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Rare use of Atrieve Vascular Snare™ for percutaneous transcatheter retrieval of central venous port catheter fragments
Diagnostic and Interventional Imaging (2015) 96, 1227—1230
TECHNICAL NOTE /Technical
Rare use of Atrieve Vascular SnareTM for percutaneous transcatheter retrieval of central venous port catheter fragments O.F. Nas a,∗, E. Kacar b, N. Dogan c, M.M. Atasoy d, C. Erdogan a a
Department of Radiology, Faculty of Medicine, Uludag University, Bursa, Turkey Department of Radiology, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey c Radiology Clinic, Bahar Hospital, Bursa, Turkey d Department of Radiology, Maltepe University, Istanbul, Turkey b
KEYWORDS Central venous port catheter; Percutaneous transcatheter; Atrieve Vascular SnareTM
Central venous port catheters and peripherally inserted central catheters (PICC lines) are implanted in the central venous system usually for administration of chemotherapeutic agents and parenteral nutrition [1,2]. Long-term use of these catheters may cause such complications as occlusion, thrombosis, infection, fracture and intravascular dislocation of the catheter [2,3]. The incidence of intravascular dislocation of port catheters is rare (0—3.1%) [1,3]. Fragments of a fractured port catheter might migrate towards the heart or pulmonary artery and cause embolization in the distal region of the organ resulting in mortality [1,4]. Therefore, port catheter fragments must be retrieved as soon as possible [1]. Percutaneous retrieval, removal by open thoracotomy and long-term anticoagulant therapy are the treatment options for fractured port catheters. Among these options, percutaneous transcatheter retrieval is usually a safe and effective method [1,5]. In this study, we report the retrieval of port catheter fragments extending from the superior vena cava to the right cardiac cavities using a three-loop 6F 12—20 mm snare (Atrieve Vascular SnareTM ; Angiotech, Gainesville, FL, United States) in two patients who complained of chest pain.
∗
Corresponding author. E-mail addresses: [email protected] (O.F. Nas), [email protected] (E. Kacar), [email protected] (N. Dogan), [email protected] (M.M. Atasoy), [email protected] (C. Erdogan). http://dx.doi.org/10.1016/j.diii.2015.03.007 2211-5684/© 2015 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
1228
Case presentation A 68-year-old man (patient 1) was diagnosed with colon cancer 2 years ago, and a 71-year-old woman (patient 2) was diagnosed with stomach cancer 1 year ago. In both patients, a subcutaneous port was implanted in the right side of the chest for administration of chemotherapeutic agents in another health care center. The ports were used for 1 and a half years in patient 1 whereas patient 2 used it for 3 months. Both subcutaneous ports were removed in another healthcare center due to completion of therapy in patient 1 and port pocket infection in patient 2. X-ray images of patient 1 — who was complaining of pain in the right side of the chest for the last 3—4 months — and patient 2 — who was complaining of similar pain for the last 5 months — both showed port catheter fragments extending from the superior vena cava to the right cardiac cavities. Both patients were referred to our hospital for retrieval of the fragments. Patients were treated with a similar technique for retrieval of the port catheter fragments. With the help of ultrasonography, a 10F introducer was inserted in the right common femoral vein in both patients who were under local anesthesia. Then, with the help of a glide wire, a 7F guiding catheter was advanced inside the 10F introducer from the level of the inferior vena cava, through the right atrium of the heart, to the level of the superior vena cava. It was inspected by fluoroscopy that the port catheter fragment was extending from the superior vena cava to the right heart cavities and moving in the craniocaudal plane with heartbeats. The superior vena cava was reached using a 6F 12—20 mm Atrieve Vascular SnareTM through the 7F guiding catheter. After a few attempts guided by fluoroscopy in different projections, the port catheter fragment was captured by the upper end using the vascular snare (Figs. 1 and 2). The presence of multiple loops in the Atrieve Vascular SnareTM facilitated the manipulation and helped capture the dislodged port catheter fragment easily and in a short time. The captured fragment was retrieved from the cardiac cavities through the inferior vena cava (Figs. 1 and 2). The lengths of the extracted ruptured parts of both ports were between 15 and 20 cm. Post-operative images showed no complications. The groin was closed by manual compression. Both patients were contacted by phone almost 1 and a half months later,
O.F. Nas et al. and both of them reported complete disappearance of the wandering pain in the right side of the chest.
