- Email: [email protected]
Technique in Port Catheter Repositioning
1828
’
Letters to the Editor
tomography imaging, which showed ethiodized oil and glue extending to the level of the previous endoleak. The ethiodized oil and glue was adjacent to and within both psoas muscles. Some embolic material surrounded the right-sided neural exit foramina at L4-5. At this level, it was identified extending along the segmental spinal artery adjacent to the right L4 nerve root (Fig b). A persistent but less marked cephalad endoleak was also demonstrated. The patient’s symptoms were managed as localized thermal irritation of the nerve root by adjacent embolic material with oral codeine and paracetamol as required. She was pain-free the next day and discharged home. Computed tomography imaging performed 3 months after the embolization procedure showed no change in the sac size, cephalad endoleak, or embolic material in the lumbar arteries. The patient presented in the clinic 5 months after the procedure complaining of extensive numbness and weakness in her right leg requiring the use of an aid to assist in mobility. A more extensive injury to the lower limb neural supply in the form of lumbosacral plexopathy secondary to occlusion of the adjacent small vessels was suspected. Repeat diagnostic angiographic examination of the endoleak was proposed, but the patient refused any further invasive investigation; a further clinical follow-up is awaited. The blood supply of the spinal cord, nerve roots, and lumbosacral plexus has a rich collateral network, and ischemic changes are rare. However, lumbosacral plexopathy and paraplegia are recognized complications of primary open and endovascular aortic surgery (2), and numerous etiologies have been proposed, including pelvic embolization and intraoperative hypotension leading to hypoperfusion (3). This complication has also been reported in a patient after undergoing embolization of a traumatic lumbar artery injury (4). Ioannou et al (5) reported a single patient who developed unilateral lumbosacral plexopathy after undergoing embolization of a type II endoleak. In their case, the complication developed after the use of superselective coil embolization of an iliolumbar artery. Similar to our case, the patient developed severe unilateral pain and unilateral paraparesis acutely after embolization that had not resolved 1 year after the procedure. The use of ethiodized oil and glue as an embolic agent allows for intentional embolization of the inflow vessel and the surrounding collaterals to prevent a persistent endoleak. In our patient, this process led to the inadvertent embolization of the rich network of vessels supplying the lumbosacral plexus.
REFERENCES 1. Hongo N, Kiyosue H, Shuto R, et al. Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair. J Vasc Interv Radiol 2014; 25: 709–716.
Shah et al
’
JVIR
2. Berg P, Kaufmann D, van Marrewijk CJ, et al. Spinal cord ischemia after stent-graft treatment for infra-renal abdominal aortic aneurysms. Analysis of the EUROSTAR database. Eur J Vasc Endovasc Surg 2001; 22:342–347. 3. Picone AL, Green RM, Ricotta JR, May AG, DeWeese JA. Spinal cord ischemia following operations on the abdominal aorta. J Vasc Surg 1986; 3:94–103. 4. Hung SC, Chen HW, Wong YC, et al. Transcatheter arterial embolization of traumatic lumbar artery injury: experience in one institution. J Radiol Sci 2011; 36:31–36. 5. Ioannou CV, Tsetis DK, Kardoulas DG, Katonis PG, Katsamouris AN. Spinal cord ischemia after endovascular embolization of a type II endoleak following endovascular repair. Ann Vasc Surg 2012; 26:860.e1–860.e7.
Technique in Port Catheter Repositioning From: Rohan Shah, MD Monish Merchant, MD Naveen Prabhakar, MD Radiology Department Advocate Illinois Masonic Medical Center 836 West Wellington Avenue Chicago, IL 60657
Editor: Central venous catheter migration is a common complication occurring in up to 6% of patients (1). It is thought to be secondary to high intrathoracic pressure, arm movements, high positioning of the catheter tip, venous anatomy, or dilated veins (1). Endovascular repositioning of migrated port catheters using angiographic catheters, gooseneck snares, or a combination thereof is a widely recognized and accepted alternative to port extraction and reimplantation. Gebaur et al (2) demonstrated a 93% success rate for interventional port catheter correction. We report a case in which the use of angiographic catheters and gooseneck snares was unsuccessful in repositioning a migrated port catheter tip. Instead, a small angioplasty balloon was placed into the leading tip of the malpositioned port to facilitate its repositioning. Institutional review board waiver was granted for preparation of this report. In a 66-year-old man with lung cancer, a left-sided implanted port looped in the left internal jugular vein was incidentally discovered approximately 3 months after initial placement on follow-up staging positron emission tomography/computed tomography (Fig 1). The port was placed in the left internal jugular vein instead of the right side because of right-sided architectural distortion including small size of the right internal jugular vein, likely secondary to prior radiation changes. It was decided to attempt repositioning of the catheter tip through an endovascular approach. Access was obtained from the right femoral vein, and a 7-F 70-cm sheath (Terumo, Tokyo, Japan) was placed with the tip in the left brachiocephalic vein. With the use of a 5-F angled glide catheter (Terumo), left internal jugular and brachiocephalic venograms were obtained. A low-grade stenosis None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.08.003
Volume 25
’
Number 11
’
November
’
2014
1829
advanced into the lumen and gently inflated until a seal with the inner wall was created (Fig 3). The entire system was slowly retracted under live fluoroscopy until the tip of the port catheter was appropriately positioned (Fig 4). On follow-up examination 8 months after repositioning, the catheter remained in the correct position. We suspect the reason for unsuccessful correction attempts using snare devices was related to fibrin sheath formation around the catheter. The low-grade stenosis at
Figure 1. Scout radiograph demonstrates a left-sided port catheter looped in the left internal jugular vein (arrow).
