|CASE IN POINT - CLINICS IN INTERVENTIONAL CARDIOLOGY
|Year : 2017 | Volume
| Issue : 3 | Page : 195-197
Percutaneous retrieval of a fractured chemoport
Varun V Nivargi1, Vihita Kulkarni2, CN Makhale1
1 Department of Cardiology, Ruby Hall Clinic, Pune, Maharashtra, India
2 Poona Hospital and Research Center, Pune, Maharashtra, India
|Date of Web Publication||30-Jan-2018|
Varun V Nivargi
Cardiology Consultant, Ruby Hall Clinic, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Chemoport, a central venous infusion system, is commonly used in cancer patients for administration of chemotherapy. Dislodgement with subsequent migration of chemoport catheter in to the heart is a rare but potentially catastrophic complication. The treatment of choice is immediate retrieval of the dislodged part of catheter by surgery or percutaneous approach. Percutaneous removal is safer and less invasive making it the standard treatment modality. We report the case of a 9-year-old child who was referred to us for the management of a dislodged chemoport catheter.
Keywords: Cancer, chemoport, snare
|How to cite this article:|
Nivargi VV, Kulkarni V, Makhale C N. Percutaneous retrieval of a fractured chemoport. Astrocyte 2017;4:195-7
| Introduction|| |
Entirely subcutaneous intravascular portals (Port-A-Cath) are frequently used to administer chemotherapeutic agents. Chemoport is an implantable device placed in the central venous system mainly for infusion of chemotherapeutic drugs in oncologic diseases. Patients with malignancy are at an increased risk for superficial thrombophlebitis due to frequent injections of aggressive chemotherapy courses. In such patients, placement of a chemoport has been advocated and reported to be safe. The subclavian vein, jugular vein, or superior vena cava are accessible central veins for chemoport catheter insertion. Several complications associated with chemoport implantations include venous thrombosis, infection, catheter extravasation, and dislodgement. The incidence of port catheter dislodgement with subsequent migration to the heart is low with an estimate of 4.1%.
In many patients, it is detected incidentally when patients undergo routine chest radiographs. The treatment of choice for port dislodgement is immediate retrieval of the distal migrated part. Percutaneous transvenous retrieval is regarded as the standard method because it is generally easy, safe, and less invasive with a high success rate.
We present a case of Port-A-Cath fracture with distal embolization in the right ventricle in a 9-year-old child undergoing chemotherapy for lymphoid malignancy.
| Case Report|| |
A 9-year-old male patient with a history of lymphoid malignancy was on chemotherapy for several days through a chemoport in the right subclavian vein. During an admission for chemotherapy the nurse was unable to aspirate through port, though in the previous month chemotherapy was successfully administered through the same port.
On examination, it was found that the port was in situ but the catheter was not palpable in the subcutaneous tissue of the infraclavicular area as per the normal assessment during the last visit (15 days back). There was no history of any chest trauma, cough, excessive straining, fever, and any infection at the port insertion site.
The consultant in charge ordered a chest X-ray. The chest X-ray showed that the distal part of the port was separated and lying in the right ventricle of the heart [Figure 1] and [Figure 2]. The symptoms related with catheter migration, which include palpitations, dyspnea, cough, and chest discomfort, were absent in the child and there were no electrocardiographic (ECG) changes in the form of ventricular premature complexes and ventricular tachycardia.
|Figure 1: Chest xray posteroanterior view showing the fragmented chemoport in the right ventricle.|
Click here to view
|Figure 2: Chest xray lateral view showing the fragmented chemoport in the anterior ventricle [ right ventricle].|
Click here to view
Patient was referred to our cardiology department for a possible percutaneous retrieval of the migrated catheter. As the patient was asymptomatic and stable, the procedure was planned for the next day. Under general anaesthesia in the cardiac catheterization lab, the catheter was retrieved with fluoroscopic guidance. The right femoral vein was punctured and a 6 French (6 Fr) sheath was inserted. Percutaneous retrieval of the migrated catheter was performed with a 6-Fr snare [Figure 4] and 5]. Initially, a 6-Fr pigtail catheter was used to grasp the port and bring it into the inferior vena cava [Figure 3]. After the port was retrieved in the inferior vena cava, it was easily snared. One of the floating end of the migrated catheter was snared and pulled down via inferior vena cava towards the right femoral vein under fluoroscopic guidance and removed [Figure 4] and [Figure 5]. Finally, the port catheter fragment along with retrieval set were removed through the right femoral vein. The length of the migrated piece was 15 cm, and no thrombus was observed at the tip. The total procedure time was 10 minutes, with a fluoroscopic time of 3 minutes. No major complication occurred during and after the procedure, and the patient's chemotherapy was resumed.
|Figure 3: 6 Fr pigtail introduced via right femoral vein grasping the fragmented chemoport and bringing it into the inferior venacava.|
Click here to view
| Discussion|| |
Port-A-Caths are widely used in the field of oncology. Catheter fracture and embolization is one of the rare complications of subclavian central venous catheters. Chemoport, a central venous infusion system, is commonly used in cancer patients for administration of chemotherapy. Dislodgement with subsequent migration of the chemoport catheter in to the heart is a rare but potentially catastrophic complication. The treatment of choice is immediate retrieval of the dislodged part of the catheter by either surgery or percutaneous approach. Percutaneous removal is safe and less invasive making it the standard treatment modality.
