Percutaneous transvenous retrieval of fractured catheter in cancer patients receiving chemotherapy

Abstract

OBJECTIVE:

To explore the clinical efficacy and safety of percutaneous transvenous retrieval of intravascular fractured catheter and to evaluate the possible reasons and final results in cancer patients.

METHODS:

A dataset of 19 patients was used. Percutaneous transvenous retrieval of intravascular fractured catheter was performed in each patients. Clinical data was retrospectively analyzed with respect to the efficacy, safety and outcome, and chest radiography was performed to verify that no catheter fragments were left.

RESULTS:

Two cases had peripherally inserted central catheter and 17 had subcutaneous implanted port catheter. The catheter fragments were located in the brachiocephalic vein-superior vena cava (n = 1), superior vena cava (n = 1), superior and inferior vena cava (n = 1), superior vena cava-right atrium (n = 2), brachiocephalic vein-superior vena cava-right atrium (n = 1), superior vena cava-right atrium-right ventricle (n = 6), brachiocephalic vein-superior vena cava-right atrium and right ventricle (n = 1) and pulmonary artery (n = 6), respectively. All of these catheter fragments were retrieved successfully. No complications such as bleeding and thrombosis were found.

CONCLUSION:

Percutaneous transvenous retrieval is a safe, minimally invasive and relatively simple procedure for the patients with fractured catheter and should be recommended as the first choice.

Keywords

Vascular access devices transvenous retrieval catheter fracture interventional radiology

Abbreviations

PICC

peripherally inserted central catheter

SVC

superior vena cava

IVC

inferior vena cava

right atrium

right ventricle

pulmonary artery

brachiocephalic vein

1 Introduction

Central venous catheters are favored clinically because they cause minimal vascular damage, particularly in the chemotherapy of patients with cancer. The types of venous access devices include subcutaneous implanted port catheter and peripherally inserted central catheter (PICC) [1]. The choice of venous access device used depends mainly on the indication and duration of treatment required in each patient. And to these cancer patients, as they will receive several courses of chemotherapy and total parenteral nutrition, most of them have the choice of using subcutaneous implantable venous ports in order to protect blood vessels from injury, besides, these catheters can be in place for a long time and made them to wear out more quickly and conveniently [2].

The most commonly used approach of catheters and ports implantation are subclavian vein and internal jugular vein. However, there are several complications associated with the using of them. Catheter facture may be the most serious complications which may lead to pulmonary artery embolism, arrhythmias, infection and cardiac perforation, although it occurs in around 1% of patients [3]. These complications are very dangerous to these patients. Severe complication rates of up to 71% have been reported for patients with catheter embolism [4]. Therefore, an attempt to remove the fractured catheter should be recommended whenever possible.

Interventional endovascular techniques are kinds of diagnosis and treatment method which are percutaneous puncture vascular and performed transvenous therapy [5, 6]. The objective of this study is to explore the clinical efficacy and safety of percutaneous transvenous retrieval of intravascular fractured catheter and to evaluate the possible reasons and final results in cancer patients receiving chemotherapy during a 6-year period.

2 Material and methods

2.1 Study population and protocol

We performed a retrospective analysis on the patients in whom percutaneous transvenous retrieval of intravascular fractured catheter was performed from November 2012 to April 2018. There were 4 females and 15 males and all of them underwent systemic intravenous chemotherapy. The average age was 48.7 years (from 21 to 67 years). Two cases were PICC and 17 cases were subcutaneous implanted port catheter. All of these catheters were implanted via the subclavian vein way. The study protocol was approved by the Institutional Ethics Review Board of our hospital. Written informed consent was obtained from each patient.

As summarized in the Table 1, the clinical characteristics including the primary disease, type of inserted catheters, interval between implantation and discovery of embolism, localization of embolized fragment, interval between discovery of embolism and retrieval, time of surgery interval, length of the embolized fragment and the reasons to find the embolized fragments were analyzed. In addition, clinical symptoms on admission were noted.