was identified at the confluence of the left internal jugular and left brachiocephalic veins. Otherwise, the left internal jugular and brachiocephalic veins were widely patent. Determining patency of the vein bearing the port catheter tip was important because if the vein were thrombosed, port removal and reimplantation would have been recommended. Subsequently, a 0.35-inch Glidewire (Terumo) was advanced into the left internal jugular vein. Over the Glidewire, use of multiple snares, including a 7-F 120-cm Amplatz Super Stiff Guidewire (Boston Scientific, Natick, Massachusetts) and a 7-F 120-cm EN SNARE (Merit Medical Systems, South Jordan, Utah), was unsuccessful at repositioning the tip. It was thought that the inability to catch either the tip or the catheter in its course by the snares was related to fibrin sheath formation with attachment of the catheter to the vessel wall. A 7-mm angioplasty balloon was placed in the lower third of the left internal jugular vein in an attempt to disrupt the fibrin sheath and change the position of the catheter tip. Multiple attempts with snares and an SOS 2 0.038-inch 80-cm catheter (AngioDynamics, Latham, New York) were again unsuccessful. As a final attempt, a 5-F angled glide catheter (Terumo) was placed adjacent to the port catheter tip, and a 0.014-inch Hi-Torque guide wire (Abbott Laboratories, Green Oaks, IL) was advanced into the port catheter lumen (Fig 2). Over the 0.014-inch guide wire, a 2-mm low-profile balloon (FOX SV; Abbott Laboratories) was
Figure 2. A 5-F angled glide catheter was placed adjacent to the port catheter tip, and a 0.014-inch Hi-torque guide wire was advanced into the port catheter lumen (arrow).
Figure 3. Over the 0.014-inch guide wire (upper arrow), a 2-mm low-profile balloon FOX SV was advanced into the lumen and gently inflated until a seal with the inner wall was created (lower arrow).
1830
’
Letters to the Editor
Maleux et al
’
JVIR
Katholieke Universiteit Leuven; and Departments of Radiology (G.M., M.L., R.O.) and Pathology (G.D.H.) University Hospitals Leuven Herestraat 49 B-3000 Leuven Belgium
Figure 4. The entire system was slowly retracted under live fluoroscopy until the tip of the port catheter was appropriately positioned (arrows).
the confluence of the left internal jugular vein and left brachiocephalic vein supports this theory. The presence of a fibrin sheath may also have aided in guiding the 0.014-inch wire into the catheter lumen. A port injection was not performed before the procedure for definitive identification of the fibrin sheath.
REFERENCES 1. Hartnell GG, Gates J, Suojanen JN, Clouse ME. Transfermoral repositioning of malpositioned central venous catheters. Cardiovasc Intervent Radiol 1996; 19:329–331. 2. Gebauer B, Teichgräber UK, Podrabsky P, Werk M, Hänninen EL, Felix R. Radiological interventions for correction of central venous port catheter migrations. Cardiovasc Intervent Radiol 2007; 30:216–221.
