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Etiology and retrieval of retained central venous catheter fragments within the heart and great vessels of infants and children
Etiology and Retrieval of Retained Central Venous Catheter Fragments Within the Heart and Great Vessels of Infants and Children By
Michael
M. Fuenfer,
Keith
E. Georgeson,
F. Bennett
S. Cain, Edward V. Colvin, and William S. McMahon
Walter
Pearce, Birmingham,
Background; eters plays children.
The use of centrally an indispensable role
positioned in the care
venous of infants
cathand
/Vethods: Since 1992 the authors have seen nine patients who experienced fragmentation and migration of catheter fragments into the central circulation. The patients ranged in age from 6 days to 15 years.
Waker
H. Johnson,
Jr,
Alabama
nition of retained from a few hours
catheter fragments to 6 weeks.
Conchsion: All retained fragments moved during cardiac catheterization J Pediatr Surg 33:454-456. Copyright ders Company.
until
retrieval
ranged
were successfully rewithout complications. @ 7998 by W.B. Saun-
Resu/fs: Sites of migration included pulmonary artery (five patients), superior vena cava (two patients), hepatic vein and innominate vein (one patient). The elapsed time from recog-
INDEX WORDS: Central venous catheter, cardiac catheterization, foreign body embolus, catheter retrieval, venous access ports, indwelling catheters.
P
of a cuffed SlLASTICa (Dow Coming, Midland, MI) catheter or depot-type device fractured during attempted removal. In two cases (3 and 7) the catheter was found, at the time of elective surgical removal. to be detached from the connection to the subcutaneous injection port with the catheter migrating m its entirety into the right ventricle and superior vena cava. Patient 1 experienced accidental sharp division of an umbilical venous catheter during attempts at placement of an umbilical arterial catheter, The most common sites of embolization were the main and left pulmonary arteries. RCFs measured from 2 to 15 cm, and there were no instances of multiple fragments. The time interval between recognition of fragmentation and retrieval ranged from less than 24 hours to 6 weeks. In seven instances, the diagnosis of catheter embolization was made by chest radiograph after climcal suspicion of fragmentation. In the two patients who had catheter-port separation, the diagnosis was not made until the time of operative exploration for port removal. No patient manifested symptoms related to catheter fragmentation or embolization. All retrieval procedures were performed m a dedicated pediatic cardiac catheterization laboratory by experienced invasive pediatric cardiologists. General anesthesia was used in all cases. Patient I, a 1.500-g infant, had a supraumbihcal cut down to expose the umbilical vem for insertion of a 4F sheath. A 3F flexible myocardlal biopsy forceps (Cook Inc, Bloomington, IN) was used to grasp and withdraw an umbilical venous catheter fragment lodged in an hepatic vein. Retrieval techniques were smnlar for the other eight patients who had percutaneous entry of the femoral vein for insertion of a vascular sheath (size range, 6F to 9F) using the Seldinger technique. An end-hole catheter was inserted through the venous sheath and advanced under iluoroscopic guidance to a position near the catheter fragment (Fig 1). Three types of retrieval devices were used. An Amplatz “gooseneck” snare (Microvena Corporation. White Bear Lake, MN) was used m five patients (2,4, 6, 8, 9), a Curry snare (Cook Inc) was used in two (3 and 5), and a Dotter snare (Cook Inc) was used in patient 7. After retrieval, all patients underwent either angiography or echocardiography or both to rule out intimal injury and retained fragments.
LACEMENT AND FZMOVAL of central venous catheters (CVC) are among the most frequent procedures performed by pediatric surgeons. CVCs play a vital role in providing venous access for administration of hypertonic intravenous alimentation fluids, long-term antibiotic therapy, and as a route for cancer chemotherapeutic agents. Fragmentation with embolization of these centrally positioned catheters is an infrequent but wellknown occurrence with potentially serious complications. In many cases, these fragments may be safely and successfully retrieved from within the heart and great vessels of even small infants by experienced invasive cardiologists using percutaneous catheter techniques. MATERIALS
AND
METHODS
From 1992 to 1996 we have seen nine children with retained catheter fragments (RCF, Table 1). Patients ranged in age from a 6-day-old 1,500-g prematwe infant to a 1.5 year old. Access for administration of cancer chemotherapy was the most common indication for placement of CVCs. In six patients (patients 2,4,5,6, 8,9) the mtravasculx portion
From the Division of Pedxztric Surgei~ Depurtment of Surgery, and the Division of Pediatric Cardiology, Department of Pediatrics, The Children k Hospital ofAlabama, The University ofAlabama ut Bwminghum. Birmingham, AL. Presented at the British Associatzon of Paediatric Surgeons Annual Meeting, St Heliec Isle of Jersey, UK, .luly 18, 1996. Address reprint requests to Dr Keith E. Georgeson MD, Divkon oj Pediatric krgev, Suite ACC 300, The Children k Hospital ofAlabama, 1600 Seventh Ave South, Birmingham, AL 35233. Copyright 0 1998 by WB. Saunders Company 0022.3468/98/3303-0009$03.00/O
454
.kxmm/
offediafric
Surgery,
Vol33,
No 3 (March),
1998: pp 454-456
RETAINED
FRAGMENTS
Table I. Patient NO.