Discussion Catheter fracture is one of the most serious complications of central venous port catheters [3] and it is also observed after placement of a PICC line [2]. Fragments of a fractured catheter may cause embolism in the right atrium, the right ventricle or the pulmonary artery. Some authors reported that embolism caused by fragments of a fractured port catheter might lead to life-threatening complications such as arrhythmias and pulmonary thromboembolisms in almost 71% of patients [3]. Therefore, it is crucial that fragments of a fractured port catheter be retrieved as soon as possible. Since it was first reported by Thomas et al. in 1964 [6], percutaneous endovascular retrieval of iatrogenic foreign bodies has been accepted as the standard application. In the literature, the success rate of percutaneous retrieval of intravascular foreign bodies was reported to be 71—100% [7]. Unless the free end of the port catheter fragment is inaccessible, such devices as loop snares, baskets and balloon catheters can be used in percutaneous endovascular retrieval of the fragment. On the other hand, if the free end of the port catheter fragment is inaccessible, a combination of loop snare and pigtail catheter or capture forceps can be used [5]. Cheng at al. [1] reported the use of loop snare, basket, pigtail and capture forceps in percutaneous retrieval of port catheter fragments. In addition, Chuang et al. [5] successfully applied a combination of loop snare and pigtail catheter in retrieval of a port catheter fragment with an inaccessible free end. Due to their rigidity, forceps are usually traumatic. Baskets, on the other hand, are quite difficult to manipulate especially in larger blood vessels as they cannot be steered [8]. The snare technique is associated with high success and low complication rates. However, use of this technique requires experience and skillful manipulation. Early designs of the loop snares had a loop in the same axis as the catheter, which made the manipulation difficult — especially in larger blood vessels. In the gooseneck snare, the right angle loop
Figure 1. A 68-year-old male patient; grasping the port catheter fragment by the upper end using a 12—20 mm Atrieve Vascular SnareTM , guided by fluoroscopy in: a: posterio-anterior projection and; b: oblique projection; c: retrieving the port catheter fragment using the vascular snare (black dotted arrow: port catheter fragment, black arrow: Atrieve Vascular SnareTM ).
Rare use of Atrieve Vascular SnareTM
1229
Figure 2. A 71-year-old female patient: a: reaching the upper end of the port catheter fragment through the superior vena cava using a 12—20 mm Atrieve Vascular SnareTM , guided by fluoroscopy; b: grasping the port catheter fragment by using the vascular snare in oblique projection; c: vascular snare and port catheter fragment in the vena cava inferior; d: extraction of the vascular snare and the port catheter fragment through a 10F introducer (black dotted arrow: port catheter fragment, black arrow: Atrieve Vascular SnareTM ).
helps grasp foreign bodies. Therefore, the first choice should be the gooseneck snare in retrieval of foreign bodies [8]. Gooseneck snares are generally made of nitinol. In this type of snare, the loop is 2—35 mm in width, and the diameter and length of the catheter are 2.3—6F and 48—175 mm, respectively. The Atrieve Vascular SnareTM , on the other hand, is more complex and consists of three interlaced loops made of super elastic nitinol. In this type of snare, the loop is 2—45 mm in width, and the length of the catheter varies between 120—175 mm. The multi-loop Atrieve Vascular SnareTM might increase the probability of grasping and retrieving foreign bodies by use of at least one loop [9]. In the literature, there are many studies reporting the use of gooseneck snares for retrieval of dislodged catheter fragments [1,3,5,7,8]. However, to the best of our knowledge, this is the first case study reporting the use of a threeloop Atrieve Vascular SnareTM for retrieval of port catheter fragments. In this study, we used a three-loop Atrieve Vascular SnareTM to retrieve port catheter fragments extending from the superior vena cava to the right heart cavities, as inspected with a fluoroscope.
