysed, the catheter was removed; and internal jugular venorrhaphy was performed. All patients recovered uneventfully. Patients had follow-up imaging studies and clinic visits documented in the medical records of the aforementioned 2 institutions, with a mean follow-up time of 18.2 ± 6.4 months. Serial radiographs at 12 and 24 months postoperatively revealed regrowth of the clavicle in patients 1 and 2 (Fig. 1). Similarly, follow-up duplex studies at 6 and 12 months demonstrated patency of the reconstructed veins in patients 3 and 4.
2. Discussion Silicone-based, long-term CVCs are designed to induce minimal tissue reaction at, or within, the vascular tree. Despite their purported biocompatibility, our experience indicates that these lines may become fixed in the vein in approximately 0.4% of all cases. Resistance to the release of the catheter may be because of pinching of the catheter between the clavicle and first rib, tethering of the catheter to the venous wall, catheter damage, or fibrinous clot attached near the tip of the catheter [2,5]. Although line placements are well recognized as carrying measurable and sometimes significant risk, line removals have been considered “simple.” These 4 cases suggest that catheter removals should be given increased consideration because they may prove more challenging and require greater resources than might generally be employed. Previous case series suggested that the type of indwelling catheter used should be considered as a risk factor of insertion complications and line malfunctions [4,5,7]. The reports disagree on which catheter is the safest. Although all 4 of the patients in this report had reservoir-style catheters, only about one third of all noncomplicated removals were performed on reservoir devices. Our experience thus shows that the corrected incidence of difficult line removal in the population with ports is approximately 2%. This finding appears to be well correlated with a recent large-scale study into tunneled CVCs complications, which demonstrated statistically significant increase in complications with completely indwelling devices, as opposed to their partially external counterparts [8]. All 4 of the patients in this case report had a silicon-based catheter. Although the scope of this case report does not allow comment on any specific correlation, it is possible that the main material composing the catheter may have a causative effect on the complication. The frictional effect at the vein-catheter interface and consequent granulation response might have played a role in developing a tethering point at the site. However, previous studies have indicated that silicon-based catheters are less likely to become adherent
I. Maizlin et al. to their fibrous sheath than polyurethane-based CVCs [8]. Moreover, silicon-based CVCs were also present in all pediatric patients undergoing uncomplicated extraction during the study period. It is possible that the catheters might adhere to the venous wall if the smooth surface of the silicon catheter is disrupted, thus allowing granulation foci. A similar mechanical hypothesis has been raised by Jones and Giacomantonio [5], although in those instances they speculated regarding such microfractures in polyurethane CVCs. The observation both by Jones and Giacomantonio and in our 4 cases that the usual fibrin sheath was not as well developed in all cases of retained catheters supports the possibility of mechanical etiology. Previous reports have suggested that the vein site may contribute to the rate of complications. Superior vena caval lines (subclavian or jugular) were more prone to complications in children than inferior vena caval lines (saphenous or femoral) [3,4]. Three of the 4 affected patients in our series had superior vena caval lines. However, this is similar to the distribution of line sites in the overall population. Notably, all affected patients had hematologic or oncologic diagnoses, although only 3 of the 4 received intravenous chemotherapy. Fratino et al [4] have noted that hematologic malignancies and nonmalignant hematologic diseases have significantly higher rates of insertion and in situ complications. Moreover, a more recent single-center study by Wilson et al [8] showed that patients receiving a CVC for a hematologic indication, of which acute lymphoblastic leukemia (ALL) was the commonest diagnosis, had significantly greater risk of difficulty at catheter removal. However, the size of our sample precludes a meaningful conclusion, especially as such diagnoses were also present in the vast majority of uncomplicated extractions. In our patients, the duration in situ averaged over 3 years (range, 1.4-5 years) but did not appear to be different from that seen in the other children who underwent line removal. This average in situ time appears to be consistent with previous reports, as Wilson et al [8] and Jones and Giacomantonio [5] had observed that all their complications occurred in catheters