Age
455
OF CVCs
Patient
Diagnoses
Data
Fragment
BreakRetrieval lm?rval
Site
d 6wk
1 2
6d 15 ml3
Prematurity Short bowel
Hepatic vein Left pulmonary
3
23 mo
Neuroblastoma
Right ventricle/supe rior vena cava
4 5
IOyr 30 mo
Leukemia V-A shunt
Innominate vein Left pulmonary artery
6 7
3 yr 15yr
Wilms’tumor Leukemia
Superior vena cava Main pulmonary
Chronic
Left pulmonary artery/ tricusprd valve
4d
Left pulmonary
Id
artery
Unknown 4wk 2d Id Unknown
artery
9
4Yr
infectron
Osteomyelitis
NOTE. Proximal-to-drstal sites of embolization catheter fragment are denoted by a slash.
artery
of a contrnuous
RESULTS
In our series, catheter fragmentation most often occurred at the time of removal (five patients). In most of these instances, fracture was suspected based on the resistance met during withdrawal and visual inspection of the length of removed catheter. In the two instances of spontaneous, in situ separation of the catheter from the hub of the subcutaneous injection port, no cause could be
Fig I. Fluoroscopic anteroposterior view of the chest in a 4-yearold child with a retained catheter fragment. A long Groshon catheter fragment extends from the main to the distal left pulmonary artery. A retrieval catheter has been passed from the femoral vein through the inferior vena cava and right heart to the left pulmonary artery. A wire snare loop encircles the catheter fragment. The loop is then tightened to grasp the catheter fragment which is removed under fluoroscopic guidance.
determined. In both instances, the ports were manufactured with the catheter bonded to the hub and no retainer ring was required. A chest radiograph was used to confirm the diagnosis and to identify the location and length of RCF, and the patient was immediately referred to the pediatric cardiology department. All nine RCFs were successfully retrieved nonsurgically without further fragmentation or other complications. Postretrieval angiography and/or echocardiography ruled out intimal injury in all patients. Total fluoroscopy time ranged from 2 to 30 minutes (mean,
DISCUSSION
Indwelling, centrally placed venous catheters play an important role in the care of pediatric patients. Among the most common indications for their use are administration of parenteral nutrition and medications, pressure monitoring, and occasionally, for ventriculoatrial shunting of cerebrospinal fluid. Although often considered routine because of the frequency of their use, the placement, maintenance, and removal of these lines is accompanied by the potential for significant complications. An unpredictable and potentially serious complication is fracture of a CVC with migration of fragments into the vena cava or its tributaries, right heart, or pulmonary arteries. Catheter fragmentation has been found to occur in 0.1% of all insertions,l and is associated with an incidence of death or serious complications between 21%= and 71%.3 Infection4 pulmonary abscess,5dysrhythmias and sudden death,6.7 thrombosis with superior vena cava syndrome,s erosion into contiguous structures,9 and right atria1 perforationlo have all been reported. Possible causes of catheter fracture include manufacturing defects; mechanical trauma to the catheter during manipulation in preparation for insertion; material degradation caused by the fluids or medications passing through the catheter lumen; stress resulting from constant motion within the central circulation; resistance to removal caused by deposition of fibrin, clot, or calcium on the intravascular portion of the catheter; fibrotic adhesion within the subcutaneous tunnel; or “pinching” of the catheter where it passes between the clavicIe and first rib in a subclavian approach, A higher incidence of fracture in catheters placed via the subclavian route is well recognized, and a “pinch off sign” seen on chest radiograph has been described by Aitken and Mintonn which may identify those catheters at risk for fracture. Entering the subclavian vein lateral to its midclavicular portion increases the likelihood that the catheter will pass through the widest space between the clavicle and first rib, lessening the catheter’s susceptibil-
456
FUENFER
ity to mechanical compression. Another possible explanation of catheter fragmentation is use of excessive hydrostatic pressure when flushing or infusing through a partially or completely occluded catheter. A chest radiograph should be obtained if there is absence of blood retnrn, or resistance to flushing. This is especially important with implanted subcutaneous port devices to prevent
ET AL
inadvertent subcutaneous injection of potent chemotherapeutic agents. Nonsurgical retrieval of RCF has been successfully and safely performed for the past 2.5 years.lz Although emergent removal of RCF is rarely indicated, we recommend prompt referral to invasive pediatric cardiologists for percutaneous catheter retrieval.
