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Retained intravascular fragments after removal of indwelling central venous catheters: a single institution experience
Journal of Pediatric Surgery (2010) 45, 1491–1495
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Retained intravascular fragments after removal of indwelling central venous catheters: a single institution experience Francisco Bautista a,⁎, Javier Gómez-Chacón b , Elisa Costa b , Lucas Moreno a , Adela Cañete a , Maria Dolores Muro c , Juan Velazquez b , Victoria Castel a a
Paediatric Oncology Unit, Hospital Infantil Universitario La Fe, Avenida de Campanar 21, 46009 Valencia, Spain Paediatric Surgery Unit, Hospital Infantil Universitario La Fe, Avenida de Campanar 21, 46009 Valencia, Spain c Paediatric Radiology Unit, Hospital Infantil Universitario La Fe, Avenida de Campanar 21, 46009 Valencia, Spain b
Received 20 August 2009; revised 23 December 2009; accepted 1 February 2010
Key words: Indwelling catheters; Device removal; Complications; Pediatrics
Abstract There are few reports regarding the presence of retained fixed fragments after removal of indwelling central venous catheters in children. We conducted a retrospective study of 355 patients who underwent removal of central venous catheter from 1996 to 2008. Six patients (1.6%) had a failed attempt of removal, resulting in a remnant of catheter left in the central venous system. All of them had underlying malignant disorders and received chemotherapy for a prolonged period of time. In 2 patients, a second attempt of retrieval was performed that was partially successful. After an average follow-up of 3.5 ± 1.8 years, 1 patient has developed mild symptoms that could be related to the remaining fragment within the vascular system. Therefore, the incidence of complications caused by retained fixed fragments is low. Patients whose line has been in place for more than 48 months (P = 0.009) and those located in the saphenous vein (P = 0.01) are more prone to experience fragment retention. The decision of retrieval should be balanced according to the presence of symptoms and the length of the fragment retained. © 2010 Elsevier Inc. All rights reserved.
1. Background Indwelling central venous catheters (CVCs) have been in use for the last 3 decades and have revolutionized the care of children with cancer and those requiring long-term access for medications and blood products [1]. ⁎ Corresponding author. E-mail addresses: [email protected], [email protected] (F. Bautista). 0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.02.001
Central venous device–related complications have been extensively described in the literature [2-4]. They can be approximately divided by thirds among infectious events, venous thrombosis, and mechanical events [5]. Up to 40% of children with CVC experience 1 of these complications [2]. Nevertheless, there are few reports regarding the presence of retained fixed fragments after removal of indwelling CVCs in children [6,7], and there is still a lack of consensus regarding the optimal management of this complication.
1492 The aim of this study is to present our series of patients with retained fixed fragments after removal of indwelling CVCs and their management and follow-up.
2. Material and methods Patients undergoing removal of CVCs by the pediatric oncology surgical team in Hospital La Fe from January 1996 to December 2008 were retrospectively reviewed. Central lines placed within the neonatal intensive care unit and peripherally inserted central catheters were excluded. The surgical team that places the CVCs, and therefore, the ones that audited the lines, do not place central lines in neonates (done by neonatologists) or peripherally inserted central catheter lines (done by anesthetists or pediatric intensivists). For every patient, informed consent had been obtained previously for surgical procedure. The types of devices used were single-lumen silicone rubber Port-A-Cath (PC) (Bard Access Systems, Inc, Salt Lake City, UT) and single- or double-lumen silicone rubber Hickman Line (HC) (Bard Access System, Inc). A heparin solution containing 2.5 μg/mL of vancomycine and 2 μg/mL of ciprofloxacin was used to flush HC and PC every time after use, and HC twice weekly and PC once monthly when they were not in use [8]. Central venous catheter insertion was performed surgically under general anesthesia via external or internal jugular vein, saphenous vein at the groin, or femoral vein cut down, according to patient clinical status and surgeon decision. The position of the distal tip of the catheter was checked during the operation using fluoroscopy, and a standard chest radiograph was obtained immediately afterward with the patient in an upright position. Port-A-Caths were electively removed when children were 5 years off treatment and relapse-free. Hickman Lines were electively removed after children were 6 months off treatment. Urgent removals were performed in case of persistent infection, thrombus, or malfunction, after a consensus between medical and surgical teams. The PCs were removed through a single incision in the skin over the port, dissection of the fibrous sheath around the port, and then removal of the catheter itself through the same incision. Similarly, the HC were removed by a small incision in the skin as the catheter was tunneled, followed by blunt dissection to release the fibrous cuff associated with the catheter. The diagnosis of retained fragment was made after the surgeon realized during the removal procedure that a fragment of the CVC could not be completely removed. To identify location of the retained fragment, x-ray and Doppler ultrasound were performed after surgery. All patients were regularly followed up in pediatric oncology clinics until CVCs were removed and then until aged 18 or 10 years of follow-up, according to the pediatric oncology unit long-term follow-up guidelines.