Transvenous Biopsy of Retroperitoneal Tumoral Masses: Value of Cone-Beam CT Guidance From: Geert Maleux, MD, PhD Gert De Hertogh, MD, PhD Matthias Lavens, MD Raymond Oyen, MD, PhD Department of Imaging and Pathology None of the authors have identified a conflict of interest http://dx.doi.org/10.1016/j.jvir.2014.07.006
Editor: Solid retroperitoneal masses with indeterminate tissue characteristics are usually investigated by biopsy percutaneously under ultrasound (US) or computed tomography (CT) guidance. However, in cases of infrarenal, pericaval masses, safe access avoiding intervening structures such as colon, kidney, or major vessels may be difficult or even impossible. In these cases, a transvenous approach might be a reasonable alternative. To improve control of the transvenous approach and to avoid inadvertent passage of intervening organs, cone-beam CT guidance can be used. Here we describe the image-guidance technique for transvenous biopsy in three patients presenting with infrarenal, pericaval indeterminate tumoral mass lesions that were judged difficult to assess by percutaneous techniques. The first case was in a 64-year-old woman who presented with pain in the right iliac fossa. Contrastenhanced CT scan revealed a mass lesion with a maximum diameter of 47 mm located in the retroperitoneum in close proximity to the aorta and invading the inferior vena cava (IVC). The nature of the lesion could not be clearly determined based on CT; subsequently, it was decided to perform a core biopsy. A percutaneous approach was considered difficult and potentially not representative, so a transvenous approach was chosen. Under local anesthesia, a 30-cm-long, 8-F introducer sheath (Flexor sheath; Cook, Bloomington, Indiana) was introduced into the right common femoral vein. Cavography showed an almost complete occlusion of the infrarenal IVC and numerous paralumbar venous collateral vessels. The tip of the 8-F sheath was positioned in front of the mass lesion invading the IVC. An endomyocardial biopsy forceps (Novatome; Scholtes, Lodi, California) was introduced through the sheath and positioned in close contact to the mass. A conebeam CT scan (Allura FD 20; Philips, Eindhoven, The Netherlands) was performed to assess the correct position of the forceps (Fig 1a), and, finally, four biopsy specimens were taken (Fig 1b). No complications were noted during or after the procedure. Histologic examination demonstrated a leiomyosarcoma with intermediate grading. The patient was treated surgically, and high-grade leiomyosarcoma was confirmed. The second case was in a 74-year-old asymptomatic woman with a medical history of breast carcinoma who presented with several small mediastinal lesions and a retroperitoneal mass lesion on positron-emission tomography CT. The retroperitoneal mass lesion had a diameter of 54 mm and was located between the aorta and the IVC with external compression of the IVC.
’
Letters to the Editor
tomography imaging, which showed ethiodized oil and glue extending to the level of the previous endoleak. The ethiodized oil and glue was adjacent to and within both psoas muscles. Some embolic material surrounded the right-sided neural exit foramina at L4-5. At this level, it was identified extending along the segmental spinal artery adjacent to the right L4 nerve root (Fig b). A persistent but less marked cephalad endoleak was also demonstrated. The patient’s symptoms were managed as localized thermal irritation of the nerve root by adjacent embolic material with oral codeine and paracetamol as required. She was pain-free the next day and discharged home. Computed tomography imaging performed 3 months after the embolization procedure showed no change in the sac size, cephalad endoleak, or embolic material in the lumbar arteries. The patient presented in the clinic 5 months after the procedure complaining of extensive numbness and weakness in her right leg requiring the use of an aid to assist in mobility. A more extensive injury to the lower limb neural supply in the form of lumbosacral plexopathy secondary to occlusion of the adjacent small vessels was suspected. Repeat diagnostic angiographic examination of the endoleak was proposed, but the patient refused any further invasive investigation; a further clinical follow-up is awaited. The blood supply of the spinal cord, nerve roots, and lumbosacral plexus has a rich collateral network, and ischemic changes are rare. However, lumbosacral plexopathy and paraplegia are recognized complications of primary open and endovascular aortic surgery (2), and numerous etiologies have been proposed, including pelvic embolization and intraoperative hypotension leading to hypoperfusion (3). This complication has also been reported in a patient after undergoing embolization of a traumatic lumbar artery injury (4). Ioannou et al (5) reported a single patient who developed unilateral lumbosacral plexopathy after undergoing embolization of a type II endoleak. In their case, the complication developed after the use of superselective coil embolization of an iliolumbar artery. Similar to our case, the patient developed severe unilateral pain and unilateral paraparesis acutely after embolization that had not resolved 1 year after the procedure. The use of ethiodized oil and glue as an embolic agent allows for intentional embolization of the inflow vessel and the surrounding collaterals to prevent a persistent endoleak. In our patient, this process led to the inadvertent embolization of the rich network of vessels supplying the lumbosacral plexus.
