Percutaneous retrieval of fractured intravascular catheters in premature infants

1 Introduction

Umbilical venous catheters (UVCs), umbilical arterial catheters (UACs), and peripherally inserted central catheters (PICCs) provide necessary intravascular access in premature infants for fluid administration, drug delivery, blood sampling, and parenteral nutrition [1, 2]. Generally, intravascular catheters are safely employed in premature infants. Nevertheless, complications can include infection in 5.3% and pericardial or pleural effusions in 1–3% [1]. A rare, but potentially fatal, complication is fracture and migration of a catheter segment into cardiovascular structures [2, 3]. The fractured fragment may cause infection, arrhythmias, mechanical obstruction to hemodynamic flow, thrombus generation, and cardiac perforation [4]. In infants with intracardiac septal defects or those with functional univentricles, a fractured catheter may be associated with stroke, central nervous system infection, and poor long-term neurological outcome. These risks require prompt retrieval of the embolized catheter fragments. The procedure can be performed surgically or by catheter-based techniques. We report percutaneous gooseneck-snare retrieval of central catheter fragments in four low birth-weight premature infants.

2 Case 1

A 3-day-old male born after a 32-week gestation with a birth weight of 840 grams was transferred to our facility with a history of a retained UVC fragment. At birth, the patient had poor respiratory effort and was limp. He was resuscitated with positive pressure ventilation and transferred to the NICU on a nasal cannula with intermittent mandatory ventilation. Attempts to place a UVC were unsuccessful. An x-ray to confirm PICC line placement incidentally showed an indwelling UVC fragment extending from the liver to the right atrium. A subsequent transthoracic echocardiogram demonstrated that the UVC fragment had moved distally, crossing through the patent foramen ovale with the distal end in the left atrium. The patient was taken to catheterization. The broken catheter was estimated to be a 3.5F. Therefore, a fresh 3.5F catheter was opened to test the minimum sheath size (5F) that it could be pulled through in a folded orientation. The proximal end of the catheter fragment was still in the liver. Under general anesthesia, a 5F sheath was initially placed in the umbilical vein to attempt to snare the proximal end of the broken catheter. However, guidewires and small catheters could only be advanced into false passages. The right leg had a PICC line so the right femoral vein was not used for access. A 5F sheath was placed in the left femoral vein. A 5F wedge catheter was advanced into the left atrium. A 4 mm Amplatzer gooseneck micro-snare was advanced through the 5F wedge catheter and was used to snare the distal end of the fractured catheter (Fig. 1A); the broken catheter was then pulled back (Fig. 1B) and exteriorized through the 5F sheath (Fig. 1C). The fluoroscopy time was 14.3 minutes.

OPEN IN VIEWER

Fig.1

Snare retrieval of a fractured catheter with the distal end in the left atrium (asterisk) and the proximal end (double asterisk) in the liver. The retrieval catheter (2 arrows) has been advanced from a femoral vein into the left atrium; a snare (advanced through the retrieval catheter) has trapped the distal end of the fractured line (black arrow) (A). The distal end has been pulled back to the sheath, which was positioned in the inferior vena cava (B). The fractured catheter has been partially pulled into the sheath (C) and was eventually fully retrieved.

A 30-day-old female born after a 26-week gestation with a birth weight of 990 gm was transferred to our facility with a history of a retained PICC fragment in the left lower extremity at the level of the knee. After birth, she was admitted with respiratory distress syndrome and was kept on mechanical ventilation. She was subsequently diagnosed with Pseudomonas pneumonia, which was treated with antibiotics through a PICC line. A cutdown attempt to remove the PICC line resulted in the removal of only a 3 cm fragment. An x-ray of her left lower extremity and abdomen showed the retained fragment of the PICC extending from the left great saphenous vein to the IVC. The patient was taken to catheterization. Under general anesthesia, a 4F sheath was placed in the right internal jugular vein. A 4F Berenstein catheter was advanced through the sheath into the IVC. A 7 mm gooseneck snare was advanced through the catheter and was used to snare and retrieve an 18 cm long PICC residual segment. A subsequent angiogram in the left iliac vein showed no evidence of additional residual PICC segments. Total fluoroscopy time was 28.5 minutes.

4 Case 3

A 5-day-old female born after a 36-week gestation with a birth weight of 1930 grams had gastroschisis repair and was found to have an embolized fractured PICC line. The proximal end was at the level of the left knee; the distal end was coiled in the right ventricle. A subsequent transthoracic echocardiogram showed that the proximal end of the fractured catheter was in the IVC at the level of the liver, the middle portion forming a loop in the right atrium, and the distal end in the main pulmonary artery. The catheter caused mild tricuspid and pulmonary valve insufficiency. The patient was taken to catheterization. Under general anesthesia, a 5F sheath was placed in the right internal jugular vein. A 5F Berenstein catheter was advanced through the sheath into the right atrium; a 7 mm Amplatzer Gooseneck micro snare was then advanced through the Berenstein catheter. The embolized catheter loop in the right atrium was snared and the fractured line was removed through the sheath. Fluoroscopy time was 3.5 minutes

