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La veine sous-clavière : Un accès inhabituel pour l’ablation des corps étrangers intravasculaires
Cas cliniques s inhabituel La veine sous-clavi ere : Un acce pour l’ablation des corps etrangers intravasculaires Joaquim Mauricio da Motta Leal Filho,1 Francisco Cesar Carnevale,1 Giovanni Guido Cerri,2 S~ao Paulo, Bresil
ter suivie de migration d’un fragment est une complication La migration ou la fracture d’un cathe pit d’une incidence limite e, l’embolisation peut rare qui se produit chez 1% des patients. En de variant causer des complications graves et potentiellement mortelles, avec des taux de mortalite fe rence de cette condition est l’extraction du cathe ter entre 24 et 60%. Le traitement de re par voie endovasculaire percutane e, par la veine fe morale commune. S’il n’est pas fragmente de d’extraction doit e ^tre fait par un acce s alternatif. Cet article de crit l’ablation possible, le proce ussie d’un cathe ter fragmente par voie endovasculaire percutane e a partir de la totalement re re droite. veine sous-clavie
The use of totally implantable central venous catheters (Port-a-Cath; Bard, Salt Lake City, UT) for the administration of chemotherapies and parenteral nutrition is more and more common in the medical practice. These devices are composed of a reservoir (port) through which the substances are injected and a polyurethane or radiopaque silicone catheter. The main complications caused by the Porta-Cath are catheter thrombosis or venous thrombosis and infection. Catheter migration or catheter fracture and consequent migration of a fragment is a rare complication that occurs in 1% of the patients.1-4 Despite the low incidence, embolization
DOI of original article: 10.1016/j.avsg.2010.02.031. 1
Interventional Radiology Unit, Radiology Institute, Hospital das Clinicas, University of S~ao Paulo Medical School, S~ao Paulo, Bresil. 2 Radiology Department, Radiology Institute, Hospital das Clinicas, University of S~ ao Paulo Medical School, S~ao Paulo, Bresil.
Correspondence : Joaquim Maurı´cio da Motta Leal Filho, Interventional Radiology Unit, Radiology Institute, Hospital das Clinicas, University of Sao Paulo Medical School, Rua Diogo Jacome, 1030/Apto. 121 e S~ ao Paulo e SP, Brazil e 04512-001, E-mail: jotamauf@yahoo. com.br Ann Vasc Surg 2010; 24: 826.e1-826.e4 DOI: 10.1016/j.acvfr.2011.01.024 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
may cause severe and potentially fatal complications such as thromboembolia,5,6 bacterial endocarditis,7 sepsis, myocardial lesions, and cardiac arrhythmias,8 and the mortality rates may vary between 24 and 60%.9 Therefore, removal of these foreign bodies is always recommended. Percutaneous intravascular removal of foreign bodies through a common femoral access is the gold standard treatment for the referred condition. It is a minimally invasive, relatively simple, safe procedure, with low complication rates, compared with conventional surgical treatment.10-16 In the absence of this venous access, removal must be performed using an alternative route.17 The present article describes the removal of a fragmented catheter by percutaneous intravascular access obtained through the right subclavian vein.
CASE REPORT A 56-year-old woman diagnosed with Hodgkin’s lymphoma received chemotherapy through the implantable venous access port, the Port-A-Cath, inserted in the right subclavian vein. After a frustrated attempt to deliver drug solution through the catheter, chest x-ray revealed fracture and embolization of a catheter fragment (Fig. 1). The first choice of access route was the jugular veins, because 899.e11
899.e12 Cas cliniques
Annales de chirurgie vasculaire
Fig. 1. Simple chest x-ray showing fractured Port-a-Cath and catheter embolization. the patient had a history of deep venous thrombosis of the lower limbs and an inferior vena cava filter, which made the access through the femoral veins impossible. Attempt to access the site through the right and left internal jugular veins was unsuccessful because these veins were also affected by thrombosis. For the patient to continue with her previous treatment, she should be referred to surgery for removal of the fragmented catheter and implantation of a new Port-a-Cath device, since peripheral venous access was not possible. We chose the same access route previously used, that is, the right subclavian vein, for the extraction of the foreign body and implantation of the new catheter. Technique Puncture of the right subclavian vein using Seldinger technique (Fig. 2), implantation of the 8-French sheath, passing of the guide wire into the distal end of the catheter located in the right ventricle, and placement of the loopsnare guiding catheter. Parallel to the guiding catheter, 260-cm hydrophilic guide wire was simultaneously introduced through the 8-French sheath, and this one was placed in the inferior vena cava, ensuring subclavian venous access (Fig. 3). The loop snare was introduced through the guiding catheter until the distal end, the catheter was grasped and the whole set was removed, including the 8-French sheath, but maintaining the access to the right subclavian vein through the guide wire located in the inferior vena cava (Fig. 4). Then, a new Port-aCath was implanted (Fig. 5).