F. Bautista et al. Statistical analysis was performed using SPSS 13.0 (SPSS Inc, Chicago Inc, IL). The variables included in the statistical analysis were as follows: age, sex, location of the CVC, time remaining within the vein, type of CVC, diagnosis (nonmalignant, solid tumors, and hematologic malignancies) and type of removal (elective/urgent). Differences in clinical variables were studied by χ2 test or Fisher exact test for categorical data and by the Student t parametric test for continuous data. Multivariate analysis was not performed because of the low number of events. A probability value (P) below 0.05 was considered statistically significant. Literature review was performed using “indwelling catheters,” “device removal,” and “complications” as search terms in PubMed and EMBASE. No restrictions to search were used. References from articles and reference pediatric oncology, medical oncology, and pediatric surgery textbooks were searched.
3. Results During the study period, 355 CVCs were removed in 317 consecutive patients, 270 of them were elective procedures (76.1%) and the rest were performed on an urgent basis for reasons described in Table 1. Baseline characteristics of our study population are outlined in Table 2. Patients were diagnosed of a malignant condition in 298 cases (94%). Eighteen patients (5.7%) had a nonmalignant hematologic disease including medullar aplasia, Fanconi anemia, hemophilia, and immunodeficiency. One patient (0.3%) with a respiratory disease had the diagnosis of cystic fibrosis. Two hundred eighty-nine CVCs (81.4%) were inserted at the time of diagnosis and 66 (18.6%) were second, third, or fourth central accesses. The lines electively removed remained in place for an average of 26.9 ± 26.6 months, whereas lines urgently removed stayed for an average of 9.9 ± 12.2 months.
Table 1
Indications for each type of CVC removal
Indication
No. of lines removed
PC
SL-HC
DL-HC
End of treatment Infection Thrombosis Malfunction Self-removal Skin necrosis Migration Total
270 (76.1%) 51 (14.4%) 12 (3.4%) 9 (2.5%) 9 (2.5%) 3 (0.8%) 1 (0.3%) 355
164 44 7 7 – 3 1 226 (63.7%)
10 – 2 – 1 – – 13 (3.7%)
96 7 3 2 8 – – 116 (32.6%)
SL-HC indicates single-lumen Hickman line; DL-HC, double-lumen Hickman line; PC, Port-A-Cath.
Retained intravascular fragments after removal of CVC Table 2
Baseline characteristics of the study population
Median age at CVC insertion (y) Sex (male/female) Diagnosis
CVC location
Average time of line remaining in site (mo)
5.2 (0.2-19.3) 1.3:1 - Malignancies: 298 (94%) Malignant hematologic diseases: 161 Solid tumors: 137 - Nonmalignant hematologic diseases: 18 (5.7%) - Respiratory diseases: 1 (0.3%) - Saphenous vein: 228 (64.2%) - Jugular vein: 126 (35.5%) - Femoral vein: 1 (0.3%) - Lines electively removed: 26.9 ± 26.6 - Lines urgently removed: 9.9 ± 12.2
At the time of removal, 349 CVCs (98.4%) were removed without complication. Six patients (1.6%) had a failed attempt at removal, resulting in a remnant of catheter left in the central venous system. Characteristics of these patients are depicted in Table 3. All of them had underlying malignant disorders (2 solid tumors and 4 hematologic malignancies). Male to female ratio was 4:2. Median age at the time of diagnosis and CVC insertion was 4.3 years (range, 2.9-13.5 years). One of them had experienced relapse at the time of removal. Treatment lasted 4 months for the patient diagnosed of Hodgkin disease, 9 months for 2 patients with Ewing sarcoma, and 2.5 years for patients diagnosed of Acute lymphoblastic leukemia (ALL) and non–Hodgkin lymphoma. None of the patients received radiotherapy on a field that involved the CVC. All of them had elective removals. Average time of line remaining in place was 61.4 ± 24.7 months; the difference was statistically significant compared with the patients in which the line was electively removed and did not experience this complication (61.4 ± 24.7 versus 26.9 ± 26.6 months, P = 0.02). Average follow-up for these 6 patients was 3.5 ± 1.8 years. None of these patients had infection, thrombosis, malfunction, or other CVC-related complications. After removal, fragments remained in external jugular vein (1 patient), femorocaval junction (1), and saphenous vein (4). In all cases, the remaining fragment of the catheter
Table 3