Conclusion Percutaneous transcatheter retrieval of port catheter fragments using a three-loop Atrieve Vascular SnareTM can be an
alternative and effective method. However, there is a need for further data and experience for widespread use of this device.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Cheng CC, Tsai TN, Yang CC, Han CL. Percutaneous retrieval of dislodged totally implantable central venous access system in 92 cases: experience in a single hospital. Eur J Radiol 2009;69:346—50. [2] Delarbre B, Dabadie A, Stremler-Lebel N, Jolibert M, Cassagneau P, Lebel S, et al. Introduction of the use of a pediatric PICC line in a French University Hospital: review of the first 91 procedures. Diagn Interv Imaging 2014;95:277—81. [3] SurovA, BuerkeM, John E, Kösling S, Spielmann RP, Behrmann C. Intravenous port catheter embolization: mechanisms, clinical features, and management. Angiology 2008;59:90—7. [4] Groebli Y, Wuthrich R, Tschantz P, Beguelin P, Piguet D. A rare complication of permanent venous access: constriction, fracture and embolization of the catheter. Swiss Surg 1998;4:141—5. [5] Chuang MT, Wu DK, Chang CA, Shih MC, Ou-Yang F, Chuang CH, et al. Concurrent use of pigtail and loop snare catheters for
1230 percutaneous retrieval of dislodged central venous port catheter. Kaohsiung J Med Sci 2011;27:514—9. [6] Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Nonsurgical retrieval of a broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation 1964;30:106—8. [7] Liu JC, Tseng HS, Chen CY, Chern MS, Chang CY. Percutaneous retrieval of 20 centrally dislodged Port-A catheter fragments. Clin Imaging 2004;28:223—9.
O.F. Nas et al. [8] Koseoglu K, Parildar M, Oran I, Memis A. Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004;49:281—5. [9] Ellis SG, Holmes DR. Strategic approaches in coronary intervention. 3rd Ed Philadelphia: Lippincott Williams & Wilkins; 2006. p. 436.
TECHNICAL NOTE /Technical
Rare use of Atrieve Vascular SnareTM for percutaneous transcatheter retrieval of central venous port catheter fragments O.F. Nas a,∗, E. Kacar b, N. Dogan c, M.M. Atasoy d, C. Erdogan a a
Department of Radiology, Faculty of Medicine, Uludag University, Bursa, Turkey Department of Radiology, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey c Radiology Clinic, Bahar Hospital, Bursa, Turkey d Department of Radiology, Maltepe University, Istanbul, Turkey b
KEYWORDS Central venous port catheter; Percutaneous transcatheter; Atrieve Vascular SnareTM
Central venous port catheters and peripherally inserted central catheters (PICC lines) are implanted in the central venous system usually for administration of chemotherapeutic agents and parenteral nutrition [1,2]. Long-term use of these catheters may cause such complications as occlusion, thrombosis, infection, fracture and intravascular dislocation of the catheter [2,3]. The incidence of intravascular dislocation of port catheters is rare (0—3.1%) [1,3]. Fragments of a fractured port catheter might migrate towards the heart or pulmonary artery and cause embolization in the distal region of the organ resulting in mortality [1,4]. Therefore, port catheter fragments must be retrieved as soon as possible [1]. Percutaneous retrieval, removal by open thoracotomy and long-term anticoagulant therapy are the treatment options for fractured port catheters. Among these options, percutaneous transcatheter retrieval is usually a safe and effective method [1,5]. In this study, we report the retrieval of port catheter fragments extending from the superior vena cava to the right cardiac cavities using a three-loop 6F 12—20 mm snare (Atrieve Vascular SnareTM ; Angiotech, Gainesville, FL, United States) in two patients who complained of chest pain.