placed for more than 20 months and 24 months, respectively. Long-term indwelling silicone lines may become fixed in the vein. Excessive efforts to traction the catheter in such a scenario may result in significant complications. A fractured catheter may lead to thromboembolization or fragment retention within the heart or the great vessels [5,9]. Freefloating lines may require retrieval in the catheterization laboratory to avoid secondary complications [9,10]. Similarly, although others report leaving lines in situ in cases of catheter fixation in the vein wall [8], the risk of consequent thrombosis and embolization remains substantial. Although a growing body of evidence, mostly from experiences of military surgeons, is beginning to emerge regarding benign endothelization of foreign bodies and their incorporation into the vein wall [11], it remains to be further investigated whether those findings are applicable to pediatric
Extraction of long-term central venous catheters in children patients. At present time, prolonged retention of a central venous line or its fragments remains the most significant risk factor for development of venous thromboembolism in the pediatric population [12]. Such problems may be avoided if the surgeon is prepared to perform a more extensive procedure such as a bony resection and/or venorrhaphy. Moreover, although some authorities advocate snaring the retained catheters via a transfemoral approach [13] or the “push” method over a wire [14], both techniques carry a theoretical risk of venous injury with inadequate exposure to rapidly address the complication. This risk is largely avoided by direct exposure of the vein. Unlike external devices, ports are generally removed in the operating room. However, it has been our experience that operating room and anesthesia staff expect and, therefore, prepare for a “short” and “simple” procedure. Unless instructed otherwise, the staff will clean a limited skin area and will assemble soft-tissue instruments. Should a more challenging procedure become necessary or complications ensue, both anesthesia and nursing staff may be unprepared. Therefore, informed parental consent and adequate operating room preparation for port removal should incorporate the possibility of more extensive procedures. Based on the experience from these cases, the authors have modified their consent approach to incorporate the possibility of more extensive procedures being required to remove port catheters.
Acknowledgments We would like to thank Jennifer Gibson for chart data mining and administrative support. Our thanks also to the Oregon Health and Science University and Legacy Emanuel institutional review boards for approval and support of this study.
1723
References [1] Cesaro S, Corrò R, Pelosin A, et al. A prospective survey on incidence and outcome of Broviac/Hickman catheter-related complications in pediatric patients affected by hematological and oncological diseases. Ann Hematol 2004;83:183-8. [2] Lee AC. Elective removal of cuffed central venous catheters in children. Support Care Cancer 2007;15(7):897-901. [3] Vegunta RK, Loethen P, Wallace LJ, et al. Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement. J Pediatr Surg 2005;40(1):47-51. [4] Fratino G, Molinari AC, Parodi S, et al. Central venous catheter-related complications in children with oncological/hematological diseases: an observational study of 418 devices. Ann Oncol 2005;16(4):648-54. [5] 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. [6] Prischl FC, Mayr H, Ulbrich W, et al. Rupture of double lumen Hickman catheter at time of removal by surgery—another potential serious complication. Nephron 1993;64(1):153. [7] Ng F, Mastoroudes H, Paul E, et al. A comparison of Hickman Line and Port-a-Cath associated complications in patients with solid tumours undergoing chemotherapy. Clin Oncol (R Coll Radiol) 2007;19(7):551-6. [8] Wilson GJ, van Noesel MM, Hop WC, et al. The catheter is stuck: complications experienced during removal of a totally implantable venous access device. A single-center study in 200 children. J Pediatr Surg 2006;41(10):1694-8. [9] Rubenstein RB, Alberty RE, Michels LG, et al. Hickman catheter separation. J Parenter Enteral Nutr 1985;9(6):754-7. [10] Fuenfer MM, Georgeson KE, Cain WS, et al. Etiology and retrieval of retained central venous catheter fragments within the heart and great vessels of infants and children. J Pediatr Surg 1998;33(3):454-6. [11] Lundy JB, Johnson EK, Seery JM, et al. Conservative management of retained cardiac missiles: case report and literature review. J Surg Educ 2009;66(4):228-35. [12] Anton N, Massicotte MP. Venous thromboembolism in pediatrics. Semin Vasc Med 2001;1(1):111-22. [13] Lesher AP, Kratz JM, Smith CD. Removal of embedded central venous catheters. J Pediatr Surg 2008;43(6):1030-4. [14] Huang SC, Tsai MS, Lai HS. A new technique to remove a “stuck” totally implantable venous access catheter. J Pediatr Surg 2009;44(7): 1465-7.