REFERENCES 1. Hongo N, Kiyosue H, Shuto R, et al. Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair. J Vasc Interv Radiol 2014; 25: 709–716.
Shah et al
’
JVIR
2. Berg P, Kaufmann D, van Marrewijk CJ, et al. Spinal cord ischemia after stent-graft treatment for infra-renal abdominal aortic aneurysms. Analysis of the EUROSTAR database. Eur J Vasc Endovasc Surg 2001; 22:342–347. 3. Picone AL, Green RM, Ricotta JR, May AG, DeWeese JA. Spinal cord ischemia following operations on the abdominal aorta. J Vasc Surg 1986; 3:94–103. 4. Hung SC, Chen HW, Wong YC, et al. Transcatheter arterial embolization of traumatic lumbar artery injury: experience in one institution. J Radiol Sci 2011; 36:31–36. 5. Ioannou CV, Tsetis DK, Kardoulas DG, Katonis PG, Katsamouris AN. Spinal cord ischemia after endovascular embolization of a type II endoleak following endovascular repair. Ann Vasc Surg 2012; 26:860.e1–860.e7.
Technique in Port Catheter Repositioning From: Rohan Shah, MD Monish Merchant, MD Naveen Prabhakar, MD Radiology Department Advocate Illinois Masonic Medical Center 836 West Wellington Avenue Chicago, IL 60657
Editor: Central venous catheter migration is a common complication occurring in up to 6% of patients (1). It is thought to be secondary to high intrathoracic pressure, arm movements, high positioning of the catheter tip, venous anatomy, or dilated veins (1). Endovascular repositioning of migrated port catheters using angiographic catheters, gooseneck snares, or a combination thereof is a widely recognized and accepted alternative to port extraction and reimplantation. Gebaur et al (2) demonstrated a 93% success rate for interventional port catheter correction. We report a case in which the use of angiographic catheters and gooseneck snares was unsuccessful in repositioning a migrated port catheter tip. Instead, a small angioplasty balloon was placed into the leading tip of the malpositioned port to facilitate its repositioning. Institutional review board waiver was granted for preparation of this report. In a 66-year-old man with lung cancer, a left-sided implanted port looped in the left internal jugular vein was incidentally discovered approximately 3 months after initial placement on follow-up staging positron emission tomography/computed tomography (Fig 1). The port was placed in the left internal jugular vein instead of the right side because of right-sided architectural distortion including small size of the right internal jugular vein, likely secondary to prior radiation changes. It was decided to attempt repositioning of the catheter tip through an endovascular approach. Access was obtained from the right femoral vein, and a 7-F 70-cm sheath (Terumo, Tokyo, Japan) was placed with the tip in the left brachiocephalic vein. With the use of a 5-F angled glide catheter (Terumo), left internal jugular and brachiocephalic venograms were obtained. A low-grade stenosis None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.08.003
Volume 25
’
Number 11
’
November
’
2014
1829
advanced into the lumen and gently inflated until a seal with the inner wall was created (Fig 3). The entire system was slowly retracted under live fluoroscopy until the tip of the port catheter was appropriately positioned (Fig 4). On follow-up examination 8 months after repositioning, the catheter remained in the correct position. We suspect the reason for unsuccessful correction attempts using snare devices was related to fibrin sheath formation around the catheter. The low-grade stenosis at
Figure 1. Scout radiograph demonstrates a left-sided port catheter looped in the left internal jugular vein (arrow).
was identified at the confluence of the left internal jugular and left brachiocephalic veins. Otherwise, the left internal jugular and brachiocephalic veins were widely patent. Determining patency of the vein bearing the port catheter tip was important because if the vein were thrombosed, port removal and reimplantation would have been recommended. Subsequently, a 0.35-inch Glidewire (Terumo) was advanced into the left internal jugular vein. Over the Glidewire, use of multiple snares, including a 7-F 120-cm Amplatz Super Stiff Guidewire (Boston Scientific, Natick, Massachusetts) and a 7-F 120-cm EN SNARE (Merit Medical Systems, South Jordan, Utah), was unsuccessful at repositioning the tip. It was thought that the inability to catch either the tip or the catheter in its course by the snares was related to fibrin sheath formation with attachment of the catheter to the vessel wall. A 7-mm angioplasty balloon was placed in the lower third of the left internal jugular vein in an attempt to disrupt the fibrin sheath and change the position of the catheter tip. Multiple attempts with snares and an SOS 2 0.038-inch 80-cm catheter (AngioDynamics, Latham, New York) were again unsuccessful. As a final attempt, a 5-F angled glide catheter (Terumo) was placed adjacent to the port catheter tip, and a 0.014-inch Hi-Torque guide wire (Abbott Laboratories, Green Oaks, IL) was advanced into the port catheter lumen (Fig 2). Over the 0.014-inch guide wire, a 2-mm low-profile balloon (FOX SV; Abbott Laboratories) was
Figure 2. A 5-F angled glide catheter was placed adjacent to the port catheter tip, and a 0.014-inch Hi-torque guide wire was advanced into the port catheter lumen (arrow).