∗
Corresponding author. E-mail addresses: [email protected] (O.F. Nas), [email protected] (E. Kacar), [email protected] (N. Dogan), [email protected] (M.M. Atasoy), [email protected] (C. Erdogan). http://dx.doi.org/10.1016/j.diii.2015.03.007 2211-5684/© 2015 Éditions franc ¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
1228
Case presentation A 68-year-old man (patient 1) was diagnosed with colon cancer 2 years ago, and a 71-year-old woman (patient 2) was diagnosed with stomach cancer 1 year ago. In both patients, a subcutaneous port was implanted in the right side of the chest for administration of chemotherapeutic agents in another health care center. The ports were used for 1 and a half years in patient 1 whereas patient 2 used it for 3 months. Both subcutaneous ports were removed in another healthcare center due to completion of therapy in patient 1 and port pocket infection in patient 2. X-ray images of patient 1 — who was complaining of pain in the right side of the chest for the last 3—4 months — and patient 2 — who was complaining of similar pain for the last 5 months — both showed port catheter fragments extending from the superior vena cava to the right cardiac cavities. Both patients were referred to our hospital for retrieval of the fragments. Patients were treated with a similar technique for retrieval of the port catheter fragments. With the help of ultrasonography, a 10F introducer was inserted in the right common femoral vein in both patients who were under local anesthesia. Then, with the help of a glide wire, a 7F guiding catheter was advanced inside the 10F introducer from the level of the inferior vena cava, through the right atrium of the heart, to the level of the superior vena cava. It was inspected by fluoroscopy that the port catheter fragment was extending from the superior vena cava to the right heart cavities and moving in the craniocaudal plane with heartbeats. The superior vena cava was reached using a 6F 12—20 mm Atrieve Vascular SnareTM through the 7F guiding catheter. After a few attempts guided by fluoroscopy in different projections, the port catheter fragment was captured by the upper end using the vascular snare (Figs. 1 and 2). The presence of multiple loops in the Atrieve Vascular SnareTM facilitated the manipulation and helped capture the dislodged port catheter fragment easily and in a short time. The captured fragment was retrieved from the cardiac cavities through the inferior vena cava (Figs. 1 and 2). The lengths of the extracted ruptured parts of both ports were between 15 and 20 cm. Post-operative images showed no complications. The groin was closed by manual compression. Both patients were contacted by phone almost 1 and a half months later,
O.F. Nas et al. and both of them reported complete disappearance of the wandering pain in the right side of the chest.
Discussion Catheter fracture is one of the most serious complications of central venous port catheters [3] and it is also observed after placement of a PICC line [2]. Fragments of a fractured catheter may cause embolism in the right atrium, the right ventricle or the pulmonary artery. Some authors reported that embolism caused by fragments of a fractured port catheter might lead to life-threatening complications such as arrhythmias and pulmonary thromboembolisms in almost 71% of patients [3]. Therefore, it is crucial that fragments of a fractured port catheter be retrieved as soon as possible. Since it was first reported by Thomas et al. in 1964 [6], percutaneous endovascular retrieval of iatrogenic foreign bodies has been accepted as the standard application. In the literature, the success rate of percutaneous retrieval of intravascular foreign bodies was reported to be 71—100% [7]. Unless the free end of the port catheter fragment is inaccessible, such devices as loop snares, baskets and balloon catheters can be used in percutaneous endovascular retrieval of the fragment. On the other hand, if the free end of the port catheter fragment is inaccessible, a combination of loop snare and pigtail catheter or capture forceps can be used [5]. Cheng at al. [1] reported the use of loop snare, basket, pigtail and capture forceps in percutaneous retrieval of port catheter fragments. In addition, Chuang et al. [5] successfully applied a combination of loop snare and pigtail catheter in retrieval of a port catheter fragment with an inaccessible free end. Due to their rigidity, forceps are usually traumatic. Baskets, on the other hand, are quite difficult to manipulate especially in larger blood vessels as they cannot be steered [8]. The snare technique is associated with high success and low complication rates. However, use of this technique requires experience and skillful manipulation. Early designs of the loop snares had a loop in the same axis as the catheter, which made the manipulation difficult — especially in larger blood vessels. In the gooseneck snare, the right angle loop
Figure 1. A 68-year-old male patient; grasping the port catheter fragment by the upper end using a 12—20 mm Atrieve Vascular SnareTM , guided by fluoroscopy in: a: posterio-anterior projection and; b: oblique projection; c: retrieving the port catheter fragment using the vascular snare (black dotted arrow: port catheter fragment, black arrow: Atrieve Vascular SnareTM ).