REFERENCES 1, Lybecker H, Anderson C, intracardiac catheter fragments. 2, Richardson JD, Grover emboli. Experience with twenty 128:722, 1974 3. Fisher RG,
Hansen MK: Transvenous retrieval of Acta Anaesth Stand 39565-567. 1989 FL, Trinkle .JK Intravenous catheter cases and collective review. Am J Surg
Ferreyro R Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. Am J Roentgen01 130:541-548, 1978 4. Wellmann KF, Reinhard A, Salazar EP: Polyethylene catheter embolism. Reviews of the literature and report of a case of fatal tricuspid and septicemic candidiasis. Circulation 37:380. 1968 5. Ayers WB: Fatal intracardiac embolization from indwelling intravenous polyethylene catheter. Arch Surg 75:259-262, 1957 6, Suarez-Penaranda JM, Concheiro-Carro L: Longstanding intracardiac catheter embolism. An unusual autopsy finding. Am .I Forensic Med Path01 16:124-126, 1995 7. Sproat IA. Bielke D. Crummy AB. et al: Transthoracic 2D
echocardiographic guidance for percutaneous removal of a nonopaque intracardiac catheter fragment. Cardiovasc Intervent Radio1 16:58-60, 1993 8. Kanada DJ. Jung RC, Ishihara S: Superior vena cava syndrome due to a retained central venous pressure catheter. Chest 75:734-735, 1979 9. Gammill SL, Smith SL: Removal of “lost” catheters and guidewires wIthout operation. South Med .I 65:463, 1972 10. Doering RB, Stemmer EH, Connolly JE Complications of indwelling venous catheters with prticular reference to catheter emboli. Am J Surg 114:259-266, 1967 11. Aitken DR, Minton JP: The “pinch off sign.” A warning of impending problems with permanent subclavian catheters. Am J Surg 148:633-636, 1984 12, Dotter CT, Rosch .I, Bilbao MK: Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. Am J Roentgen01 111:467-472, 1971
Michael
M. Fuenfer,
Keith
E. Georgeson,
F. Bennett
S. Cain, Edward V. Colvin, and William S. McMahon
Walter
Pearce, Birmingham,
Background; eters plays children.
The use of centrally an indispensable role
positioned in the care
venous of infants
cathand
/Vethods: Since 1992 the authors have seen nine patients who experienced fragmentation and migration of catheter fragments into the central circulation. The patients ranged in age from 6 days to 15 years.
Waker
H. Johnson,
Jr,
Alabama
nition of retained from a few hours
catheter fragments to 6 weeks.
Conchsion: All retained fragments moved during cardiac catheterization J Pediatr Surg 33:454-456. Copyright ders Company.
until
retrieval
ranged
were successfully rewithout complications. @ 7998 by W.B. Saun-
Resu/fs: Sites of migration included pulmonary artery (five patients), superior vena cava (two patients), hepatic vein and innominate vein (one patient). The elapsed time from recog-
INDEX WORDS: Central venous catheter, cardiac catheterization, foreign body embolus, catheter retrieval, venous access ports, indwelling catheters.
P
of a cuffed SlLASTICa (Dow Coming, Midland, MI) catheter or depot-type device fractured during attempted removal. In two cases (3 and 7) the catheter was found, at the time of elective surgical removal. to be detached from the connection to the subcutaneous injection port with the catheter migrating m its entirety into the right ventricle and superior vena cava. Patient 1 experienced accidental sharp division of an umbilical venous catheter during attempts at placement of an umbilical arterial catheter, The most common sites of embolization were the main and left pulmonary arteries. RCFs measured from 2 to 15 cm, and there were no instances of multiple fragments. The time interval between recognition of fragmentation and retrieval ranged from less than 24 hours to 6 weeks. In seven instances, the diagnosis of catheter embolization was made by chest radiograph after climcal suspicion of fragmentation. In the two patients who had catheter-port separation, the diagnosis was not made until the time of operative exploration for port removal. No patient manifested symptoms related to catheter fragmentation or embolization. All retrieval procedures were performed m a dedicated pediatic cardiac catheterization laboratory by experienced invasive pediatric cardiologists. General anesthesia was used in all cases. Patient I, a 1.500-g infant, had a supraumbihcal cut down to expose the umbilical vem for insertion of a 4F sheath. A 3F flexible myocardlal biopsy forceps (Cook Inc, Bloomington, IN) was used to grasp and withdraw an umbilical venous catheter fragment lodged in an hepatic vein. Retrieval techniques were smnlar for the other eight patients who had percutaneous entry of the femoral vein for insertion of a vascular sheath (size range, 6F to 9F) using the Seldinger technique. An end-hole catheter was inserted through the venous sheath and advanced under iluoroscopic guidance to a position near the catheter fragment (Fig 1). Three types of retrieval devices were used. An Amplatz “gooseneck” snare (Microvena Corporation. White Bear Lake, MN) was used m five patients (2,4, 6, 8, 9), a Curry snare (Cook Inc) was used in two (3 and 5), and a Dotter snare (Cook Inc) was used in patient 7. After retrieval, all patients underwent either angiography or echocardiography or both to rule out intimal injury and retained fragments.