www.elsevier.com/locate/jpedsurg
Difficult extraction of long-term central venous catheters in children—case report Ilan Maizlina,⁎, Heather Carpentier a , David Bliss b a
School of Medicine, Oregon Health & Science University, Portland, OR 97034, USA Oregon Health & Science University, Portland, OR 97034, USA
b
Received 7 October 2009; revised 15 May 2010; accepted 17 May 2010
Key words: Central venous catheter; Removal; Surgical complications; Port-a-Cath; Hickman line; Broviac line
Abstract Although many publications address the complications associated with insertion of long-term, indwelling central venous catheters, there are only scattered reports of problems related to their removal. We report 4 cases of pediatric patients in whom the lines could not be pulled from the vein by standard methods, requiring 2 intraperiosteal clavicle resections with venorrhaphy, 1 femoral vein exploration and reconstruction, and 1 jugular venorrhaphy. Despite their relative biocompatibility, long-term silicone lines may become fixed in the vein. The rare and unpredictable occurrence of this problem may present the surgeon with unexpected intraoperative dilemmas. Before attempting localized extraction, surgeons should consider what venue, equipment, and anesthesia support may be required to successfully remove these catheters. © 2010 Published by Elsevier Inc.
Central venous catheters (CVCs) have become a common tool in the treatment of chronic pediatric conditions. They provide durable and atraumatic venous access for blood sampling and administration of medications, blood components, and parenteral nutrition [1,2]. Routes of access include a subclavian; an internal jugular; an external jugular; a femoral; and, more rarely, a saphenous, a cephalic, or a facial vein [3]. Although many publications address the complications associated with insertion and in situ presence of longterm, indwelling CVCs [3,4], there are only scattered reports of problems related to their removal [2,5,6]. We detail a retrospective review of 4 such events in pediatric patients and compare their details to the general pediatric population with successfully removed CVCs.
⁎ Corresponding author. Tel.: +1 503 515 6006; fax: +1 503 635 5307. E-mail address: [email protected] (I. Maizlin). 0022-3468/$ – see front matter © 2010 Published by Elsevier Inc. doi:10.1016/j.jpedsurg.2010.05.026
1. Cases Between January 2001 and July 2008, 1019 patients underwent removal of CVCs in 2 regional children's hospitals. All procedures were performed by a single academic pediatric surgical group serving both institutions. All catheter types were silicone based and either entirely indwelling (Port) or cuffed, partially external (Hickman, Broviac). The patients ranged in age from newborn to 18 years and required the central line for a wide range of conditions, including oncologic, hematologic, infectious, gastrointestinal, and other disorders. Of the 1019 patients, 4 patients were identified as requiring more extensive procedures for catheter removal. Characteristics of these children and the overall population are shown in Table 1. Vein site was originally determined by the operating surgeon, based upon individual preference or experience,
Extraction of long-term central venous catheters in children
1721
Table 1
Patient and catheter characteristics
Patient/ gender
Primary diagnosis
Age Time in Type/method placed place of placement
Structural material
Size
Vein
Patient 1/F
ALL
8y
3y
Port/percutaneous
6.0F
Left subclavian
Patient 2/F
ALL
2y
3y
Port/percutaneous
3y
5y
Port/percutaneous
7 mo
17 mo
PowerPort/ percutaneous Approx 1/3 Ports and 2/3 Hickman, Broviac
Silicon based Silicon based Silicon based Silicon based Silicon based
Patient 3/F
Sickle cell anemia Patient 4/M Wilms tumor, intersex General pediatric Equal among population gastrointestinal, infectious, oncologic, and hematologic disorders
b1 wk 1 mo to 18 y to 3 y
Removal procedure
Removal of clavicle 5.4F Left subclavian Removal of clavicle 5.8F Left femoral Femoral venorrhaphy 5.8F Left internal Jugular jugular venorrhaphy Local dissection 5.0F to Subclavian, 7.0F internal jugular, followed by external jugular, simple traction femoral
Patient, line, and procedure data of the 4 patients requiring more extensive extraction procedures and correlating data of general pediatric population.