Table 1
Clinical characteristics of the 19 patients with fractured catheter fragments

Case No. Age (years)/gender Diagnosis Embolized fragment Interval between implantation and discovery of embolism Localization of embolized fragment Interval between discovery of embolism and retrieval Time of surgery interval (min) Length of embolized fragment (cm) Mechanism

1 60/M rectal cancer Port catheter 7 months PA <1 day 85 10 Fracture during removal

2 33/M gastric cancer Port catheter 14 months SVC-IVC <1 day 25 19 found on routine imaging

3 47/M rectal cancer Port catheter 6 months SVC-RA <1 day 35 14 Fracture during removal

4 58/F rectal cancer Port catheter 17 days BV-SVC-RA <1 day 40 9 found on routine imaging

5 60/M rectal cancer Port catheter <1days SVC-RA-RV <1 day 55 15 catheter lost during placement

6 67/M colorectal cancer PICC 1 months BV-SVC-RA-RV 2 days 30 17 found on routine imaging

7 35/M rectal cancer Port catheter 26 months SVC-RA-RV 2 days 115 9 found on routine imaging

8 43/M colorectal cancer Port catheter 3 months PA 2 days 50 7 found on routine chemotherapy

9 43/M rectal cancer PICC 13 months PA <1 day 50 38 found on routine chemotherapy

10 54/F colorectal cancer Port catheter 14 months SVC <1 day 65 9 found on routine imaging

11 45/M rectal cancer Port catheter 2 hours SVC-RA-RV <1 day 60 17 catheter lost during placement

12 21/M rectal cancer Port catheter 8 months PA 2 days 60 9 found on routine imaging

13 51/F gastric cancer Port catheter 53 months BV-SVC <1 day 20 16 found on routine imaging

14 42/M rectal cancer Port catheter 13 months PA 2 days 50 6 found on routine imaging

15 49/M rectal cancer Port catheter 37 months SVC-RA-RV 1 day 20 13 Fracture during removal

16 41/M rectal cancer Port catheter 7 months SVC-RA <1 day 55 13 found on routine chemotherapy

17 49/M gastric cancer Port catheter 13 months SVC-RA-RV 1 day 35 13 found on routine imaging

18 66/M esophageal cancer Port catheter 5 months SVC-RA-RV <1 day 20 16 found on routine imaging

19 62/F gastric cancer Port catheter 2 months PA <1 day 25 6 found on routine imaging

Case No.	Age (years)/gender	Diagnosis	Embolized fragment	Interval between implantation and discovery of embolism	Localization of embolized fragment	Interval between discovery of embolism and retrieval	Time of surgery interval (min)	Length of embolized fragment (cm)	Mechanism
1	60/M	rectal cancer	Port catheter	7 months	PA	<1 day	85	10	Fracture during removal
2	33/M	gastric cancer	Port catheter	14 months	SVC-IVC	<1 day	25	19	found on routine imaging
3	47/M	rectal cancer	Port catheter	6 months	SVC-RA	<1 day	35	14	Fracture during removal
4	58/F	rectal cancer	Port catheter	17 days	BV-SVC-RA	<1 day	40	9	found on routine imaging
5	60/M	rectal cancer	Port catheter	<1days	SVC-RA-RV	<1 day	55	15	catheter lost during placement
6	67/M	colorectal cancer	PICC	1 months	BV-SVC-RA-RV	2 days	30	17	found on routine imaging
7	35/M	rectal cancer	Port catheter	26 months	SVC-RA-RV	2 days	115	9	found on routine imaging
8	43/M	colorectal cancer	Port catheter	3 months	PA	2 days	50	7	found on routine chemotherapy
9	43/M	rectal cancer	PICC	13 months	PA	<1 day	50	38	found on routine chemotherapy
10	54/F	colorectal cancer	Port catheter	14 months	SVC	<1 day	65	9	found on routine imaging
11	45/M	rectal cancer	Port catheter	2 hours	SVC-RA-RV	<1 day	60	17	catheter lost during placement
12	21/M	rectal cancer	Port catheter	8 months	PA	2 days	60	9	found on routine imaging
13	51/F	gastric cancer	Port catheter	53 months	BV-SVC	<1 day	20	16	found on routine imaging
14	42/M	rectal cancer	Port catheter	13 months	PA	2 days	50	6	found on routine imaging
15	49/M	rectal cancer	Port catheter	37 months	SVC-RA-RV	1 day	20	13	Fracture during removal
16	41/M	rectal cancer	Port catheter	7 months	SVC-RA	<1 day	55	13	found on routine chemotherapy
17	49/M	gastric cancer	Port catheter	13 months	SVC-RA-RV	1 day	35	13	found on routine imaging
18	66/M	esophageal cancer	Port catheter	5 months	SVC-RA-RV	<1 day	20	16	found on routine imaging
19	62/F	gastric cancer	Port catheter	2 months	PA	<1 day	25	6	found on routine imaging

Note: SVC, superior vena cava; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; PA, pulmonary artery; BV, brachiocephalic vein; PICC, peripherally inserted central catheter.