1493 was ligated at the entrance point into the vein at the time of removal to prevent migration of the fixed fragment, but the jugular vein was not ligated in itself in any case. Patients 2 and 3 underwent attempts to remove the remnants. In the first case, 12 cm was removed via percutaneous catheterization 3 days after the first attempt, but a 1.5-cm fragment remained into right external iliac vein. The latter underwent a cardiac catheterism to close an interauricular communication 23 months later. In the same surgical procedure, an attempt was done to remove the remaining fragment, but only a partial reposition of the fragment was achieved. Only patient 4 with a remnant on saphenous vein has complained about local swelling, edema, and discomfort when walking. The rest of the patients remained asymptomatic during follow-up. On the univariate analysis, the unique statistically significant variables associated with retained fixed fragments after removal of CVC were location of the CVC in the saphenous vein (P = 0.01) and permanence of the line more than 48 months within the vein (P = 0.009).
4. Discussion Retained intravascular fragments after removal of indwelling CVCs are a scarcely described complication for this group of devices. Our review provides a wide retrospective series and the first including statistical analysis to identify risk factors related to this complication. It is highly representative of a tertiary care pediatric centre in Spain, including all the pediatric specialities with a dedicated surgical team to pediatric oncology, and extends for a long period of time in which the surgical and medical team, the procedures, and long-term follow-up guidelines have remained stable. Virtually all patients from our series had different forms of cancer and most had received chemotherapy as well as all children described by Milbrandt et al [7]. However, the number of patients experiencing nonmalignant conditions in our series is low and thus hampers drawing valid conclusions for all kind of patients carrying CVC. The nature of the relationship between the CVC and the “cancer patient” might add some special features not present in nonmalignant
Baseline characteristics of the patients with intravascular retained fixed fragments
Patient
Sex
Age (y)
Diagnosis
Type CVC
Location
CVC-RT (mo)
Symptoms
Follow-up (mo)
Status
1 2 3 4 5 6
Female Female Male Male Male Male
7.2 2.9 4.7 13.5 2.5 3.8
Ewing ALL Ewing HL ALL NHL
DL-HC PC PC PC PC PC
right external jugular Right femoral Right saphenous Left saphenous Right saphenous Right saphenous
19.9 73.3 55.9 74.9 90.8 53.9
No No No Yes No No
15.2 64.5 25.9 60.2 27.2 59.4
Dead Alive Alive Alive Alive Alive
HL indicates Hodgkin lymphoma; NHL, non–Hodgkin lymphoma; DL-HC, double-lumen Hickman line; CVC-RT, CVC-remaining time within the vein; Age, at insertion of CVC (years); Follow-up, after CVC removal (months).
1494 disorders. In the other hand, the long-term follow-up in our series gives a special strength to our observations. The global incidence of this complication in our series is 1.6% for all patients and 2.2% for children undergoing elective removals. Milbrandt et al [7] reported an incidence of this complication of 2% in 299 patients who underwent removal of their CVC, in the largest series of patients reported before ours. Little is known about the underlying cause of this complication. It seems to be related to the formation of a scar, often with calcification, of the “fibrin sheath” around the catheter. It seems to be precipitated by an initial injury with occasional thrombus with subsequent overlapping of tissue around the length of the CVC [9-11]. Athale and Chan [12] have described how ALL and its therapy (including CVCs) provided an ideal environment for the development of thrombotic complications in patients who also inherit 1 or more genetic prothrombotic defects. Therefore, thrombotic and retained fixed fragments complications could share some similarities in its etiopathogenic, related with the underlying malignancies and its treatment. In our series, a permanence of the CVC within the vein more than 48 months was significantly associated with the possibility of retained fixed fragments after removal of the CVC (P = 0.009). The longer the CVC remains within the vein, the higher is the possibility of presenting this complication, probably related with the underlying process of scar formation and calcification of the “fibrin sheath” around the CVC described above. Other authors have not found the same correlation [6,7]. In our study, macroscopic calcification was not observed at any time. Unfortunately, histologic review was not performed. In our study, location of the CVC seems to play a role in the etiopathogenic of retained fixed fragments because 4 of our patients had the CVC located in the saphenous vein, and it was significantly associated with this complication (P = 0.01). Nevertheless, other authors have suggested that placement of the catheter tip high in the superior vena cava results in a higher incidence of thrombosis [11,12]. According to our results, we would recommend inserting the CVC in the superior vena cava rather than in the inferior vena cava and to remove the CVC not later than 48 months after its insertion once treatment is finished to prevent this complication. In cases when the child is still having treatment (ie, relapse), electively replacing the catheter would add further risks, and therefore, we would suggest to maintain the CVC. With such a rare complication, which has possibly been underreported, it is therefore extremely difficult to draw management recommendations when a catheter fragment is retained intravascular. If the catheter seems fixed at the time of removal, the options are to either leave the catheter fragment in situ or to attempt its removal (intravascular or open surgery). In the situations in which the CVCs lack a free end and are probably completely endothelialized, CVCs should be left in
