Rev. Bras. Anestesiol. vol.64 número4

RevBrasAnestesiol.2014;64(4):275---277

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

CLINICAL

INFORMATION

Percutaneous

endovascular

removal

of

intracardiac

migrated

port

A

catheter

in

a

child

with

acute

lymphoblastic

leukemia

Feraye

Cakır

_,

_Sukran

_Geze

,

M.

Halil

Ozturk

,

Hasan

Dınc

a_{DepartmentofRadiology,MedicalParkHospital,Ordu,Turkey}

b_{DepartmentofAnesthesiologyandCriticalCare,FacultyofMedicine,KaradenizTechnicalUniversity,Trabzon,Turkey} c_{DepartmentofRadiology,FacultyofMedicine,KaradenizTechnicalUniversity,Trabzon,Turkey}

Received16October2012;accepted21November2012

Availableonline16October2013

KEYWORDS Catheter; Cardiac; Migration; Percutaneous

Abstract

A2-year-oldboywithacutelymphoblasticleukemiawaspresentedwithperipherallyinserted centralcatheterdysfunction. Radiologicalexaminationsrevealed acatheterremnantinthe rightatriumextendingintopulmonaryvein.Thecatheterremnantwassuccessfullyremoved fromtherightatriumbypercutaneousendovascularinterventionwithoutanycomplications. © 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

PALAVRAS-CHAVE Cateter;

Cardíaco; Migrac¸ão; Percutâneo

Remoc¸ãoendovascularpercutâneadecatetertotalmenteimplantávelcommigrac¸ão intracardíacaemcrianc¸acomleucemialinfoblásticaaguda

Resumo

Meninocomdoisanosdeidadecomleucemialinfoblásticaagudafoiapresentadocomdisfunc¸ão de catetercentralperifericamenteinserido.Oexame radiológicorevelouum fragmentodo cateternoátriodireitoqueseestendiaatéaveia pulmonar.Ofragmentofoiremovidocom sucessoporintervenc¸ãoendovascularpercutânea,semqualquercomplicac¸ão.

©2013SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Central venous catheters areused frequentlyin pediatric patients. Especially port A catheters are inserted for the

∗_{Correspondingauthor.}

E-mails:drgezes@yahoo.com,gezes@hotmail.com(S.Geze).

purpose of injection of the chemotherapeutic agents in thetreatmentofmalignancyorhighcalorictotalparenteral nutrition in children. The port A catheter consists of an injection port with a self-sealing silicone septum and a radio-opaque silicone or polyurethane catheter. The port Acatheterusuallyisplacedintheinterventionalradiology units.Postinsertioncomplicationsincludingleaks, acciden-tal removal,migrationof the tip,fracture, embolization, infection, occlusion of the catheter, venous perforation,

276 F.Cakıretal.

Figure1 AbrokenportA catheterfragmentina2-year-old

malewithacutelymphoblasticlymphomawasdislodgedinthe

rightventriclereachingthemainpulmonaryvein.

atrial perforation, arrhythmias, and phlebitis previously arereported.1---3_{Catheterfragmentscentrallyembolizedin}

the heart and pulmonary artery has been also previously reported.1,4,5 _{If themigrated fragmentsarenot removed,}

theymay cause serious complications and deathas well. Long termserious complications arechanged between 21 and 33%6---8 _{and death rate is changed between 23.7 and}

60%.6---9_{Percutaneousremovalofthesemigratedfragments}

decreasedtheneedformajorsurgery.

We present successful percutaneous endovascular removal of port A catheter fragment migrated into the rightventricleina2-year-oldboywithacutelymphoblastic leukemia(ALL).

Case

report

A 8F port-A catheter (Polysite, France.) was inserted in a2-year-oldboy withALL(acutelymphoblastic leukemia) forchemotherapy. Threemonths lateraport revisionwas planned due to dysfunction. However,the familydid not accepttheintervention.Theportwastriedtoberemoved bythepediatricsurgeons.Thediaphragmoftheportcould beremovedwithoutthedistalcatheter.AchestX-ray(Fig.1) andcomputedtomographyrevealedadistalcatheterinthe rightatrium.