patient and family preferences, and available sites. No perioperative complications were reported during any of the 4 percutaneous placement procedures of the single-lumen silicon-based catheters. The CVCs remained in situ for a period of 17 months to 5 years, with 3 of the patients reporting minor complications while using the catheters. One patient (patient 1) experienced bacterial sepsis, which resolved with a 7-day antibiotic regimen. Another (patient 4) was readmitted on several occasions for febrile neutropenia, though without any documented bacteremias. Patient 3 presented with catheter thrombosis, secondary to parental noncompliance with care recommendations. In all patients, the removal procedure was elective, owing either to completion of therapy (patients 1, 2, and 4) or to dysfunction of catheter secondary to complete thrombosis (patient 3). In all cases, the standard “simple traction” method of removal was first attempted, in which the subcutaneous reservoirs are removed by reopening the prior incision, dissecting the port free of surrounding tissue,
and pulling the catheter from the vessel. This approach is the published standard of practice [2,5,6] and is the method that was used in all cases of uncomplicated extractions. In all 4 cases of extraction complications, an intraoperative finding of catheter fixation to the vessel wall was noted, owing to calcification (patients 1 and 2), to thrombosis (patient 3), or to extensive scarring (patient 4). Consequently, 2 of the patients (patients 1 and 2) underwent infraclavicular incision and intraperiosteal resection of the clavicle, lysis of calcifications surrounding the catheter and fusing it to the vessel wall, catheter extraction, and subclavian venorrhaphy. In patient 3, a dissection of the reservoir followed by superficial groin dissection failed to release the catheter. This required deeper dissection with ultrasonographic examination of the femoral and iliac vein, revealing partial venous thrombosis with entrapment of the catheter. After isolation of the femoral vein, an extensive venotomy to release the catheter from adhesions to the vein wall and vein reconstruction were performed. Patient 4 required a second incision over the left neck entry
Fig. 1 Serial chest radiographs of patient 1, demonstrating claviculectomy and regrowth of the left clavicle. A, Chest radiograph before central line removal (arrow = central line as it passes under the left clavicle). B, Chest radiograph immediately following central line removal via left partial claviculectomy (arrow = site of claviculectomy). C, Chest radiograph 2 years following central line removal (arrow = regrowth of left clavicle).
1722 point and dissection to the level of the left internal jugular vein. Extensive scarring was noted at the level of the vessel. Once the scar was lysed, the catheter was removed; and internal jugular venorrhaphy was performed. All patients recovered uneventfully. Patients had follow-up imaging studies and clinic visits documented in the medical records of the aforementioned 2 institutions, with a mean follow-up time of 18.2 ± 6.4 months. Serial radiographs at 12 and 24 months postoperatively revealed regrowth of the clavicle in patients 1 and 2 (Fig. 1). Similarly, follow-up duplex studies at 6 and 12 months demonstrated patency of the reconstructed veins in patients 3 and 4.
