Foreign body and iatrogenic dislocation: (un)expected success

Clinical History

A 31-year-old female patient, with a recent history of breast cancer, had a central venous catheter (CVC) implanted to allow adjuvant chemotherapy. In January 2012 she was referred to our institution with an X-ray that showed the fracture of the distal portion of the CVC, without the complete detachment.

Imaging Findings

The fragment, still attached to a small part of the central portion, could suddenly embolise (Fig. 1). After written informed consent, we punctured the right common femoral vein with previous local anaesthesia and we introduced a 5Fvalved-sheath (Terumo, Tokyo, Japan). A 100-cm pigtail catheter (5F; Cook, Bloomington, USA) with 0.35’’standard guidewire (Terumo, Tokyo, Japan) was also employed (Fig. 2).
We attempted the fragment's retrieval with a 10 mm diameter loop Amplatz GooseNeck Snare (Micr.Corp, White Bear Lake, USA), but during the withdrawal, for an uncorrected catch, we assisted the fragment's migration in the pulmonary trunk. The images show as we closed the goose snare in its proximal portion (Fig. 3); the patient was agitated and our haste led us to err!
She presented no clinical symptoms. We decided to perform retrieval of iatrogenic dislocation (Fig. 4). This time, we encircled the fragment in its central portion (Fig. 5) and successfully retrieved it (Fig. 6).

Discussion

In the last 20 years of medical practice, the number of minimally invasive and interventional techniques involving the implantation and use of intravascular objects has rapidly increased [1]. In particular the use of central venous catheter has increased: the more common application included drug administration, chemotherapies and haemodynamic monitoring [2]. The most frequent complications, associated to vascular catheters, are: infections, thrombosis and stenosis. The embolisation of a venous catheter fragment is a rare complication, but despite its low incidence (0.1~1%) [3], it may cause severe and potentially fatal complications (sepsis, endocarditis, myocardial perforation, arrhythmias) with a mortality rate varying from 24 to 60% [4]. Although it has been reported that foreign bodies have remained in the body for up to seventeen years without major complications, the immediate removal of any embolised material is necessary [5-6]. Fisher and Ferreyro reported the incidence of death or serious complications in up to 71% of patients in whom the foreign body is not removed [4].
One of the most frequent causes of rupture and subsequent embolisation of the catheter is called “pinch-off syndrome”, due to a prolonged and continuous compression of the port-catheter below the clavicle close to the subclavius muscle-costoclavicular ligament complex during the movements of the arm [7].
Currently, there are two treatment options for foreign bodies retrieval: surgery and endovascular approach.
The percutaneous removal of foreign bodies from the vascular system has been carried out since 1964 and currently the percutaneous approach is the most used and the best treatment option for patients. It is a minimally invasive, relatively simple, safe procedure, with low complication rates compared to conventional surgical treatment [8]. Techniques for non-surgical retrieval of embolised foreign materials include loop-snare technique, helical basket, bronchoscopic forceps and hook guide wire. There are some devices for extraction of intravascular foreign bodies in the market, which have proven to be very effective in some situations. However, the most versatile, used and preferred technique by the expert team is the loop- snare.
In this case, despite the complication of iatrogenic dislocation, the percutaneous approach with goose neck has been proven safe and effective.
Considering this, we believe that percutaneous retrieval should be regarded as the treatment of choice for intracardiac or intravascular foreign bodies.

Differential Diagnosis List

Final Diagnosis

Fractured catheter retrieval and iatrogenic dislocation in pulmonary trunk

URL:	https://www.eurorad.org/case/10133
DOI:	10.1594/EURORAD/CASE.10133
ISSN:	1563-4086