DISCUSSION Embolization of intravascular catheters, by fracture or migration, is a rare condition that occurs in 1% of
Fig. 2. Puncture of the right subclavian vein.
the cases,1-4 however, if left untreated, it may cause serious complications and even death, with a mortality rate between 24 and 60%.9 Because of these high mortality rates, extraction of foreign bodies is strongly recommended even in asymptomatic patients. The venous access recommended for the removal of intravascular foreign bodies is the common femoral vein,10 preferably the right one. The advantages of this approach include easier handling, the patient feels more comfortable, puncture is facilitated by the blood vessel diameter and because the vessel is situated close to the surface of the skin, presence of posterior bone protection that allows its fixation during puncture and application of effective pressure after catheter removal, access to the main sites of migration of intravascular foreign bodies, and a vessel diameter that allows for the insertion of materials of various sizes. Depending on the degree of difficulty of the procedure, one femoral vein can be used, or both of them simultaneously, although it is always preferable to use only one. This venous access is always available except in the case of deep venous thrombosis of the lower limbs and/or the presence of a definitive inferior vena cava filter. The second choice of venous access route are the jugular veins, which present the following advantages: puncture facilitated by the blood vessel diameter, access to the main sites of migration of intravascular foreign bodies, vessel diameter that
Vol. 24, No. 6, 2010
Cas cliniques 899.e13
Fig. 3. A Implantation of the 8-French sheath in the right subclavian vein. B Distal end of catheter was grasped with the loop snare. Hydrophilic guide wire parallel to the loop snare with its distal end located in the inferior vena cava.
Fig. 4. A Removal of the whole set, but maintaining the hydrophilic guide wire in the inferior vena cava (maintenance of subclavian venous access). B Fragment of catheter.
allows for the insertion of materials of various sizes, and application of effective pressure to the puncture site.18,19 In the absence of these four access routes, alternative routes such as dissection or puncture of
basilic or cephalic veins, dissection of axillary veins, or else puncture of subclavian veins can be used. Despite the easy access to basilic and cephalic veins, these vessels cannot be used for the insertion of
899.e14 Cas cliniques
Annales de chirurgie vasculaire
can be used. Subclavian veins are a possible alternative for foreign body retrieval, but should be used in selected or exceptional cases only. REFERENCES
Fig. 5. Implantation of another Port-a-Cath through the right subclavian vein.
large devices. Besides, the patient has been fighting cancer for around 3 years, and, thus, there were clots in the veins of her arms and forearms (phlebitis). Some advantages of the subclavian veins include easier handling, puncture facilitated by the blood vessel diameter, access to the main sites of migration of intravascular foreign bodies, and a vessel diameter that allows for the insertion of materials of various sizes. In the case described earlier, we were aware of the permeability of the right subclavian vein, and of the need for implantation of a new Port-a-Cath, and, consequently, this access was chosen. However, it has some disadvantages such as difficulties in applying effective pressure after catheter removal, hematomas, pneumothorax, and hemothorax.17
CONCLUSION Percutaneous intravascular removal of foreign bodies is considered a gold standard treatment because it is a minimally invasive, relatively simple, safe procedure, with low complication rates compared with conventional surgical treatment. Vascular access should always be made through the femoral veins. If this is not possible, other alternative routes