LACEMENT AND FZMOVAL of central venous catheters (CVC) are among the most frequent procedures performed by pediatric surgeons. CVCs play a vital role in providing venous access for administration of hypertonic intravenous alimentation fluids, long-term antibiotic therapy, and as a route for cancer chemotherapeutic agents. Fragmentation with embolization of these centrally positioned catheters is an infrequent but wellknown occurrence with potentially serious complications. In many cases, these fragments may be safely and successfully retrieved from within the heart and great vessels of even small infants by experienced invasive cardiologists using percutaneous catheter techniques. MATERIALS
AND
METHODS
From 1992 to 1996 we have seen nine children with retained catheter fragments (RCF, Table 1). Patients ranged in age from a 6-day-old 1,500-g prematwe infant to a 1.5 year old. Access for administration of cancer chemotherapy was the most common indication for placement of CVCs. In six patients (patients 2,4,5,6, 8,9) the mtravasculx portion
From the Division of Pedxztric Surgei~ Depurtment of Surgery, and the Division of Pediatric Cardiology, Department of Pediatrics, The Children k Hospital ofAlabama, The University ofAlabama ut Bwminghum. Birmingham, AL. Presented at the British Associatzon of Paediatric Surgeons Annual Meeting, St Heliec Isle of Jersey, UK, .luly 18, 1996. Address reprint requests to Dr Keith E. Georgeson MD, Divkon oj Pediatric krgev, Suite ACC 300, The Children k Hospital ofAlabama, 1600 Seventh Ave South, Birmingham, AL 35233. Copyright 0 1998 by WB. Saunders Company 0022.3468/98/3303-0009$03.00/O
454
.kxmm/
offediafric
Surgery,
Vol33,
No 3 (March),
1998: pp 454-456
RETAINED
FRAGMENTS
Table I. Patient NO.
Age
455
OF CVCs
Patient
Diagnoses
Data
Fragment
BreakRetrieval lm?rval
Site
d 6wk
1 2
6d 15 ml3
Prematurity Short bowel
Hepatic vein Left pulmonary
3
23 mo
Neuroblastoma
Right ventricle/supe rior vena cava
4 5
IOyr 30 mo
Leukemia V-A shunt
Innominate vein Left pulmonary artery
6 7
3 yr 15yr
Wilms’tumor Leukemia
Superior vena cava Main pulmonary
Chronic
Left pulmonary artery/ tricusprd valve
4d
Left pulmonary
Id
artery
Unknown 4wk 2d Id Unknown
artery
9
4Yr
infectron
Osteomyelitis
NOTE. Proximal-to-drstal sites of embolization catheter fragment are denoted by a slash.
artery
of a contrnuous
RESULTS
In our series, catheter fragmentation most often occurred at the time of removal (five patients). In most of these instances, fracture was suspected based on the resistance met during withdrawal and visual inspection of the length of removed catheter. In the two instances of spontaneous, in situ separation of the catheter from the hub of the subcutaneous injection port, no cause could be
Fig I. Fluoroscopic anteroposterior view of the chest in a 4-yearold child with a retained catheter fragment. A long Groshon catheter fragment extends from the main to the distal left pulmonary artery. A retrieval catheter has been passed from the femoral vein through the inferior vena cava and right heart to the left pulmonary artery. A wire snare loop encircles the catheter fragment. The loop is then tightened to grasp the catheter fragment which is removed under fluoroscopic guidance.