F. Bautista et al. place because the risk of complication from leaving the catheter in place is probably lower than that from retrieving it [5]. Nevertheless, Bessoud et al [5] suggested that, because determination of endothelialized catheter cannot be done until a retrieving device is placed close to the catheter, retrieval should be attempted in all cases. This conclusion was done based on a population of 156 patients who developed mechanical complications of the CVCs including fracture and embolized CVCs fragments; probably, this represents a population at a higher risk because CVCs fragments were located within the vascular system close to vital organs, and therefore more likely to produce lifethreatening complications. In these cases, percutaneous line retrieval avoids the need for surgery and has demonstrated its utility in high-risk populations, even in children [5,13]. In our series, 2 patients underwent a second attempt of percutaneous line retrieval of the retained fragment. In patient 2, a long fragment remained within the vascular system and 12 cm of the line were successfully removed by lassoing, but a 1.5-cm fragment remained into the right external iliac vein. In patient 3, only a partial reposition of the fragment was achieved. Likely complications of retained catheter fragments within the central venous system would be thrombosis, catheter migration, or infection. None of our patients developed 1 of these complications, neither any child in the series published by Milbrandt et al [7], after an average of 5.4 ± 3.9 years of follow-up. To the best of our knowledge, there are no published cases of life-threatening complications related to retained fragments of CVCs in children, although this fact might be underrepresented and not published. In our experience, ligating the remaining fixed fragment at the time of removal seems to be a sensible approach for these patients, because the incidence of associated complications is low. Despite the weaknesses of our study and the lack of available data, we would consider that a second attempt of retrieving fixed fragments should only be considered in cases of symptomatic patients, or in those whose retained fragments are to long and, therefore, more likely to have complications. In these situations, the sooner the second attempt is done, the more likely it could be successful. In all cases, a close follow-up should be taken in this group of patients. Milbrandt et al [7] suggested a sensible approach with yearly chest x-ray to detect line migration and Doppler ultrasound to detect any clot formation. In conclusion, retained intravascular fragments after removal of indwelling CVCs is a rare complication of this type of devices. In our series, all cases occurred in children with underlying malignancies who received chemotherapy. It is more likely to happen in patients whose line has been in place for more than 48 months and in those located in the saphenous vein. It is related with a low incidence of complications, so the decision of retrieval should be balanced according to the presence of symptoms and the length of the fragment retained.
Retained intravascular fragments after removal of CVC
References [1] Hastings C. Central venous catheters. In: Hastings C, editor. The Children's Hospital Oakland hematology/oncology handbook. St. Louis (Mo): Mosby; 2002. p. 141-4. [2] Fratino G, Molinar A, Parodi S. Central venous catheter-related complications in children with oncological/hematological diseases: an observational study of 418 devices. Ann Oncol 2005;16:648-54. [3] Fratino G, Mazzola C, Buffa P. Mechanical complications related to indwelling central venous catheter in pediatric hematology/oncology patients. J Pediatr Hematol Oncol 2001;17:317-24. [4] Perdirakis P, Petsios K, Vasilatou-Kosmidis H, et al. Complications of Hickman-Broviac catheters in children with malignancies. J Pediatr Hematol Oncol 2008;25:375-84. [5] Bessoud B, De Baere T, Kuoch V, et al. Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol 2003;180:527-32. [6] Jones S, Giacomantio M. A complication associated with central line removal in the pediatric population: retained fixed catheter fragments. J Pediatr Surg 2003;38:594-6.