1. Smouse HB, Fox PF, Brady TM, Swischuk JL, Casta~ neda F, Pham MT. Intravascular foreign body removal. Semin Intervent Radiol 2000;17:201-212. 2. Andrews RE, Tulloh RM, Rigby ML. Percutaneous retrieval of central venous catheter fragments. Arch Dis Child 2002;87:149-150. 3. Uflacker R, Lima S, Melichar AC. Intravascular foreign bodies: percutaneous retrieval. Radiology 1986;160: 731-735. 4. Andrade G, Marques R, Brito N, Bomfim A, Cavalcanti D, Abath C. Cateteres intravenosos fraturados: retirada por tecnicas endovasculares. Radiol Bras 2006;39:199-202. 5. Suarez-Penaranda JM, Guitian-Barreiro D, ConcheiroCarro L. Long-standing intracardiac catheter embolism. An unusual autopsy finding. Am J Forensic Med Pathol 1995;16:124-126. 6. Knutson H, Stenberg K. Pulmonary embolism after catheter break. Nord Med 1959;62:1491. 7. Balbi M, Bertero G, Bellotti S, Rolandelli ML, Caponnetto S. Right-sided valvular endocarditis supported by an unexpected intracardiac foreign body. Chest 1990;97:1486-1488. 8. Denny MA, Frank LR. Ventricular tachycardia secondary to port-a-cath fracture and embolization. J Emerg Med 2003;24:29-34. 9. Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176:1509-1513. 10. Egglin TK, Dickey KW, Rosenblatt M, Pollak JS. Retrieval of intravascular foreign bodies: experience in 32 cases. Am J Roentgenol 1995;164:1259-1264. 11. Yang FS, Ohta I, Chiang HJ, Lin JC, Shih SL, Ma YC. Nonsurgical retrieval of intravascular foreign body: experience of 12 cases. Eur J Radiol 1994;18:1-5. 12. Liu JC, Tseng HS, Chen CY, Chern MS, Chang CY. Percutaneous retrieval of intravascular foreign bodies: experience with 19 cases. Kaohsiung J Med Sci 2002;18:492-499. 13. Surov A, Jordan K, Buerke M, Persing M, Wollschlaeger B, Behrmann C. Atypical pulmonary embolism of port catheter fragments in oncology patients. Support Care Cancer 2006;14:479-483. 14. Cheng C-C, Tsai T-N, Yang C-C, Han C-L. Percutaneous retrieval of dislodged totally implantable central venous access system in 92 cases: experience in a single hospital. Eur J Radiol 2009;69:346-350. 15. Chow LM, Friedman JN, Macarthur C, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr 2003;142:141-144. 16. Bloomfield DA. Techniques of nonsurgical retrieval of iatrogenic foreign bodies from the heart. Am J Cardiol 1971;27:538-545. 17. Struck MF, Kaden I, Heiser A, Steen M. Cross-over endovascular retrieval of a lost guide wire from the subclavian vein. J Vasc Access 2008;9:304-306. 18. Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002;28: 1-17. 19. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Eng J Med 1994;331:1735-1738.
ter suivie de migration d’un fragment est une complication La migration ou la fracture d’un cathe pit d’une incidence limite e, l’embolisation peut rare qui se produit chez 1% des patients. En de variant causer des complications graves et potentiellement mortelles, avec des taux de mortalite fe rence de cette condition est l’extraction du cathe ter entre 24 et 60%. Le traitement de re par voie endovasculaire percutane e, par la veine fe morale commune. S’il n’est pas fragmente de d’extraction doit e ^tre fait par un acce s alternatif. Cet article de crit l’ablation possible, le proce ussie d’un cathe ter fragmente par voie endovasculaire percutane e a partir de la totalement re re droite. veine sous-clavie
The use of totally implantable central venous catheters (Port-a-Cath; Bard, Salt Lake City, UT) for the administration of chemotherapies and parenteral nutrition is more and more common in the medical practice. These devices are composed of a reservoir (port) through which the substances are injected and a polyurethane or radiopaque silicone catheter. The main complications caused by the Porta-Cath are catheter thrombosis or venous thrombosis and infection. Catheter migration or catheter fracture and consequent migration of a fragment is a rare complication that occurs in 1% of the patients.1-4 Despite the low incidence, embolization
DOI of original article: 10.1016/j.avsg.2010.02.031. 1
Interventional Radiology Unit, Radiology Institute, Hospital das Clinicas, University of S~ao Paulo Medical School, S~ao Paulo, Bresil. 2 Radiology Department, Radiology Institute, Hospital das Clinicas, University of S~ ao Paulo Medical School, S~ao Paulo, Bresil.
