Transjugular retrieval of a fractured port catheter from middle cardiac vein

Author(s)

Lin M-J¹, Liu C-C², Chiu C-M³
¹The Division of Cardiology, ²The Division of Radiology and ³The Division of Colorectal Surgery, Buddhist Tzu Chi General Hospital, Taichung, Taiwan

Patient

male, 63 year(s)

Clinical History

A 63-year-old male patient was admitted to our cardiologic service due to abnormal chest roentgenography. He had received a colectomy due to colorectal cancer about 5 years before in another hospital. A port catheter was in the meantime implanted via the right subclavian vein.

Imaging Findings

The chest film showed that the port catheter was fractured and that the distal part appeared to lie horizontally within the right ventricle with the tip of the catheter pointed toward the apex (Fig. 1a). A chest computed tomography (CT) revealed that the body of the catheter was floating in the right atrium and that the tip had protruded into the middle cardiac vein via the coronary sinus (Fig. 1b). The loop snare technique was selected for retrieval. A 6-10 mm loop snare was initially delivered from the right femoral vein. However, the snare failed to grasp the broken tip of the port catheter due to the tip being pointed cranially (Fig. 2a).We switched to the transjugular venous approach. Finally, the loop snare successfully captured the broken tip of the port catheter and the whole device including the sheath was then removed simultaneously (Fig. 2b).

Discussion

A fragmented central venous portal catheter with distal segment embolisation is a rare but well-documented complication, and may pose difficulties during retrieval. The true incidence rate of the fractured portal catheter is unknown and may range from 0.5-1% [1]. The most frequent fractured site of the catheter is at the anastomosis between injection port and catheter [2]. The most common location of a distal segment embolisation is between the superior vena cava and right atrium. Besides, migration to the right ventricle or pulmonary artery is occasionally found. A percutaneous transvenous retrieval technique should be tried first because it is feasible, less invasive and less risky, although some unusual complications have been reported in the real world [3].
Most of the fragmented catheter can be removed successfully via transfemoral access. Other access sites such as the internal jugular venous approach have been reported. As for the distal segment migration into the coronary sinus, there is only one reported case thus far and it was successfully retrieved from right basilar vein access via the loop-snare technique [4].Catheter migration into the middle cardiac vein has yet to be reported in the literature. In this case, we first approached from the right femoral venous route because the inferior vena cava (IVC) is large enough to have most loop-snares inserted, and quite safe during manipulation of the device. However, this access failed due to the broken tip being pointed cranially and because there was a sharp angle between the loop snare and the proximal fractured segment. The orifice of the coronary sinus is situated along the inferomedial surface of the right atrium, and the curve of the lumen points cranially toward the superior vena cava and the internal jugular vein. Hence it is extremely difficult to retrieve the fragmented catheter from the IVC access. On the contrary, the transjugular venous approach would be technically easier because the alignment between the fractured catheter and lasso is more coaxial.
In conclusion, once it is highly suspected that the broken port catheter has migrated into the coronary sinus, a CT is strongly recommended as a tool to define the location of the fragmented catheter, and transjugular venous retrieval is a feasible and effective approach.

Final Diagnosis

Differential Diagnosis List

References

[1]

Biffi R, Orsi F, Grasso F, De Braud F, Cenciarelli S, Andreori B (2000) Catheter rupture and distal embolisation: a rare complication of central venous ports. J Vasc Access 1:19-22
[2]

Wang PC, Liang HL,Wu TH, Huang JS, Lin YH, Huang YL, Chou CP, Yang TL, Pan HB (2009) Percutaneous retrieval of dislodged central venous port catheter: experience of 25 patients in a single institute. Acta Radiolo 50:15-20
[3]

Tsai TN, Chu KM, Tzeng BH, Yang SP, Lin WS (2007) Flailed tricuspid valve as a complication of retrieving fractured catheter. Int J Cardiol 119:225-6
[4]

Karam AR, Hourani MH, Al-Kutoubi AO (2009) Catheter fracture and migration into the coronary sinus – an unusual migration site: case report and review. Clinical Imaging 33:140-143

Citation

Lin M-J¹, Liu C-C², Chiu C-M³
¹The Division of Cardiology, ²The Division of Radiology and ³The Division of Colorectal Surgery, Buddhist Tzu Chi General Hospital, Taichung, Taiwan (2011, Jul 12).

Transjugular retrieval of a fractured port catheter from middle cardiac vein, {Online}.

URL: http://www.eurorad.org/case.php?id=9424

DOI: 10.1594/EURORAD/CASE.9424

ISSN: 1563-4086

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