1495 [7] Milbrandt K, Beaudry P, Anderson R, et al. A multiinstitutional review of central venous line complications: retained intravascular fragments. J Pediatr Surg 2009;44:972-6. [8] Henrikson KJ, Axtell RA, Hoover SM, et al. Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: a randomized, multicenter, double-blind trial. J Clin Oncol 2000;18:1269-78. [9] Forauer A, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol 2003;14:1163-8. [10] Suojanen J, Brophy D, Nasser I. Thrombus on indwelling central venous catheters: the histopathology of “fibrin sheaths”. Cardiovasc Interv Radiol 2000;23:194-7. [11] Kutter D. Thrombotic complications of central venous catheters in cancer patients. Oncologist 2004;9:207-16. [12] Athale U, Chan A. Thrombosis in children with acute lymphoblastic leukemia. Part II. Pathogenesis of thrombosis in children with acute lymphoblastic leukemia: effects of the disease and therapy. Thromb Res 2009;111:199-212. [13] Andrews R, Tulloh R, Rigby M. Percutaneous retrieval of central venous catheter fragments. Arch Dis Child 2002;87:149-50.
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Retained intravascular fragments after removal of indwelling central venous catheters: a single institution experience Francisco Bautista a,⁎, Javier Gómez-Chacón b , Elisa Costa b , Lucas Moreno a , Adela Cañete a , Maria Dolores Muro c , Juan Velazquez b , Victoria Castel a a
Paediatric Oncology Unit, Hospital Infantil Universitario La Fe, Avenida de Campanar 21, 46009 Valencia, Spain Paediatric Surgery Unit, Hospital Infantil Universitario La Fe, Avenida de Campanar 21, 46009 Valencia, Spain c Paediatric Radiology Unit, Hospital Infantil Universitario La Fe, Avenida de Campanar 21, 46009 Valencia, Spain b
Received 20 August 2009; revised 23 December 2009; accepted 1 February 2010
Key words: Indwelling catheters; Device removal; Complications; Pediatrics
Abstract There are few reports regarding the presence of retained fixed fragments after removal of indwelling central venous catheters in children. We conducted a retrospective study of 355 patients who underwent removal of central venous catheter from 1996 to 2008. Six patients (1.6%) had a failed attempt of removal, resulting in a remnant of catheter left in the central venous system. All of them had underlying malignant disorders and received chemotherapy for a prolonged period of time. In 2 patients, a second attempt of retrieval was performed that was partially successful. After an average follow-up of 3.5 ± 1.8 years, 1 patient has developed mild symptoms that could be related to the remaining fragment within the vascular system. Therefore, the incidence of complications caused by retained fixed fragments is low. Patients whose line has been in place for more than 48 months (P = 0.009) and those located in the saphenous vein (P = 0.01) are more prone to experience fragment retention. The decision of retrieval should be balanced according to the presence of symptoms and the length of the fragment retained. © 2010 Elsevier Inc. All rights reserved.
1. Background Indwelling central venous catheters (CVCs) have been in use for the last 3 decades and have revolutionized the care of children with cancer and those requiring long-term access for medications and blood products [1]. ⁎ Corresponding author. E-mail addresses: [email protected], [email protected] (F. Bautista). 0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.02.001
Central venous device–related complications have been extensively described in the literature [2-4]. They can be approximately divided by thirds among infectious events, venous thrombosis, and mechanical events [5]. Up to 40% of children with CVC experience 1 of these complications [2]. Nevertheless, there are few reports regarding the presence of retained fixed fragments after removal of indwelling CVCs in children [6,7], and there is still a lack of consensus regarding the optimal management of this complication.
1492 The aim of this study is to present our series of patients with retained fixed fragments after removal of indwelling CVCs and their management and follow-up.