Correspondence : Joaquim Maurı´cio da Motta Leal Filho, Interventional Radiology Unit, Radiology Institute, Hospital das Clinicas, University of Sao Paulo Medical School, Rua Diogo Jacome, 1030/Apto. 121 e S~ ao Paulo e SP, Brazil e 04512-001, E-mail: jotamauf@yahoo. com.br Ann Vasc Surg 2010; 24: 826.e1-826.e4 DOI: 10.1016/j.acvfr.2011.01.024 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
may cause severe and potentially fatal complications such as thromboembolia,5,6 bacterial endocarditis,7 sepsis, myocardial lesions, and cardiac arrhythmias,8 and the mortality rates may vary between 24 and 60%.9 Therefore, removal of these foreign bodies is always recommended. Percutaneous intravascular removal of foreign bodies through a common femoral access is the gold standard treatment for the referred condition. It is a minimally invasive, relatively simple, safe procedure, with low complication rates, compared with conventional surgical treatment.10-16 In the absence of this venous access, removal must be performed using an alternative route.17 The present article describes the removal of a fragmented catheter by percutaneous intravascular access obtained through the right subclavian vein.
CASE REPORT A 56-year-old woman diagnosed with Hodgkin’s lymphoma received chemotherapy through the implantable venous access port, the Port-A-Cath, inserted in the right subclavian vein. After a frustrated attempt to deliver drug solution through the catheter, chest x-ray revealed fracture and embolization of a catheter fragment (Fig. 1). The first choice of access route was the jugular veins, because 899.e11
899.e12 Cas cliniques
Annales de chirurgie vasculaire
Fig. 1. Simple chest x-ray showing fractured Port-a-Cath and catheter embolization. the patient had a history of deep venous thrombosis of the lower limbs and an inferior vena cava filter, which made the access through the femoral veins impossible. Attempt to access the site through the right and left internal jugular veins was unsuccessful because these veins were also affected by thrombosis. For the patient to continue with her previous treatment, she should be referred to surgery for removal of the fragmented catheter and implantation of a new Port-a-Cath device, since peripheral venous access was not possible. We chose the same access route previously used, that is, the right subclavian vein, for the extraction of the foreign body and implantation of the new catheter. Technique Puncture of the right subclavian vein using Seldinger technique (Fig. 2), implantation of the 8-French sheath, passing of the guide wire into the distal end of the catheter located in the right ventricle, and placement of the loopsnare guiding catheter. Parallel to the guiding catheter, 260-cm hydrophilic guide wire was simultaneously introduced through the 8-French sheath, and this one was placed in the inferior vena cava, ensuring subclavian venous access (Fig. 3). The loop snare was introduced through the guiding catheter until the distal end, the catheter was grasped and the whole set was removed, including the 8-French sheath, but maintaining the access to the right subclavian vein through the guide wire located in the inferior vena cava (Fig. 4). Then, a new Port-aCath was implanted (Fig. 5).
DISCUSSION Embolization of intravascular catheters, by fracture or migration, is a rare condition that occurs in 1% of
Fig. 2. Puncture of the right subclavian vein.
the cases,1-4 however, if left untreated, it may cause serious complications and even death, with a mortality rate between 24 and 60%.9 Because of these high mortality rates, extraction of foreign bodies is strongly recommended even in asymptomatic patients. The venous access recommended for the removal of intravascular foreign bodies is the common femoral vein,10 preferably the right one. The advantages of this approach include easier handling, the patient feels more comfortable, puncture is facilitated by the blood vessel diameter and because the vessel is situated close to the surface of the skin, presence of posterior bone protection that allows its fixation during puncture and application of effective pressure after catheter removal, access to the main sites of migration of intravascular foreign bodies, and a vessel diameter that allows for the insertion of materials of various sizes. Depending on the degree of difficulty of the procedure, one femoral vein can be used, or both of them simultaneously, although it is always preferable to use only one. This venous access is always available except in the case of deep venous thrombosis of the lower limbs and/or the presence of a definitive inferior vena cava filter. The second choice of venous access route are the jugular veins, which present the following advantages: puncture facilitated by the blood vessel diameter, access to the main sites of migration of intravascular foreign bodies, vessel diameter that
Vol. 24, No. 6, 2010
Cas cliniques 899.e13
Fig. 3. A Implantation of the 8-French sheath in the right subclavian vein. B Distal end of catheter was grasped with the loop snare. Hydrophilic guide wire parallel to the loop snare with its distal end located in the inferior vena cava.