2. Discussion Silicone-based, long-term CVCs are designed to induce minimal tissue reaction at, or within, the vascular tree. Despite their purported biocompatibility, our experience indicates that these lines may become fixed in the vein in approximately 0.4% of all cases. Resistance to the release of the catheter may be because of pinching of the catheter between the clavicle and first rib, tethering of the catheter to the venous wall, catheter damage, or fibrinous clot attached near the tip of the catheter [2,5]. Although line placements are well recognized as carrying measurable and sometimes significant risk, line removals have been considered “simple.” These 4 cases suggest that catheter removals should be given increased consideration because they may prove more challenging and require greater resources than might generally be employed. Previous case series suggested that the type of indwelling catheter used should be considered as a risk factor of insertion complications and line malfunctions [4,5,7]. The reports disagree on which catheter is the safest. Although all 4 of the patients in this report had reservoir-style catheters, only about one third of all noncomplicated removals were performed on reservoir devices. Our experience thus shows that the corrected incidence of difficult line removal in the population with ports is approximately 2%. This finding appears to be well correlated with a recent large-scale study into tunneled CVCs complications, which demonstrated statistically significant increase in complications with completely indwelling devices, as opposed to their partially external counterparts [8]. All 4 of the patients in this case report had a silicon-based catheter. Although the scope of this case report does not allow comment on any specific correlation, it is possible that the main material composing the catheter may have a causative effect on the complication. The frictional effect at the vein-catheter interface and consequent granulation response might have played a role in developing a tethering point at the site. However, previous studies have indicated that silicon-based catheters are less likely to become adherent
I. Maizlin et al. to their fibrous sheath than polyurethane-based CVCs [8]. Moreover, silicon-based CVCs were also present in all pediatric patients undergoing uncomplicated extraction during the study period. It is possible that the catheters might adhere to the venous wall if the smooth surface of the silicon catheter is disrupted, thus allowing granulation foci. A similar mechanical hypothesis has been raised by Jones and Giacomantonio [5], although in those instances they speculated regarding such microfractures in polyurethane CVCs. The observation both by Jones and Giacomantonio and in our 4 cases that the usual fibrin sheath was not as well developed in all cases of retained catheters supports the possibility of mechanical etiology. Previous reports have suggested that the vein site may contribute to the rate of complications. Superior vena caval lines (subclavian or jugular) were more prone to complications in children than inferior vena caval lines (saphenous or femoral) [3,4]. Three of the 4 affected patients in our series had superior vena caval lines. However, this is similar to the distribution of line sites in the overall population. Notably, all affected patients had hematologic or oncologic diagnoses, although only 3 of the 4 received intravenous chemotherapy. Fratino et al [4] have noted that hematologic malignancies and nonmalignant hematologic diseases have significantly higher rates of insertion and in situ complications. Moreover, a more recent single-center study by Wilson et al [8] showed that patients receiving a CVC for a hematologic indication, of which acute lymphoblastic leukemia (ALL) was the commonest diagnosis, had significantly greater risk of difficulty at catheter removal. However, the size of our sample precludes a meaningful conclusion, especially as such diagnoses were also present in the vast majority of uncomplicated extractions. In our patients, the duration in situ averaged over 3 years (range, 1.4-5 years) but did not appear to be different from that seen in the other children who underwent line removal. This average in situ time appears to be consistent with previous reports, as Wilson et al [8] and Jones and Giacomantonio [5] had observed that all their complications occurred in catheters placed for more than 20 months and 24 months, respectively. Long-term indwelling silicone lines may become fixed in the vein. Excessive efforts to traction the catheter in such a scenario may result in significant complications. A fractured catheter may lead to thromboembolization or fragment retention within the heart or the great vessels [5,9]. Freefloating lines may require retrieval in the catheterization laboratory to avoid secondary complications [9,10]. Similarly, although others report leaving lines in situ in cases of catheter fixation in the vein wall [8], the risk of consequent thrombosis and embolization remains substantial. Although a growing body of evidence, mostly from experiences of military surgeons, is beginning to emerge regarding benign endothelization of foreign bodies and their incorporation into the vein wall [11], it remains to be further investigated whether those findings are applicable to pediatric