5 Case 4

A 17-day-old male born after a 28-week gestation with a birth weight of 1230 grams was admitted with respiratory distress syndrome and hyperbilirubinemia. He was intubated and treated with mechanical ventilation and phototherapy. A PICC line was inserted in his right leg for medications and IV fluids. On day 16 of life, the PICC line was noted to be broken and leaking on the bed. An x-ray of the right leg and abdomen showed the proximal end of the line at mid-thigh level and the distal tip in the IVC, near the right atrium. A repeat x-ray showed that the PICC had migrated and coiled in the heart and main pulmonary artery, with the distal tip in a hepatic vein and the proximal end in the right atrium near the inferior vena cava (Fig. 2A and 2B). The patient was taken to catheterization. Under general anesthesia, a 4F sheath was placed in the left femoral vein. A 10 mm loop snare was advanced through the catheter; the proximal end of the PICC line was snared in the IVC (Fig. 2C) and pulled out through the sheath. Total fluoroscopy duration was 12.5 min.

OPEN IN VIEWER

Fig.2

Retrieval of a broken catheter that was coiled in the heart and pulmonary artery. A broken PICC line was looped in the heart with the distal end in a hepatic vein (double asterisk) and the proximal end in the right atrium (asterisk) depicted in an angiographic still frame (A) and in diagrammatic representation (B). The proximal end of the catheter was pulled back to the IVC where it was snared (C) and subsequently exteriorized through the sheath.

Percutaneous retrieval of fractured intravascular catheters and central venous lines in premature infants is a preferable and less invasive option compared to open surgical removal. The first removal of an intracardiac foreign body by a technique not requiring surgery was by Thomas et al in 1964 [5]. The earliest report of non-surgical retrieval of broken UVC lines in two premature infants was by PL Smith in 1978 [6]. Various percutaneous methods have been described to recover broken catheter fragments, including gooseneck snaring, basket retrieval, balloon retrieval and forceps-assisted removal [7–9]. Catheter retrieval, while less invasive, may be associated with complications such as injury to fragile blood vessels or cardiac structures resulting in perforation, recognized or undetected internal bleeding, thrombosis, and arrhythmias.

A limited number of case reports have described percutaneous retrieval of fractured catheters or indwelling lines in preterm and low birthweight newborns [2, 10–13]. Even fewer reports describe a successful broken line retrieval in premature infants weighing less than 1000 grams [3, 13]. Two of the infants in our series weighed less than 1000 grams. The first case described in our series illustrates that a 5F sheath could to be placed in the femoral vein in an 840-gram infant, without subsequent leg circulatory consequences. Our second case shows that access for retrieval through an internal jugular vein (with a 4 F sheath) at 990 grams was also feasible and uncomplicated. The aim is to always utilize the smallest sheath possible, and this is often a 4F sheath. But in our first case, the folded catheter could not be test passed through a 4F sheath; therefore, a 5F sheath was necessary. If a broken catheter or line is secured very close to the tip, the catheter may be pulled co-axially through the sheath and its profile will be lower. However, if a broken catheter is secured further away from the tip, the catheter will be folded when it is pulled back into the sheath and will have a larger profile. An alternative technique consists of pulling the broken catheter into a structure such as the IVC or RA, releasing the catheter and re-snaring its tip to allow for lower profile removal.

In cases where there is a patent foramen ovale, the broken catheter fragment may cross into the left atrium, which occurred in case 1. However, the snare catheter was also maneuvered into the left atrium, making it possible for the fractured catheter to be snared and pulled back. If a broken catheter embolizes to the left ventricle or systemic circulation, either a venous or an arterial approach may be necessary to perform the retrieval. In premature infants, unlike older children, the umbilical vein and artery can potentially be used to attempt broken catheter retrieval, sparing risk to important veins and arteries. It is key to remember that access from internal jugular veins may be more direct and simpler than from femoral veins [14], as illustrated by cases 2 and 3 from our series.

Among the methods for intraluminal foreign body retrieval, the gooseneck-snare technique is the most commonly employed, but others have been utilized. A myocardial biopsy forceps (available in 3F size) has “biting jaws” on the distal tip that may be used to grasp foreign objects and pulled back through sheaths [9]. Two coronary guidewires can be passed next to the foreign object and the distal ends of the wires can be looped and twisted around each other trapping the foreign body and pulling it out through a sheath. If the foreign body has a lumen (like a UVC catheter) and is appropriately oriented, a guidewire can be passed through the lumen, followed by a coronary balloon that is advanced into the lumen as well. When the balloon is inflated, it can “trap” the broken catheter and allow it to be pulled back into the sheath [2]. An adjustable snare can also be self-made by passing a wire that has been bent 180 degrees through a delivery catheter. When the bent wire exits the catheter, it forms a loop that can be used to snare a foreign object and be exteriorized through a sheath.

Despite the multiple techniques to retrieve fractured catheters, prevention of line fracture is still essential with meticulous, detailed and careful line care.

7 Conclusion

We describe successful and uncomplicated percutaneous retrieval of broken indwelling intravascular catheters in four premature infants, two with a weight under 1000 grams, using the gooseneck-snare technique via femoral and internal jugular venous routes and through a sheath as large as 5F.

Financial disclosure statement

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Human research statement

Authors affirm that research involving human subjects submitted to the journal was conducted in accordance with the ethical standards of all applicable national and institutional committees and the World Medical Association’s Helsinki Declaration.