Percutaneous Retrieval of an Embolized Mediport ...

Pediatric Hematology and Oncology

ISSN: 0888-0018 (Print) 1521-0669 (Online) Journal homepage: http://www.tandfonline.com/loi/ipho20

Percutaneous Retrieval of an Embolized Mediport Catheter in a Patient Receiving Therapy for Hodgkins Lymphoma Abraham Rothman & Faith H. Kling To cite this article: Abraham Rothman & Faith H. Kling (1993) Percutaneous Retrieval of an Embolized Mediport Catheter in a Patient Receiving Therapy for Hodgkins Lymphoma, Pediatric Hematology and Oncology, 10:2, 179-182 To link to this article: http://dx.doi.org/10.3109/08880019309016554

Published online: 09 Jul 2009.

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Date: 04 November 2015, At: 12:16

L.etter to the Editor

PERCUTANEOUS RETRIEVAL OF AN EMBOLIZED MEDIPORT CATHETER IN A PATIENT RECEIVING THERAPY FOR HODGKINS LYMPHOMA

Abraham Rothman, MD

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0 Division of Pediatric Cardiology, 8445, Department of Pediatrics, University of California San Diego Medical Center, 225 Dickinson Street, San Diego, California 92103, USA

Faith H. Kung, MD 0 Division of Hematology and Oncology, Department of Pediatrics, University of California San Diego Medical Center, 225 Dickinson Street, San Diego, California 92103, USA

The use of indwelling venous access lines in pediatric patients with malignant diseases has become widespread.”* External venous catheters have reduced the number of venipunctures for laboratory studies and intravenous catheter insertions for administration of chemotherapy. Subcutaneous ports offer the additional advantage of lower incidence of infection and mechanical complications, less restriction of physical activity, no need for parental maintenance of patency, and better body image. The potential drawbacks of indwelling catheters include infection, malfunction, thrombus formation, migration, arrhythmias, endocarditis, and perforations of veins or right atrium with resultant hemothorax, hemomediastinum, or hemopericardium.’ In this report we describe another rare complication, catheter embolization to the left pulmonary artery, and a simple percutaneous technique to manage it.

CASE REPORT An 11-year-old boy with stage I11 A Hodgkins lymphoma underwent a staging laparotomy and simultaneous surgical placement of an indwelling Mediport catheter in the right subclavian vein 7 months earlier. His most recent chemotherapy course was 1 month prior, and he was doing well clinically. On a routine visit, attempts to draw blood out of the reservoir were unsuccessful. A chest roentgenogram demonstrated that the Mediport catheter had separated from the subcutaneous disc and had migrated through the right heart into a distal left lower lobe pulmonary artery. The proximal end of Pediatric Hematoloo and Oncology, 10:179-182, 1993 Copyn’ht 0 1993 Tylor d Francis .OO 0888-0018/93 $10.00

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the catheter was in the right ventricular outflow tract. O n further questioning, the patient recalled playing basketball 1 week previously and being hit by the ball in his right chest. He did not have any symptoms. To retrieve the embolized catheter, he was taken to the cardiac catheterization laboratory after premedication with 5 mg of diazepam orally. Through a 6 French sheath in the right femoral vein, an angiogram was performed in the main pulmonary artery to rule out a thrombus around the embolized catheter or in the left pulmonary artery. At this time, it was noted that the proximal portion of the severed catheter had migrated to the proximal right pulmonary artery. The 6 French sheath was replaced with a 7 French Mullins long sheath, and through the latter a 5 French snare catheter (Meditech, Watertown, MA) was advanced to the left pulmonary artery. The hooks at the end of the snare catheter were enlarged manually to enable it to grasp the Mediport catheter. The hooks of the snare catheter were opened, the stray Mediport catheter was secured at its midportion, and the snare catheter together with the long sheath were pulled back to the right femoral vein. The trapped catheter was in a “U” configuration and could not be removed despite moderate percutaneous tension. Therefore a small cutdown incision along the snare catheter was performed, the trapped catheter was removed, and the femoral vein was repaired. After a bolus, a heparin infusion (20 U/kg/hr) was continued for 24 hours. Doppler ultrasound scan revealed free flow in the right femoral vein 24 hours later. The patient resumed normal activities the next day, and the subcutaneous reservoir was removed as an outpatient procedure 2 weeks later.

