A problematic catheter fragment retrieval: a useful trick (the movie)

Clinical History

A 60-year-old female patient with a left subclavian-access port inserted below the clavicle underwent a chemotherapy session for an anal cancer. Preliminary heparin injection to test patency of the port and absence of blood flow back were highly suspicious for port rupture.

Imaging Findings

A chest X-ray was performed to confirm the port-catheter rupture. The catheter fragment, about 15 cm long, was positioned between the left and right pulmonary arteries, in harness with the arterial wall (Fig.1). After puncture of the right femoral vein a 7F introducer sheath was placed and after catheterisation of the main pulmonary artery a snare-device (Multi-Snare Set 15 mm-PFM, Köln, Germany) was advanced until the pulmonary trunk and several attempts to capture the fragment were done without success. For this reason we decided to move the catheter fragment from the pulmonary artery in the right atrium. This was possible using a 5F pig-tail catheter which engaged the fragment and moved it in the atrium (Fig.2, 3movie), where it was easier to capture it with the snare (Fig.4). The fragment was dragged into the introducer sheath and both were removed simultaneously (Fig.5). End-procedure control demonstrated that no other fragments were left.

Discussion

Catheter fracture represents one of the major complications occurring in the port devices. In many cases the patients are almost asymptomatic and the first appearance of port rupture is frequently represented by its dysfunction or by an incidental detection of the port fragment, for instance on a chest X-ray. Among the most important consequences of port-fragment embolisation there are ventricular arrhythmia, due to irritative stimulus on cardiac wall and sudden death. Considering the use for long-term treatment of port devices the subclavicular site and the subclavian venous access represent the most comfortable choice. However, subclavian access demonstrates a higher probability of embolism compared with transjugular implantation. The cause may be the so 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 [1]. Another possibility is the disconnection between port chamber and catheter. Usually the fragment migrates from the superior caval vein to the pulmonary trunk, but other frequent sites are represented by the right atrium or ventricle and the superior vena cava or peripheral veins. When one of these conditions occurs, the patient undergoes a surgical procedure to remove the port chamber from the subclavicular pouch, but it is not always possible to retrieve the distal fragment of the port-catheter. In this case a good option is represented by percutaneous endovascular approach, whereas nowadays open surgical approach is quite obsolete. Usually the femoral vein is the preferred access point. In the last years several commercially available retrieval devices with different morphology of the snare have been introduced. The one used here has a double snare: one stays "orthogonal" to the vessel lumen while the other opens in a "longitudinal" fashion. Sometimes the catheter is so close and sticking to the vascular wall that it is not easily retrieved with the appropriate device. In this case some authors suggest the use of multipurpose, Simmons or pigtail catheter to reposition the embolised fragment if there is no chance of catching it directly with the snare device. The "movie" shown here (Fig. 3) is a demonstration of "how to do it". Finally the endovascular procedure has a high success rate, less periprocedural side effects and requires less hospitalisation [2-4].

Differential Diagnosis List

Final Diagnosis

Port-catheter rupture and retrieval from pulmonary artery

URL:	https://www.eurorad.org/case/9722
DOI:	10.1594/EURORAD/CASE.9722
ISSN:	1563-4086