2.2 Procedure techniques of percutaneous transvenous retrieval

Catheter fracture or migration before percutaneous transvenous retrieval was confirmed by chest X-ray or CT scan. The embolized catheter fragments were retrieved under local anesthesia and DSA guidance via the right femoral veins with a gooseneck loop snare with a loop diameter of 25 mm in all patients.

Briefly, after the successful puncture of right femoral veins by Seldinger technique, an 8-F or 10-F sheath was inserted. Then angiography by a 5-F pigtail was performed to confirm the location of the catheter fragment and local vascular morphology. For these catheter located in the pulmonary artery, one 6-F guiding catheter (Boston Scientific) and 5-French DAV catheter (Cook) with a curved configuration were used to locate the catheter fragment, and then the loop-snare was introduced through the guiding catheter and DAV catheter until it was placed at the anterior end of the catheter. The catheter fragment was grasped by the loop-snare and taken to the 8-F sheath to be removed.

To the catheter conglutinate to the vessel wall or cardiac chamber, a pigtail catheter (Cook Medical) was used to turn them to a more suitable catching location and then the catheter fragments were caught by gooseneck loop snare. The lengths of the catheter fragment were measured after the retrieval, and fluoroscopy was performed to verify that no catheter fragments were left [7, 8].

2.3 Statistical analysis

The variables for statistical analysis included age, length of the catheter fragments, operation time, interval time between implantation and discovery of embolism, interval between the discovery of embolism and retrieval. The mean and standard deviation analysis were conducted using SPSS 13.0 (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL).

3 Results

A total of 19 patients with a catheter fragment were treated in this study, including 2 cases (10.5%) of PICC and 17 cases (89.5%) of subcutaneous implanted port catheter. All of the catheter fragments were retrieved successfully, and chest radiography was performed to verify that no catheter fragments were left. In addition, the integrity of the retrieved fragments was examined carefully in vitro and no catheter was fractured again during the process of retrieval.

As shown in Table 1, the catheter fragments were located in the brachiocephalic vein-superior vena cava (n = 1), superior vena cava (n = 1), superior and inferior vena cava (n = 1), superior vena cava-right atrium (n = 2), brachiocephalic vein-superior vena cava-right atrium (n = 1), superior vena cava-right atrium-right ventricle (n = 6), brachiocephalic vein-superior vena cava-right atrium and right ventricle (n = 1) and pulmonary artery (n = 6). The mean length of the catheter fragments was 13.5±7.1 cm (range 6 to 38 cm). The mean operation time was from 20 minutes to 115 minutes (mean 47.1±24.3 minutes). Interval time between implantation and discovery of embolism was from 2 hours to 53 months, averaging 12.7±13.4 months. The interval between the discovery of embolism and retrieval ranged from <1 day to 2 days (median, 1 day). Clinical technical success was achieved in all of the patients.

Because of the missed diagnosis in primary hospital, the retention time of 2 catheter fragment was more than 10 months in the vascular cavity (case 7 and case 14). A pigtail catheter (Cook Medical) was used first to migrate them to a more suitable catching location and then the catheter fragments were withdraw successfully by gooseneck loop snare (Fig. 1). The heart rate, blood pressure and oxygen saturation were normal during the whole process.

Fig.1

Chest radiography showed a fractured catheter that located in the heart (A, white arrow). As the retention time of the catheter fragment was 20 months, the head of the catheter had been partially adherent to the blood vessels and cardiac chamber; a 5-French DAV catheter was used to turn it into a more suitable catching location (B, C, black arrow). The catheter fragment was grasped by a gooseneck loop snare (D).

Once the catheter fragments were drifted into the pulmonary artery, the loop-snare needed to pass through the right atrium and right ventricle to the pulmonary artery during the operation (Fig. 2). Five of the 6 patients with catheter fragments in pulmonary artery suffered a transient ventricular tachycardia during the catheter crossing right atrium and right ventricle, but by adjusting the position of the devices, both of them immediately disappeared.