2. Material and methods Patients undergoing removal of CVCs by the pediatric oncology surgical team in Hospital La Fe from January 1996 to December 2008 were retrospectively reviewed. Central lines placed within the neonatal intensive care unit and peripherally inserted central catheters were excluded. The surgical team that places the CVCs, and therefore, the ones that audited the lines, do not place central lines in neonates (done by neonatologists) or peripherally inserted central catheter lines (done by anesthetists or pediatric intensivists). For every patient, informed consent had been obtained previously for surgical procedure. The types of devices used were single-lumen silicone rubber Port-A-Cath (PC) (Bard Access Systems, Inc, Salt Lake City, UT) and single- or double-lumen silicone rubber Hickman Line (HC) (Bard Access System, Inc). A heparin solution containing 2.5 μg/mL of vancomycine and 2 μg/mL of ciprofloxacin was used to flush HC and PC every time after use, and HC twice weekly and PC once monthly when they were not in use [8]. Central venous catheter insertion was performed surgically under general anesthesia via external or internal jugular vein, saphenous vein at the groin, or femoral vein cut down, according to patient clinical status and surgeon decision. The position of the distal tip of the catheter was checked during the operation using fluoroscopy, and a standard chest radiograph was obtained immediately afterward with the patient in an upright position. Port-A-Caths were electively removed when children were 5 years off treatment and relapse-free. Hickman Lines were electively removed after children were 6 months off treatment. Urgent removals were performed in case of persistent infection, thrombus, or malfunction, after a consensus between medical and surgical teams. The PCs were removed through a single incision in the skin over the port, dissection of the fibrous sheath around the port, and then removal of the catheter itself through the same incision. Similarly, the HC were removed by a small incision in the skin as the catheter was tunneled, followed by blunt dissection to release the fibrous cuff associated with the catheter. The diagnosis of retained fragment was made after the surgeon realized during the removal procedure that a fragment of the CVC could not be completely removed. To identify location of the retained fragment, x-ray and Doppler ultrasound were performed after surgery. All patients were regularly followed up in pediatric oncology clinics until CVCs were removed and then until aged 18 or 10 years of follow-up, according to the pediatric oncology unit long-term follow-up guidelines.
F. Bautista et al. Statistical analysis was performed using SPSS 13.0 (SPSS Inc, Chicago Inc, IL). The variables included in the statistical analysis were as follows: age, sex, location of the CVC, time remaining within the vein, type of CVC, diagnosis (nonmalignant, solid tumors, and hematologic malignancies) and type of removal (elective/urgent). Differences in clinical variables were studied by χ2 test or Fisher exact test for categorical data and by the Student t parametric test for continuous data. Multivariate analysis was not performed because of the low number of events. A probability value (P) below 0.05 was considered statistically significant. Literature review was performed using “indwelling catheters,” “device removal,” and “complications” as search terms in PubMed and EMBASE. No restrictions to search were used. References from articles and reference pediatric oncology, medical oncology, and pediatric surgery textbooks were searched.
3. Results During the study period, 355 CVCs were removed in 317 consecutive patients, 270 of them were elective procedures (76.1%) and the rest were performed on an urgent basis for reasons described in Table 1. Baseline characteristics of our study population are outlined in Table 2. Patients were diagnosed of a malignant condition in 298 cases (94%). Eighteen patients (5.7%) had a nonmalignant hematologic disease including medullar aplasia, Fanconi anemia, hemophilia, and immunodeficiency. One patient (0.3%) with a respiratory disease had the diagnosis of cystic fibrosis. Two hundred eighty-nine CVCs (81.4%) were inserted at the time of diagnosis and 66 (18.6%) were second, third, or fourth central accesses. The lines electively removed remained in place for an average of 26.9 ± 26.6 months, whereas lines urgently removed stayed for an average of 9.9 ± 12.2 months.
Table 1
Indications for each type of CVC removal
Indication
No. of lines removed
PC
SL-HC
DL-HC
End of treatment Infection Thrombosis Malfunction Self-removal Skin necrosis Migration Total
270 (76.1%) 51 (14.4%) 12 (3.4%) 9 (2.5%) 9 (2.5%) 3 (0.8%) 1 (0.3%) 355
164 44 7 7 – 3 1 226 (63.7%)
10 – 2 – 1 – – 13 (3.7%)
96 7 3 2 8 – – 116 (32.6%)
SL-HC indicates single-lumen Hickman line; DL-HC, double-lumen Hickman line; PC, Port-A-Cath.
