Christoffer Blegvad, Osama Hamed JwaiydPatient
76 years, male
During a complicated postoperative course following vascular surgery, a 76-year-old male patient inadvertently removed his jugular central venous catheter. A CT scan one month later revealed that the catheter had fractured with a 10 cm embolised piece lodged in the right atrium and the inferior vena cava causing hepatic vein thrombosis.
The patient underwent a late portal phase CT scan due to unknown site of infection. Unexpectedly, a long drain-like foreign body, approximately 10 cm in length, was lodged in the auricle of the right atrium and distally into the inferior vena cava to the level just below the hepatic veins (Figs. 1–4). A partially occluding thrombus in the right hepatic vein, in relation to the foreign body, was also evident (Figs. 4–5). There was no accompanying ascites. The foreign body had a tubular structure consisting of three separate lines (Figs. 3, 4, and 6), and in combination with a medical history of inadvertent central venous catheter removal by the patient, this raised the suspicion of an embolised catheter fragment after catheter fracture. Hepatic vein thrombosis was also evident by ultrasound on later follow-up (Fig. 7). Pacemaker electrodes make it possible to miss the catheter fragment on the CT scan.
To our knowledge, this is the first case report of an inadvertently fractured and embolised central venous catheter causing hepatic vein thrombosis. Catheter fracture is an uncommon complication (<1 %), usually occurring during placement or removal . Possible sites for embolisation of catheter fragments include the superior vena cava, the right atrium and ventricle, and most frequently, the pulmonary arteries . Apart from catheter dysfunction, clinical manifestations of catheter embolisation include arrhythmia, dyspnoea, infection, and rarely, death. Our case was asymptomatic and the embolised fragment was identified accidentally, a month after the inadvertent catheter removal by the patient, on a CT scan performed for a different indication. The patient had pacemaker electrodes that made the catheter fragment—lodged in the right atrium extending to the hepatic veins—more prone to be missed upon image reading.
Catheter-related thrombosis is a well-known complication of central venous catheter placement, and the pathophysiological mechanism is believed to be a combination of pericatheter fibrin sheath formation and endothelial erosion . The prevalence of catheter-related symptomatic deep vein thrombosis is estimated to be around 1–5 %, with possible locations including the superior vena cava and right atrium, in addition to pulmonary embolisation [3,4]. Similar to our patient, however, the majority of cases are asymptomatic and may therefore go undetected. Hepatic vein thrombosis, and even fulminant Budd-Chiari syndrome, has previously been reported as result of a malpositioned catheter, which in one case was fatal [5–7].
One week after discovery, our case had the catheter fragment removed by an uneventful endovascular procedure in the angiography suite, where a 10 cm fragment was extracted via the left femoral vein using a loop snare. Endovascular treatment has been shown to be both effective and safe in the management of mechanical complications to central venous catheters . The patients had no further complications and started oral anticoagulant therapy to treat the hepatic vein thrombosis with a scheduled follow-up in 3 months.
Take Home Message / Teaching Points:
Written informed patient consent for publication has been obtained.
 Nayeemuddin M, Pherwani AD, Asquith JR (2013) Imaging and management of complications of central venous catheters. Clin Radiol 68(5):529–44 (PMID: 23415017)
 Surov A, Wienke A, Carter JM, Stoevesandt D, Behrmann C, Spielmann R-P, et al. (2009) Intravascular embolization of venous catheter--causes, clinical signs, and management: a systematic review. JPEN J Parenter Enteral Nutr 33(6):677–85 (PMID: 19675301)
 Geerts W (2014) Central venous catheter-related thrombosis. Hematol Am Soc Hematol Educ Progr 2014(1):306–11 (PMID: 25696870)
 Burns KEA, McLaren A (2009) Catheter-related right atrial thrombus and pulmonary embolism: a case report and systematic review of the literature. Can Respir J 16(5):163–5 (PMID: 19851535)
 Husainy MA, Chhina R, Alchanan R, Peddu P (2017) Fatal outcome of haemodialysis catheter malposition into the hepatic vein causing Budd-Chiari Syndrome. J Vasc Access 18(3):e37–8 (PMID: 28058703)
 Fitoz S, Atasoy C, Yagmurlu A, Akyar S (2002) Segmental hyperattenuation in the liver as a result of right hepatic vein thrombosis: an unusual complication of central venous catheterization. Australas Radiol 46(3):299–301 (PMID: 12196241)
 Araujo GN, Restelatto LM, Prompt CA, Karohl C (2017) Budd-Chiari syndrome secondary to catheter-associated inferior vena cava thrombosis. J Bras Nefrol 39(1):91–4 (PMID: 28355402)
 Bessoud B, de Baere T, Kuoch V, Desruennes E, Cosset M-F, Lassau N, et al. (2003) Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol 180(2):527–32 (PMID: 12540466)