JVA ISSN 1129-7298
J Vasc Access 2015; 00 (00): 000-000 DOI: 10.5301/jva.5000430
CASE REPORT
Retained embolized fragment of totally implantable central venous catheter in right ventricle: it is really necessary to remove? Giovanni Tazzioli1, Eleonora Gargaglia1, Ilaria Vecchioni1, Simona Papi1, Petronilla Di Blasio1, Rosario Rossi2 1
Department of Surgery and Clinical Specialties, University of Modena and Reggio Emilia, Policlinico di Modena, Modena - Italy Section of Cardiology, Department of Medicine and Emergency Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena - Italy
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Abstract Introduction: Central venous catheters are often required in oncologic patients for long-term safe administration of chemotherapeutic agents, antibiotics, and parenteral nutrition. Rupture of these devices and intracardiac migration is a rare complication. Methods: We report one spontaneous rupture and embolization of a totally implantable vascular access device (TIVAD) in an asymptomatic patient. Results: A 50-year-old woman received a TIVAD silicone catheter 8 FR for adjuvant chemotherapy. After 3 years of port time in situ, during a follow-up control, a catheter malfunction was found and radiologic investigations showed a rupture and migration of the catheter to the right ventricle. The attempt to remove the fragment under fluoroscopic control using the femoral route was unsuccessful. We did not try a surgical approach because of the complete absence of symptomatology and hemodynamic impairment. Conclusions: The catheter rupture and intracardiac embolization is a rare complication associated with totally implantable or tunneled central venous catheters. When such an event happens, the patient should be managed by expert hemodynamists or interventional radiologists making an effort to remove the fragment without surgical measures. When the intravascular percutaneous route fails, the possibility to leave the fragmented catheter in heart chambers should be evaluated, being surgery questionable in asymptomatic patients. Keywords: Embolization, Rupture, Totally implanted central venous catheter
Introduction Long-term central venous catheters, tunneled cuffed (Groshong, Hickman, Broviac, and so on) and totally implantable access devices (TIVADs) are largely used in oncologic patients. They allow safe administration of chemotherapeutic agents and parenteral nutrition, and also blood and blood products transfusions or withdrawal in patients lacking peripheral venous accesses, with a minimal disruption to a patient’s lifestyle. Insertion techniques vary depending on the operator, but all consist of catheter placement in the central venous circuAccepted: May 9, 2015 Published online: June 20, 2015 Corresponding author: Giovanni Tazzioli, MD University of Modena e Reggio Emilia Policlinico di Modena Via del Pozzo 71 41124 Modena, Italy
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© 2015 Wichtig Publishing
lation (through internal jugular, brachicephalic, subclavian, or axillary vein) followed by catheter tunneling and subcutaneous pocket creation for reservoir (in Port). Complications could occur even if all procedures of safeimplantation are respected, such as asepsis and maximal barrier precautions, ultrasoundguided venipuncture, intraoperative assessment of the position of the tip of the catheter, careful handling of the guide wire, appropriate stabilization of tunneled catheters, and proper choice of the site of implantation of the reservoir. Early insertion-related complications are pneumothorax, repeated attempts at venipuncture, arterial puncture with consequent hematoma and hemothorax, arrhythmias, and primary malposition. Late insertion-related complications are central venous thrombosis, pinch-off syndrome, secondary malposition (tip migration), early dislocation (for external tunneled catheter), difficult puncture of the reservoir (for Port), and complex regional pain syndrome (CRPS). Late management-related complications are infections, kinking, rupture of the external tract of the catheter (in external tunneled catheter), partial or total dislocation, extravasation for incorrect positioning of dislocation of Huber needle (in Port), and occlusion of the lumen.
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Rupture of a totally implantable central venous catheter
Rupture of the intravascular catheter and its embolization is a rare but potentially serious complication and can go undiagnosed for prolonged periods (1). Patients might be asymptomatic or may develop severe systemic clinical signs.
Case presentation In a 50-year-old woman in May 2008, a totally implantable central venous catheter (TIVAD) (Groshong power port silicone catheter 8 FR - Bard Access Systems, Inc.) was positioned via the right jugular vein for adjuvant chemotherapy administration by the Seldinger technique and under ultrasonography guide. The proper positioning of the catheter tip at the junction of superior vena cava and right atrium was confirmed by fluoroscopy. In April 2011, during a routinary maintenance of the device, a malfunction was found. A chest X-ray revealed the rupture of the proximal third of the catheter and its migration into the right ventricle (Fig. 1). These findings were already present in a staging computed tomographic (CT) scan of August 2010 (Fig. 2). All the time, the patient was completely asymptomatic. The patient underwent cardiologic evaluation and an attempt to remove the fragment through the femoral route was unsuccessful for its strong adherence at the right ventricle wall. It was decided not to proceed with other attempts for the complete absence of symptoms. At present, 3 years after, the patient is still completely asymptomatic.