Retained intravascular fragments after removal of CVC Table 2
Baseline characteristics of the study population
Median age at CVC insertion (y) Sex (male/female) Diagnosis
CVC location
Average time of line remaining in site (mo)
5.2 (0.2-19.3) 1.3:1 - Malignancies: 298 (94%) Malignant hematologic diseases: 161 Solid tumors: 137 - Nonmalignant hematologic diseases: 18 (5.7%) - Respiratory diseases: 1 (0.3%) - Saphenous vein: 228 (64.2%) - Jugular vein: 126 (35.5%) - Femoral vein: 1 (0.3%) - Lines electively removed: 26.9 ± 26.6 - Lines urgently removed: 9.9 ± 12.2
At the time of removal, 349 CVCs (98.4%) were removed without complication. Six patients (1.6%) had a failed attempt at removal, resulting in a remnant of catheter left in the central venous system. Characteristics of these patients are depicted in Table 3. All of them had underlying malignant disorders (2 solid tumors and 4 hematologic malignancies). Male to female ratio was 4:2. Median age at the time of diagnosis and CVC insertion was 4.3 years (range, 2.9-13.5 years). One of them had experienced relapse at the time of removal. Treatment lasted 4 months for the patient diagnosed of Hodgkin disease, 9 months for 2 patients with Ewing sarcoma, and 2.5 years for patients diagnosed of Acute lymphoblastic leukemia (ALL) and non–Hodgkin lymphoma. None of the patients received radiotherapy on a field that involved the CVC. All of them had elective removals. Average time of line remaining in place was 61.4 ± 24.7 months; the difference was statistically significant compared with the patients in which the line was electively removed and did not experience this complication (61.4 ± 24.7 versus 26.9 ± 26.6 months, P = 0.02). Average follow-up for these 6 patients was 3.5 ± 1.8 years. None of these patients had infection, thrombosis, malfunction, or other CVC-related complications. After removal, fragments remained in external jugular vein (1 patient), femorocaval junction (1), and saphenous vein (4). In all cases, the remaining fragment of the catheter
Table 3
1493 was ligated at the entrance point into the vein at the time of removal to prevent migration of the fixed fragment, but the jugular vein was not ligated in itself in any case. Patients 2 and 3 underwent attempts to remove the remnants. In the first case, 12 cm was removed via percutaneous catheterization 3 days after the first attempt, but a 1.5-cm fragment remained into right external iliac vein. The latter underwent a cardiac catheterism to close an interauricular communication 23 months later. In the same surgical procedure, an attempt was done to remove the remaining fragment, but only a partial reposition of the fragment was achieved. Only patient 4 with a remnant on saphenous vein has complained about local swelling, edema, and discomfort when walking. The rest of the patients remained asymptomatic during follow-up. On the univariate analysis, the unique statistically significant variables associated with retained fixed fragments after removal of CVC were location of the CVC in the saphenous vein (P = 0.01) and permanence of the line more than 48 months within the vein (P = 0.009).
4. Discussion Retained intravascular fragments after removal of indwelling CVCs are a scarcely described complication for this group of devices. Our review provides a wide retrospective series and the first including statistical analysis to identify risk factors related to this complication. It is highly representative of a tertiary care pediatric centre in Spain, including all the pediatric specialities with a dedicated surgical team to pediatric oncology, and extends for a long period of time in which the surgical and medical team, the procedures, and long-term follow-up guidelines have remained stable. Virtually all patients from our series had different forms of cancer and most had received chemotherapy as well as all children described by Milbrandt et al [7]. However, the number of patients experiencing nonmalignant conditions in our series is low and thus hampers drawing valid conclusions for all kind of patients carrying CVC. The nature of the relationship between the CVC and the “cancer patient” might add some special features not present in nonmalignant
Baseline characteristics of the patients with intravascular retained fixed fragments
Patient
Sex
Age (y)
Diagnosis
Type CVC
Location
CVC-RT (mo)
Symptoms
Follow-up (mo)
Status
1 2 3 4 5 6
Female Female Male Male Male Male
7.2 2.9 4.7 13.5 2.5 3.8
Ewing ALL Ewing HL ALL NHL
DL-HC PC PC PC PC PC
right external jugular Right femoral Right saphenous Left saphenous Right saphenous Right saphenous
19.9 73.3 55.9 74.9 90.8 53.9
No No No Yes No No
15.2 64.5 25.9 60.2 27.2 59.4
Dead Alive Alive Alive Alive Alive
HL indicates Hodgkin lymphoma; NHL, non–Hodgkin lymphoma; DL-HC, double-lumen Hickman line; CVC-RT, CVC-remaining time within the vein; Age, at insertion of CVC (years); Follow-up, after CVC removal (months).