In this case report, we describe a rare, yet potentially catastrophic, complication in which catheter was dislodged and migrated to the heart. To date, the complication rate for dislodged catheter of a chemoport has remained low with prevalence of 0.4–4%. Since the first reported by Turner et al. in 1954, port catheter dislodgement has been reported occasionally. The mechanism of catheter dislodgement and migration is not clear. Suggested mechanisms include improper connection between the catheter and port, distortion or angulation of the anastomosis site, use of incorrect equipment, malposition of the catheter, and pinch-off syndrome secondary to compression between the clavicle and first rib., High intrathoracic pressure induced by coughing and straining could cause migration of the port.
The most common presentation of catheter embolization is asymptomatic discovery on chest radiology, with other presentations including infra/supraclavicular swelling. No matter how, when dislodged fragment is found on chest X-ray, early removal as soon as possible is necessary because of two reasons, one is to prevent its distal embolization, which makes retrieval more difficult and because foreign bodies can cause septicemia, lung abscess, multiple pulmonary emboli, arrhythmias, cardiac wall necrosis leading to perforation, and sudden cardiac death.
A previous case series of 20 patients with asymptomatic catheter embolization and percutaneous retrieval demonstrated successful retrieval in all cases; 16 with a snare and 4 using a basket retrieval system.
Since percutaneous retrieval of a broken guidewire was first introduced by Thomas et al. in 1964, percutaneous endovascular retrieval has become a standard technique for foreign body removal. Now, it is a preferred method with a high success rate of 71–100%. Such a high success rate depends upon the expertise and available hardware in catheterization lab. Many types of equipment have been used to retrieve intravascular foreign bodies, including snares, baskets, grasping forceps, tip deflecting wires, and balloon catheters. As reported in the literature, the loop snare is the most popular device despite its main disadvantage of poor torque control. There are several causes of retrieval failure such as absence of free ends to be snared, the catheter end dislodged far into the peripherally localized vessel, foreign bodies are nonopaque, and the catheter is manufactured of friable material. When no free end is accessible, a pigtail catheter can be used to reposition the dislodged fragment by pigtail catheter to the optimal site first and then grasp by loop snare. Chuang et al. reported that the concurrent use of pigtail and loop snare is a feasible and easy method for percutaneous retrieval of a dislodged catheter.
Previously the mortality following catheter remobilization was 28–57% between 1950 and 1980. Currently, the mortality rate has been markedly reduced to 0–1.8% due to the higher success rate of percutaneous retrieval. In this case, a snare and a pigtail catheter was used to remove the dislodged catheter.
The most common complications of percutaneous intravascular retrieval procedures are cardiac arrhythmias followed by vascular or cardiac perforation. In our patient, cardiac arrhythmias were not documented. Through a percutaneous, transvenous approach, we successfully retrieved the migrated catheter of chemoport from the right chambers of the heart.
Given the subtle nature of the embolization and the potential complications, clinicians should be vigilant for catheter fracture and embolization. Percutaneous removal has been shown to be a safe procedure, allowing for prompt removal of the embolized catheter fragments.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chaung MT, Wu DK, Chang CA, Shih MC, Ou-Yang F, Chuang CH, et al
. Concurrent use of pigtail and loop snare catheters for percutaneous retrieval of dislodged central venous port catheter. Kaohsiung J Med Sci 2011;27:514-9.
Cheng CC, Tsai TN, Yang CC, Han CL. Percutaneous retrieval of dislodged totally implantable central venous access system in 92 cases: Experience in a single hospital. Eur J Radiol 2009;69:346-50.
Turner DD, Sommers SC. Accidental passage of a polyethylene catheter from cubital vein to right atrium; report of a fatal case. N Eng J Med 1954;251:744-5.
Wu PY, Yeh YC, Huang CH, Lau HP, Yeh HM. Spontaneous migration of a port-a-cath catheter into ipsilateral jugular vein in two patients with severe cough. Ann Vas Surg 2005;19:734-6.
Surov A, Buerke M, John E, Kösling S, Spielmann RP, Behrmann C. Intravenous port catheter embolization mechanisms, clinical features, and management. Angiology 2008;59:90-7.
Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Non-surgical retrieval of a broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation 1964;30:106-8.
Dondelinger RF, Lepoutre B, Kurdziel JC. Percutaneous vascular foreign body retrieval: Experience of an 11-year period. Eur J Radiol 1991;12:4-10.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]