determined. In both instances, the ports were manufactured with the catheter bonded to the hub and no retainer ring was required. A chest radiograph was used to confirm the diagnosis and to identify the location and length of RCF, and the patient was immediately referred to the pediatric cardiology department. All nine RCFs were successfully retrieved nonsurgically without further fragmentation or other complications. Postretrieval angiography and/or echocardiography ruled out intimal injury in all patients. Total fluoroscopy time ranged from 2 to 30 minutes (mean,
DISCUSSION
Indwelling, centrally placed venous catheters play an important role in the care of pediatric patients. Among the most common indications for their use are administration of parenteral nutrition and medications, pressure monitoring, and occasionally, for ventriculoatrial shunting of cerebrospinal fluid. Although often considered routine because of the frequency of their use, the placement, maintenance, and removal of these lines is accompanied by the potential for significant complications. An unpredictable and potentially serious complication is fracture of a CVC with migration of fragments into the vena cava or its tributaries, right heart, or pulmonary arteries. Catheter fragmentation has been found to occur in 0.1% of all insertions,l and is associated with an incidence of death or serious complications between 21%= and 71%.3 Infection4 pulmonary abscess,5dysrhythmias and sudden death,6.7 thrombosis with superior vena cava syndrome,s erosion into contiguous structures,9 and right atria1 perforationlo have all been reported. Possible causes of catheter fracture include manufacturing defects; mechanical trauma to the catheter during manipulation in preparation for insertion; material degradation caused by the fluids or medications passing through the catheter lumen; stress resulting from constant motion within the central circulation; resistance to removal caused by deposition of fibrin, clot, or calcium on the intravascular portion of the catheter; fibrotic adhesion within the subcutaneous tunnel; or “pinching” of the catheter where it passes between the clavicIe and first rib in a subclavian approach, A higher incidence of fracture in catheters placed via the subclavian route is well recognized, and a “pinch off sign” seen on chest radiograph has been described by Aitken and Mintonn which may identify those catheters at risk for fracture. Entering the subclavian vein lateral to its midclavicular portion increases the likelihood that the catheter will pass through the widest space between the clavicle and first rib, lessening the catheter’s susceptibil-
456
FUENFER
ity to mechanical compression. Another possible explanation of catheter fragmentation is use of excessive hydrostatic pressure when flushing or infusing through a partially or completely occluded catheter. A chest radiograph should be obtained if there is absence of blood retnrn, or resistance to flushing. This is especially important with implanted subcutaneous port devices to prevent
ET AL
inadvertent subcutaneous injection of potent chemotherapeutic agents. Nonsurgical retrieval of RCF has been successfully and safely performed for the past 2.5 years.lz Although emergent removal of RCF is rarely indicated, we recommend prompt referral to invasive pediatric cardiologists for percutaneous catheter retrieval.
REFERENCES 1, Lybecker H, Anderson C, intracardiac catheter fragments. 2, Richardson JD, Grover emboli. Experience with twenty 128:722, 1974 3. Fisher RG,
Hansen MK: Transvenous retrieval of Acta Anaesth Stand 39565-567. 1989 FL, Trinkle .JK Intravenous catheter cases and collective review. Am J Surg
Ferreyro R Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. Am J Roentgen01 130:541-548, 1978 4. Wellmann KF, Reinhard A, Salazar EP: Polyethylene catheter embolism. Reviews of the literature and report of a case of fatal tricuspid and septicemic candidiasis. Circulation 37:380. 1968 5. Ayers WB: Fatal intracardiac embolization from indwelling intravenous polyethylene catheter. Arch Surg 75:259-262, 1957 6, Suarez-Penaranda JM, Concheiro-Carro L: Longstanding intracardiac catheter embolism. An unusual autopsy finding. Am .I Forensic Med Path01 16:124-126, 1995 7. Sproat IA. Bielke D. Crummy AB. et al: Transthoracic 2D
echocardiographic guidance for percutaneous removal of a nonopaque intracardiac catheter fragment. Cardiovasc Intervent Radio1 16:58-60, 1993 8. Kanada DJ. Jung RC, Ishihara S: Superior vena cava syndrome due to a retained central venous pressure catheter. Chest 75:734-735, 1979 9. Gammill SL, Smith SL: Removal of “lost” catheters and guidewires wIthout operation. South Med .I 65:463, 1972 10. Doering RB, Stemmer EH, Connolly JE Complications of indwelling venous catheters with prticular reference to catheter emboli. Am J Surg 114:259-266, 1967 11. Aitken DR, Minton JP: The “pinch off sign.” A warning of impending problems with permanent subclavian catheters. Am J Surg 148:633-636, 1984 12, Dotter CT, Rosch .I, Bilbao MK: Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. Am J Roentgen01 111:467-472, 1971