1494 disorders. In the other hand, the long-term follow-up in our series gives a special strength to our observations. The global incidence of this complication in our series is 1.6% for all patients and 2.2% for children undergoing elective removals. Milbrandt et al [7] reported an incidence of this complication of 2% in 299 patients who underwent removal of their CVC, in the largest series of patients reported before ours. Little is known about the underlying cause of this complication. It seems to be related to the formation of a scar, often with calcification, of the “fibrin sheath” around the catheter. It seems to be precipitated by an initial injury with occasional thrombus with subsequent overlapping of tissue around the length of the CVC [9-11]. Athale and Chan [12] have described how ALL and its therapy (including CVCs) provided an ideal environment for the development of thrombotic complications in patients who also inherit 1 or more genetic prothrombotic defects. Therefore, thrombotic and retained fixed fragments complications could share some similarities in its etiopathogenic, related with the underlying malignancies and its treatment. In our series, a permanence of the CVC within the vein more than 48 months was significantly associated with the possibility of retained fixed fragments after removal of the CVC (P = 0.009). The longer the CVC remains within the vein, the higher is the possibility of presenting this complication, probably related with the underlying process of scar formation and calcification of the “fibrin sheath” around the CVC described above. Other authors have not found the same correlation [6,7]. In our study, macroscopic calcification was not observed at any time. Unfortunately, histologic review was not performed. In our study, location of the CVC seems to play a role in the etiopathogenic of retained fixed fragments because 4 of our patients had the CVC located in the saphenous vein, and it was significantly associated with this complication (P = 0.01). Nevertheless, other authors have suggested that placement of the catheter tip high in the superior vena cava results in a higher incidence of thrombosis [11,12]. According to our results, we would recommend inserting the CVC in the superior vena cava rather than in the inferior vena cava and to remove the CVC not later than 48 months after its insertion once treatment is finished to prevent this complication. In cases when the child is still having treatment (ie, relapse), electively replacing the catheter would add further risks, and therefore, we would suggest to maintain the CVC. With such a rare complication, which has possibly been underreported, it is therefore extremely difficult to draw management recommendations when a catheter fragment is retained intravascular. If the catheter seems fixed at the time of removal, the options are to either leave the catheter fragment in situ or to attempt its removal (intravascular or open surgery). In the situations in which the CVCs lack a free end and are probably completely endothelialized, CVCs should be left in
F. Bautista et al. place because the risk of complication from leaving the catheter in place is probably lower than that from retrieving it [5]. Nevertheless, Bessoud et al [5] suggested that, because determination of endothelialized catheter cannot be done until a retrieving device is placed close to the catheter, retrieval should be attempted in all cases. This conclusion was done based on a population of 156 patients who developed mechanical complications of the CVCs including fracture and embolized CVCs fragments; probably, this represents a population at a higher risk because CVCs fragments were located within the vascular system close to vital organs, and therefore more likely to produce lifethreatening complications. In these cases, percutaneous line retrieval avoids the need for surgery and has demonstrated its utility in high-risk populations, even in children [5,13]. In our series, 2 patients underwent a second attempt of percutaneous line retrieval of the retained fragment. In patient 2, a long fragment remained within the vascular system and 12 cm of the line were successfully removed by lassoing, but a 1.5-cm fragment remained into the right external iliac vein. In patient 3, only a partial reposition of the fragment was achieved. Likely complications of retained catheter fragments within the central venous system would be thrombosis, catheter migration, or infection. None of our patients developed 1 of these complications, neither any child in the series published by Milbrandt et al [7], after an average of 5.4 ± 3.9 years of follow-up. To the best of our knowledge, there are no published cases of life-threatening complications related to retained fragments of CVCs in children, although this fact might be underrepresented and not published. In our experience, ligating the remaining fixed fragment at the time of removal seems to be a sensible approach for these patients, because the incidence of associated complications is low. Despite the weaknesses of our study and the lack of available data, we would consider that a second attempt of retrieving fixed fragments should only be considered in cases of symptomatic patients, or in those whose retained fragments are to long and, therefore, more likely to have complications. In these situations, the sooner the second attempt is done, the more likely it could be successful. In all cases, a close follow-up should be taken in this group of patients. Milbrandt et al [7] suggested a sensible approach with yearly chest x-ray to detect line migration and Doppler ultrasound to detect any clot formation. In conclusion, retained intravascular fragments after removal of indwelling CVCs is a rare complication of this type of devices. In our series, all cases occurred in children with underlying malignancies who received chemotherapy. It is more likely to happen in patients whose line has been in place for more than 48 months and in those located in the saphenous vein. It is related with a low incidence of complications, so the decision of retrieval should be balanced according to the presence of symptoms and the length of the fragment retained.
Retained intravascular fragments after removal of CVC
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