Rare use of Atrieve Vascular SnareTM
1229
Figure 2. A 71-year-old female patient: a: reaching the upper end of the port catheter fragment through the superior vena cava using a 12—20 mm Atrieve Vascular SnareTM , guided by fluoroscopy; b: grasping the port catheter fragment by using the vascular snare in oblique projection; c: vascular snare and port catheter fragment in the vena cava inferior; d: extraction of the vascular snare and the port catheter fragment through a 10F introducer (black dotted arrow: port catheter fragment, black arrow: Atrieve Vascular SnareTM ).
helps grasp foreign bodies. Therefore, the first choice should be the gooseneck snare in retrieval of foreign bodies [8]. Gooseneck snares are generally made of nitinol. In this type of snare, the loop is 2—35 mm in width, and the diameter and length of the catheter are 2.3—6F and 48—175 mm, respectively. The Atrieve Vascular SnareTM , on the other hand, is more complex and consists of three interlaced loops made of super elastic nitinol. In this type of snare, the loop is 2—45 mm in width, and the length of the catheter varies between 120—175 mm. The multi-loop Atrieve Vascular SnareTM might increase the probability of grasping and retrieving foreign bodies by use of at least one loop [9]. In the literature, there are many studies reporting the use of gooseneck snares for retrieval of dislodged catheter fragments [1,3,5,7,8]. However, to the best of our knowledge, this is the first case study reporting the use of a threeloop Atrieve Vascular SnareTM for retrieval of port catheter fragments. In this study, we used a three-loop Atrieve Vascular SnareTM to retrieve port catheter fragments extending from the superior vena cava to the right heart cavities, as inspected with a fluoroscope.
Conclusion Percutaneous transcatheter retrieval of port catheter fragments using a three-loop Atrieve Vascular SnareTM can be an
alternative and effective method. However, there is a need for further data and experience for widespread use of this device.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Cheng CC, Tsai TN, Yang CC, Han CL. Percutaneous retrieval of dislodged totally implantable central venous access system in 92 cases: experience in a single hospital. Eur J Radiol 2009;69:346—50. [2] Delarbre B, Dabadie A, Stremler-Lebel N, Jolibert M, Cassagneau P, Lebel S, et al. Introduction of the use of a pediatric PICC line in a French University Hospital: review of the first 91 procedures. Diagn Interv Imaging 2014;95:277—81. [3] SurovA, BuerkeM, John E, Kösling S, Spielmann RP, Behrmann C. Intravenous port catheter embolization: mechanisms, clinical features, and management. Angiology 2008;59:90—7. [4] Groebli Y, Wuthrich R, Tschantz P, Beguelin P, Piguet D. A rare complication of permanent venous access: constriction, fracture and embolization of the catheter. Swiss Surg 1998;4:141—5. [5] Chuang MT, Wu DK, Chang CA, Shih MC, Ou-Yang F, Chuang CH, et al. Concurrent use of pigtail and loop snare catheters for
1230 percutaneous retrieval of dislodged central venous port catheter. Kaohsiung J Med Sci 2011;27:514—9. [6] Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Nonsurgical retrieval of a broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation 1964;30:106—8. [7] Liu JC, Tseng HS, Chen CY, Chern MS, Chang CY. Percutaneous retrieval of 20 centrally dislodged Port-A catheter fragments. Clin Imaging 2004;28:223—9.
O.F. Nas et al. [8] Koseoglu K, Parildar M, Oran I, Memis A. Retrieval of intravascular foreign bodies with goose neck snare. Eur J Radiol 2004;49:281—5. [9] Ellis SG, Holmes DR. Strategic approaches in coronary intervention. 3rd Ed Philadelphia: Lippincott Williams & Wilkins; 2006. p. 436.