Figure 3. Over the 0.014-inch guide wire (upper arrow), a 2-mm low-profile balloon FOX SV was advanced into the lumen and gently inflated until a seal with the inner wall was created (lower arrow).
1830
’
Letters to the Editor
Maleux et al
’
JVIR
Katholieke Universiteit Leuven; and Departments of Radiology (G.M., M.L., R.O.) and Pathology (G.D.H.) University Hospitals Leuven Herestraat 49 B-3000 Leuven Belgium
Figure 4. The entire system was slowly retracted under live fluoroscopy until the tip of the port catheter was appropriately positioned (arrows).
the confluence of the left internal jugular vein and left brachiocephalic vein supports this theory. The presence of a fibrin sheath may also have aided in guiding the 0.014-inch wire into the catheter lumen. A port injection was not performed before the procedure for definitive identification of the fibrin sheath.
REFERENCES 1. Hartnell GG, Gates J, Suojanen JN, Clouse ME. Transfermoral repositioning of malpositioned central venous catheters. Cardiovasc Intervent Radiol 1996; 19:329–331. 2. Gebauer B, Teichgräber UK, Podrabsky P, Werk M, Hänninen EL, Felix R. Radiological interventions for correction of central venous port catheter migrations. Cardiovasc Intervent Radiol 2007; 30:216–221.
Transvenous Biopsy of Retroperitoneal Tumoral Masses: Value of Cone-Beam CT Guidance From: Geert Maleux, MD, PhD Gert De Hertogh, MD, PhD Matthias Lavens, MD Raymond Oyen, MD, PhD Department of Imaging and Pathology None of the authors have identified a conflict of interest http://dx.doi.org/10.1016/j.jvir.2014.07.006
Editor: Solid retroperitoneal masses with indeterminate tissue characteristics are usually investigated by biopsy percutaneously under ultrasound (US) or computed tomography (CT) guidance. However, in cases of infrarenal, pericaval masses, safe access avoiding intervening structures such as colon, kidney, or major vessels may be difficult or even impossible. In these cases, a transvenous approach might be a reasonable alternative. To improve control of the transvenous approach and to avoid inadvertent passage of intervening organs, cone-beam CT guidance can be used. Here we describe the image-guidance technique for transvenous biopsy in three patients presenting with infrarenal, pericaval indeterminate tumoral mass lesions that were judged difficult to assess by percutaneous techniques. The first case was in a 64-year-old woman who presented with pain in the right iliac fossa. Contrastenhanced CT scan revealed a mass lesion with a maximum diameter of 47 mm located in the retroperitoneum in close proximity to the aorta and invading the inferior vena cava (IVC). The nature of the lesion could not be clearly determined based on CT; subsequently, it was decided to perform a core biopsy. A percutaneous approach was considered difficult and potentially not representative, so a transvenous approach was chosen. Under local anesthesia, a 30-cm-long, 8-F introducer sheath (Flexor sheath; Cook, Bloomington, Indiana) was introduced into the right common femoral vein. Cavography showed an almost complete occlusion of the infrarenal IVC and numerous paralumbar venous collateral vessels. The tip of the 8-F sheath was positioned in front of the mass lesion invading the IVC. An endomyocardial biopsy forceps (Novatome; Scholtes, Lodi, California) was introduced through the sheath and positioned in close contact to the mass. A conebeam CT scan (Allura FD 20; Philips, Eindhoven, The Netherlands) was performed to assess the correct position of the forceps (Fig 1a), and, finally, four biopsy specimens were taken (Fig 1b). No complications were noted during or after the procedure. Histologic examination demonstrated a leiomyosarcoma with intermediate grading. The patient was treated surgically, and high-grade leiomyosarcoma was confirmed. The second case was in a 74-year-old asymptomatic woman with a medical history of breast carcinoma who presented with several small mediastinal lesions and a retroperitoneal mass lesion on positron-emission tomography CT. The retroperitoneal mass lesion had a diameter of 54 mm and was located between the aorta and the IVC with external compression of the IVC.