Extraction of long-term central venous catheters in children patients. At present time, prolonged retention of a central venous line or its fragments remains the most significant risk factor for development of venous thromboembolism in the pediatric population [12]. Such problems may be avoided if the surgeon is prepared to perform a more extensive procedure such as a bony resection and/or venorrhaphy. Moreover, although some authorities advocate snaring the retained catheters via a transfemoral approach [13] or the “push” method over a wire [14], both techniques carry a theoretical risk of venous injury with inadequate exposure to rapidly address the complication. This risk is largely avoided by direct exposure of the vein. Unlike external devices, ports are generally removed in the operating room. However, it has been our experience that operating room and anesthesia staff expect and, therefore, prepare for a “short” and “simple” procedure. Unless instructed otherwise, the staff will clean a limited skin area and will assemble soft-tissue instruments. Should a more challenging procedure become necessary or complications ensue, both anesthesia and nursing staff may be unprepared. Therefore, informed parental consent and adequate operating room preparation for port removal should incorporate the possibility of more extensive procedures. Based on the experience from these cases, the authors have modified their consent approach to incorporate the possibility of more extensive procedures being required to remove port catheters.
Acknowledgments We would like to thank Jennifer Gibson for chart data mining and administrative support. Our thanks also to the Oregon Health and Science University and Legacy Emanuel institutional review boards for approval and support of this study.
1723
References [1] Cesaro S, Corrò R, Pelosin A, et al. A prospective survey on incidence and outcome of Broviac/Hickman catheter-related complications in pediatric patients affected by hematological and oncological diseases. Ann Hematol 2004;83:183-8. [2] Lee AC. Elective removal of cuffed central venous catheters in children. Support Care Cancer 2007;15(7):897-901. [3] Vegunta RK, Loethen P, Wallace LJ, et al. Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement. J Pediatr Surg 2005;40(1):47-51. [4] Fratino G, Molinari AC, Parodi S, et al. Central venous catheter-related complications in children with oncological/hematological diseases: an observational study of 418 devices. Ann Oncol 2005;16(4):648-54. [5] 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. [6] Prischl FC, Mayr H, Ulbrich W, et al. Rupture of double lumen Hickman catheter at time of removal by surgery—another potential serious complication. Nephron 1993;64(1):153. [7] Ng F, Mastoroudes H, Paul E, et al. A comparison of Hickman Line and Port-a-Cath associated complications in patients with solid tumours undergoing chemotherapy. Clin Oncol (R Coll Radiol) 2007;19(7):551-6. [8] Wilson GJ, van Noesel MM, Hop WC, et al. The catheter is stuck: complications experienced during removal of a totally implantable venous access device. A single-center study in 200 children. J Pediatr Surg 2006;41(10):1694-8. [9] Rubenstein RB, Alberty RE, Michels LG, et al. Hickman catheter separation. J Parenter Enteral Nutr 1985;9(6):754-7. [10] Fuenfer MM, Georgeson KE, Cain WS, et al. Etiology and retrieval of retained central venous catheter fragments within the heart and great vessels of infants and children. J Pediatr Surg 1998;33(3):454-6. [11] Lundy JB, Johnson EK, Seery JM, et al. Conservative management of retained cardiac missiles: case report and literature review. J Surg Educ 2009;66(4):228-35. [12] Anton N, Massicotte MP. Venous thromboembolism in pediatrics. Semin Vasc Med 2001;1(1):111-22. [13] Lesher AP, Kratz JM, Smith CD. Removal of embedded central venous catheters. J Pediatr Surg 2008;43(6):1030-4. [14] Huang SC, Tsai MS, Lai HS. A new technique to remove a “stuck” totally implantable venous access catheter. J Pediatr Surg 2009;44(7): 1465-7.