Fig.2

Chest radiography showed a catheter fractured (black arrow), and the catheter fragment migrated to left pulmonary artery (white arrow) (A). A gooseneck loop snare was placed at the anterior end of the catheter in the pulmonary artery through the right atrium and right ventricle (B). The fractured catheter was grasped by the gooseneck loop snare (C). The fractured catheter was taken out via the right femoral veins (D). A chest radiography was performed to confirm that there was no fragment residual (E). The catheter fragment was taken out (F).

In case 9, the PICC fragment located in the left and right pulmonary artery was confirmed on CT scans with chest discomfort and palpitations. The PICC fragment was successfully retrieved with the length of 38 cm (Fig. 3) and the symptoms disappeared gradually.

Fig.3

Coronary computed tomography (CT) scan of the chest revealed a fractured catheter (white arrow) located in the left and right pulmonary artery (A). A gooseneck loop snare combined with one 6-French guiding catheter and 5-French DAV catheter was used to grasp the fractured catheter (B). The fractured catheter was taken out and the length was as long as 38 cm (C). A chest radiography was performed to confirm there was no fragment residual (D).

In our series, fifteen patients didn’t have obvious symptoms. The other four patients complained chest tightness, chest pain and palpitations discomfort which were relieved gradually after the catheter fragment retrieved. No complications such as bleeding, thrombosis, infection and so on were found during at least 1 months of postoperative follow-up.

4 Discussion

The fractured catheter fragment has become one of the most common complications of central venous catheters. The incidence of this complication was reported to be 0.3–2.9% in adults [9 –11] and 1.4% –3.6% in children [12 –14]. The most common complications of the fractured catheter fragment are pulmonary artery embolism, arrhythmias, infection and cardiac perforation. Bernhardt et al reported that the mortality of the untreated embolism was as high as 60% to these untreated patients, and those patients whose embolized catheter was removed were all alive [4]. Once the fractured catheter was confirmed, it should be removed as soon as possible to prevent the serious complications.

The reasons for catheter fracture are various which including a poor connection between the port chamber and the port catheter, improper catheter position, distortion of the anastomosis site, fatigue of the catheter, catheter severing, chronic compression of the catheter between the clavicle and the first rib (pinch-off syndrome) [15, 16]. Besides, the drugs administered may degrade and alter the catheter material and greater pressure in flushing of the catheter by using smaller syringes may increases the risk of catheter fracture [17, 18].

In this study, one case of PICC catheter fractured in the vicinity of the elbow joint. Because the puncture site crossed the elbow, the catheter was squeezed by the surrounding tissues and fractured with the repeatedly flexion and movement of the elbow joint. Therefore, the puncture site should be avoided across the elbow joint.

There were 13 case of subcutaneous implanted port catheter fractured in the distal two thirds or the middle of the catheter. The main reason might be pinch-off syndrome [19]. Pinch-off syndrome occurs when a subclavian catheter passes through the anatomic space between the clavicle and the first rib and becomes compressed or kinked by the motion of the neck and arm, jewelry or clothing with a stiff collar, and strap of the backpack or a safety belt. It could affect the structure of the catheter wall and caused catheter fractures.

In order to prevent the occurrence of catheter fracture, the instructions of catheter implantation should be strictly abided during the operation [18]. In our experience, ultrasound-guided puncture of the internal jugular vein have a low incidence rate of catheter fracture compared with those puncture of subclavian vein. Flushing of the catheter after each use or monthly during times of port inactivity should be done gently with a 10 mL syringe which has a proper pressure to the wall of the port catheter [20].

In fact, there are more than 50% of the fractured catheters were clinically asymptomatic, and it was found accidentally during scheduled flushing of the catheter, scheduled chest radiography or port removal, so the fracture time of the catheter cannot be adequately predicted [21, 22]. Therefore, scheduled chest radiography is necessary. In our hospital, chest radiography or chest computed tomography is usually performed every 3 chemotherapy courses (about 45 days) to evaluate the chemotherapeutic efficacy. Once the catheter fracture was confirmed, the chemotherapy and other infusions should be cancelled and percutaneous transvenous retrieval should be performed in order to avoid serious complications.

5 Conclusions

The rise in the use of central venous catheters has meant that complications, including catheter fracture, have increased. Percutaneous transvenous retrieval is a safe, minimally invasive and relatively simple procedure for the patients with fractured catheter and should be recommended as the first choice.

Declaration of Conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Footnotes

Acknowledgments

The authors gratefully acknowledge the National Natural Science Foundation of China (No. 81301978).

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