Fig. 1 - Standard chest X-Ray showing the fractured catheter and its fragment inside the right atrium (arrow).
Discussion Totally implantable or tunneled central venous catheters are important devices for long-term intravenous therapies, especially for oncologic patients, but positioning and use of these devices are associated with perioperative complications and long-term problems. The complications rate depends on basic pathology (solid or haematological malignancy), patient’s performance status, and placement technique. For this reason, the personnel’s experience about the positioning and use of the device, the routine maintenance procedures, and also about the treatment options when the complications occur is crucial. Spontaneous rupture and embolization of port catheters is a rare but well-known event with potential life-threating implications. When happened, the patients could be completely asymptomatic or present clinical signs such as catheter malfunction or pulmonary and/or cardiac symptoms. The event could occur but go undiagnosed for a long period and found incidentally during routine controls (2). It is accepted in literature that an early diagnosis and treatment in asymptomatic patients could also prevent more severe complications and could permit the complete removing of the fragment by percutaneous transfemoral approach without increasing morbility. Biffi et al, in 1320 subclavian port placements during a 5-year period, reported nine cases of catheters rupture and embolization. Two of these patients showed a ‘pinch-off sign’ at the radiological investigations; eight patients have a painful swelling around the port, but none had symptoms
Fig. 2 - CT scan and fragment of the catheter inside the right atrium.
from the embolized fragment. In all cases, the removal of catheters was carried out by interventional radiology technique with venous transfemoral approach without complications (3). Seelig et al reported a case of spontaneous rupture and embolization of a subclavian port catheter after 31 weeks from the implantation. The patient had parasternal and subclavian pain and the chest X-ray showed the tip embolization into the right atrium. The fragment was extracted with a loop-snare technique without complications (4). © 2015 Wichtig Publishing
Tazzioli et al
Filippou et al reported three cases of rupture and embolization of subclavian port, but the events occurred during the catheter removal. Two patients were treated by percutaneous intravascular route under fluoroscopic control, while in the other case, the catheter could not be removed and was retained in the right ventricle until 2 months later when the patients died because of the basic disease (5). Surov et al in a systematic review identified a total of 215 cases of catheter embolizations, 143 were port catheters and 72 percutaneous venous catheters. The total mortality rate was estimated about 1.8%. The sites of embolization were vena cava or peripheral veins (15.4%), the right atrium (27.6%), right ventricle (22%) and pulmonary arteries (35%). In 56.3% of cases, the patients presented only catheter malfunction and 24.2% of patients were completely asymptomatic. Other clinical signs were arrhythmia (13%), pulmonary symptoms (4.7%) and septic syndromes (1.8%). The catheter rupture was present in 11.6% of cases, while in the other cases, the cause of catheter embolization was pinch-off syndrome, injury during explantation, and disconnection. The fragment was removed percutaneously in 93.5% of cases, by a thoracotomy approach in 2.3%, while the fragments were retained in vascular bed in 4.2% of cases (2). Actis Dato remarked that iatrogenic foreign bodies completely embedded in the heart could be left in place in asymptomatic patients. Indication for surgery should be disussed on an individual basis particularly in patients with associated risks such as oncologic ones. Conservative management requires a close follow-up (6). We described the possibility of a spontaneous rupture of an unused port catheter placed in right jugular vein and its migration in right heart chambers. The other cases in literature reported principally subclavian catheters ruptures because of the so-called ‘pinch-off syndrome’ due to the passage of the catheter under the clavicle. A spontaneous rupture of a catheter placed in jugular vein, though there are very few cases described in the literature, is a possible event, without welldefined risk factors and causes. The catheter entrance was not high, as it is routinely performed in our institution by an ‘in-plane’ ultrasound technique. The rupture occurred at the proximal third of the catheter; in fact, the proximal segment was positioned inside the vessel and was functioning normally. I think that a malfunction of the distal valve of the catheter had caused an excessive pression into the device during the infusion procedures. In our case, the diagnosis of the embolization occurred 3 years after the placement of the port and 2 years and 8 months
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after the last chemotherapy administration, but probably it was present before and misidentified. The fragment, in fact, was strongly adherent to the right ventricle wall and auricola and it was impossible to move it away by percutaneous transfemoral access under fluoroscopy control. Once the catheter is endothelialized, its removal is extremely difficult (7). After the necessary investigations, we did not perform surgery because of the absence of subjective symptoms and clinical signs and the patient is still in good health. Although there are not many data about the morbility and mortality in case of retained fragments, as our case demonstrated, when the interventional radiologic approach fails, the possibility to leave a fragment of TIVAD embolized in right heart chambers should be considered in asymptomatic patients.
Disclosures Financial support: The authors have no financial disclosures to make. Conflict of interest: The authors have no conflict of interest.
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