Fig. 4. A Removal of the whole set, but maintaining the hydrophilic guide wire in the inferior vena cava (maintenance of subclavian venous access). B Fragment of catheter.
allows for the insertion of materials of various sizes, and application of effective pressure to the puncture site.18,19 In the absence of these four access routes, alternative routes such as dissection or puncture of
basilic or cephalic veins, dissection of axillary veins, or else puncture of subclavian veins can be used. Despite the easy access to basilic and cephalic veins, these vessels cannot be used for the insertion of
899.e14 Cas cliniques
Annales de chirurgie vasculaire
can be used. Subclavian veins are a possible alternative for foreign body retrieval, but should be used in selected or exceptional cases only. REFERENCES
Fig. 5. Implantation of another Port-a-Cath through the right subclavian vein.
large devices. Besides, the patient has been fighting cancer for around 3 years, and, thus, there were clots in the veins of her arms and forearms (phlebitis). Some advantages of the subclavian veins include easier handling, puncture facilitated by the blood vessel diameter, access to the main sites of migration of intravascular foreign bodies, and a vessel diameter that allows for the insertion of materials of various sizes. In the case described earlier, we were aware of the permeability of the right subclavian vein, and of the need for implantation of a new Port-a-Cath, and, consequently, this access was chosen. However, it has some disadvantages such as difficulties in applying effective pressure after catheter removal, hematomas, pneumothorax, and hemothorax.17
CONCLUSION Percutaneous intravascular removal of foreign bodies is considered a gold standard treatment because it is a minimally invasive, relatively simple, safe procedure, with low complication rates compared with conventional surgical treatment. Vascular access should always be made through the femoral veins. If this is not possible, other alternative routes
1. Smouse HB, Fox PF, Brady TM, Swischuk JL, Casta~ neda F, Pham MT. Intravascular foreign body removal. Semin Intervent Radiol 2000;17:201-212. 2. Andrews RE, Tulloh RM, Rigby ML. Percutaneous retrieval of central venous catheter fragments. Arch Dis Child 2002;87:149-150. 3. Uflacker R, Lima S, Melichar AC. Intravascular foreign bodies: percutaneous retrieval. Radiology 1986;160: 731-735. 4. Andrade G, Marques R, Brito N, Bomfim A, Cavalcanti D, Abath C. Cateteres intravenosos fraturados: retirada por tecnicas endovasculares. Radiol Bras 2006;39:199-202. 5. Suarez-Penaranda JM, Guitian-Barreiro D, ConcheiroCarro L. Long-standing intracardiac catheter embolism. An unusual autopsy finding. Am J Forensic Med Pathol 1995;16:124-126. 6. Knutson H, Stenberg K. Pulmonary embolism after catheter break. Nord Med 1959;62:1491. 7. Balbi M, Bertero G, Bellotti S, Rolandelli ML, Caponnetto S. Right-sided valvular endocarditis supported by an unexpected intracardiac foreign body. Chest 1990;97:1486-1488. 8. Denny MA, Frank LR. Ventricular tachycardia secondary to port-a-cath fracture and embolization. J Emerg Med 2003;24:29-34. 9. Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176:1509-1513. 10. Egglin TK, Dickey KW, Rosenblatt M, Pollak JS. Retrieval of intravascular foreign bodies: experience in 32 cases. Am J Roentgenol 1995;164:1259-1264. 11. Yang FS, Ohta I, Chiang HJ, Lin JC, Shih SL, Ma YC. Nonsurgical retrieval of intravascular foreign body: experience of 12 cases. Eur J Radiol 1994;18:1-5. 12. Liu JC, Tseng HS, Chen CY, Chern MS, Chang CY. Percutaneous retrieval of intravascular foreign bodies: experience with 19 cases. Kaohsiung J Med Sci 2002;18:492-499. 13. Surov A, Jordan K, Buerke M, Persing M, Wollschlaeger B, Behrmann C. Atypical pulmonary embolism of port catheter fragments in oncology patients. Support Care Cancer 2006;14:479-483. 14. Cheng C-C, Tsai T-N, Yang C-C, Han C-L. Percutaneous retrieval of dislodged totally implantable central venous access system in 92 cases: experience in a single hospital. Eur J Radiol 2009;69:346-350. 15. Chow LM, Friedman JN, Macarthur C, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr 2003;142:141-144. 16. Bloomfield DA. Techniques of nonsurgical retrieval of iatrogenic foreign bodies from the heart. Am J Cardiol 1971;27:538-545. 17. Struck MF, Kaden I, Heiser A, Steen M. Cross-over endovascular retrieval of a lost guide wire from the subclavian vein. J Vasc Access 2008;9:304-306. 18. Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002;28: 1-17. 19. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Eng J Med 1994;331:1735-1738.