DISCUSSION Catheter embolization is a rare complication of indwelling central venous lines. Between 0% and 2.0% of long-term catheters have been documented to embolize to the right Unless there is a complication, intravascular or intracardiac migration of soft foreign bodies usually does not produce symptoms, as was the case in our patient, because the vascular endothelium and endocardium are generally devoid of sensory nerve endings. However, if there is associated thrombosis, perforation, or hemorrhage , patients may present with chest pain or discomfort, respiratory distress, cough, hemoptysis, nausea, or abdominal Venous catheters tend to migrate most frequently to the pulmonary arteries, followed by the great veins, right ventricle and right atrium.’ Foreign bodies should be removed from the cardiovascular system because, if left untreated, they have an associated mortality rate of 27% to 61 % and a complication rate ranging from 21 % to 71 % .4**

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RETRIEVAL OF EMBOLIZED MEDIPORT CATHETER

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The therapeutic alternatives to remove foreign bodies from the heart and great vessels include surgery or percutaneous retrieval. The disadvantages of surgery are the thoracotomy, potential use of cardiopulmonary bypass, and the associated discomfort and length of hospital stay. The percutaneous method is simple, fast, low risk, and comparatively inexpensive. The first percutaneous retrieval of a foreign body in the cardiovascular system was reported by Thomas in 1964.’ He used a forceps device to remove a stray guidewire from the right atrium and inferior vena cava. Since then, several investigators have reported successful transcutaneous retrieval of a variety of foreign objects from the heart and adjacent vessel^.^"^ We describe a similar technique to retrieve a Mediport catheter that separated from its reservoir, presumably following trauma to the right upper chest. The multipurpose snare catheter that we utilized is one of a variety of devices designed for the purpose of retrieving foreign bodies from the cardiovascular system. Others include a helical basket, a right angle snare, a forceps catheter, a guidewire hook, and a loop snare. The latter can easily be made by bending a guidewire at its midpoint and extruding this portion of the guidewire through the end of a catheter, thereby forming an adjustable “button hole” that can snare objects when the wire is pulled back into the catheter. At the time of surgical implantation of the catheter in our patient, care was taken to properly attach the catheter to the disc. The reason for the separation is unclear. The mechanism of attachment of the catheter to the reservoir varies with the type of catheter. Some are simply manually connected, others have a locking latch, while others come as a unit from the manufacturers. Slippage of an O-ring (which attaches the catheter to the infusion port) and embolization of the catheter to the right heart has been described previ~usly.~ For improved security, perhaps a suture should be placed between the catheter and the reservoir or between the catheter and the surrounding tissue to prevent similar episodes of catheter separation and migration. Catheter embolization remains a potential complication of indwelling lines in patients with neoplastic disease. To minimize this risk, care should be taken to meticulously attach the catheter to the reservoir and the surrounding tissue, and recommendations should be given for judicious physical activity. In case this complication occurs, the percutaneous approach offers a simple and advantageous method of retrieval.

REFERENCES 1 . Mirro J, Rao BN, Stokes DC, et al. A prospective study of HickmadBroviac catheters and implantable ports in pediatric oncology patients. J Clin Oncol. 1989;7:214-222. 2. Ingram J, Weitzman S, Greenberg ML, et al. Complications of indwelling venous access lines in the

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pediatric hematology patient: a prospective comparison of external venous catheters and subcutaneous ports. Am J Pediatr H m t o l Oncol. 1991;13:130-136. 3. Harvey WH, Pick TE, Reed K, et al. A prospective evaluation of the Port-A-Cath implantable venous access system in chronically ill adults and children. Surg Gynccol Obst. 1989;169:495-500. 4. Dondelinger RF, Lepoutre B, Kurdziel JC. Percutaneous vascular foreign body retrieval: experience of an 11-year period. Eur J Radiol. 1991;12:4-10. 5. Carr ME. Catheter embolization from implanted venous access devices: case reports. Angiology. 1989;4O:3 19-323. 6. Prager D, Hertzberg RW. Spontaneous intravenous catheter fracture and embolization from an implanted venous access port and analysis by scanning electron microscopy. Cancer. 1987;60:270-273. 7. Richardson JD, Grover FL, Trinkle JK. Intravenous catheter emboli. Experience with twenty cases and collective review. Am J Surg. 1974;128:722-727. 8. Grabenwoeger F, Dock W, Pinterits F, et al. Fixed intravascular foreign bodies: a new method for removal. Radiology 1988;167:555-556. 9. Thomas J, Sinclair-Smith B, Bloomfield D, et al. Non-surgical retrieval of a broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation. 1964;30: 106-108. 10. Bloomfield DA. The nonsurgical retrieval of intracardiac foreign bodies-an international survey. Cath Cardiounsc Diagn. 1978;4:1-14.

Recciued June 9, 1992 Accepted Jub 21, I992 Address cowespondmce to Abraham Rothman.