Anemergencypercutaneousremovalofthecatheterwas planned.Avascularintroducer wasinserted intotheright jugularveinwithultrasonicandfluoroscopicguidanceunder generalanesthesia.The remnantoftheportcatheterwas lying in the right atrium and reaching to the main pul-monaryvein.The migratedport catheterwaspulledback tothevena cavasuperior withmanipulations ofa 5F pig-tail diagnostic catheter(Cordis, USA). Thereafter a snare catheter (Microvena, USA) was introduced. The catheter tip was successfully caught with the snare catheter and removedsmoothly throughthevascular sheet.At theend of the procedure, patency of the atrium and vessels was confirmedwithanangiography.

Discussion

Central catheters have been used in the treatment of patientswithcancerformorethantwentyyearsfor deliv-eryoffluids,sclerosingagentsandchemotherapeutics.Port catheterscanbeusedforlongtimeintravenoustreatments. Theyarecosmetically accepted bypatients andaremore hygienic.Theuseofcentralcathetersinoncologypatients at the beginning of the treatment reduces the

extrava-Figure2 Thefragmentwas repositionedinto superiorvena

cava(SVC)witha6Fpigtailcatheter.Thereafteritsdistalfree

endwascapturedbyasnareinSVCandremovedsuccessfully.

sation risk of irritating chemotherapeutic agents, enables continuousperipheralaccess,andpreventspatients’ anxi-etyrelatedwithmultiplevenouspuncture.

It has been reported that applications of the port catheters by interventional radiologists are safe. Complications after catheter insertion are: embolization, infection, occlusionof the catheters,venous perforation, atrialperforation,arrhythmias,flebitis,leakage,migration andbreakageofthecatheters.1---3

Thereareseveralfactorsaffectingthebreakageofthe central venous catheters. The breakage points of periph-erallyinsertedcentralcathetersaregenerallyclosetothe insertionpoint,andthecathetersbreakmoreeasilywhen theyare insertedin places ofrepeated stress,like elbow oriliaccrease.Thehistoryofocclusionorflushingdifficulty shouldbeinvestigatedforthecatheterintegrity,especially whenthecatheterdwellingtimeislong.6

Breakageandembolizationofperipherallyinserted cen-tral catheters is more often than expected especially in pediatricpatients.Caregiverstothesepatientsshouldbe trainedaboutbreakageandleakageofthecatheters. Flush-ing of the catheter lines should be made with injectors smallerthan5mLtopreventcatheterbreakagecaused by excessiveforces.6

Inthepast,surgerywastheonlychoiceinthetreatment ofbroken andmigratedcatheters.Recently, percutaneous removal of migrated catheter pats is possible withmuch lowermorbidityandmortalitywhencomparedwithsurgery. Howeverinlowbirth weightbabiespercutaneousremoval may cause seriouscomplications such asvascular rupture or atrial perforation, but these procedures stillhave less morbidity and mortalitywhen comparedwith open heart surgery.

Thesuccessratesofpercutaneousremovalofintravenous foreignbodiesintheliteratureare71---100%.10 _Thefailure

Figure3 Attheendoftheprocedurepatencyoftheatrium

RemovalofintracardiacmigratedportAcatheter 277

ofpercutaneousremovalisgenerallyrelatedtofactorssuch aslackof afreeendofthe foreignbodymigrationof the smallcatheterpartstoperipheralarterialbranches, immer-sion of the foreign bodyinto the vascular wall,presence oftheforeignbodyinathrombosedvascularsegment,and extravasationoftheforeignbody.

Theproblemsoftheabsenceofafree-endandmigration ofsmallfragmentstotheperipheralarteriescouldbe over-comewiththeuseofappropriatematerialandtechnique.

Inourcasetheproblemsweredistalintra-cardiac local-izationofthecatheterandabsenceofafree-endbecause ofthe overlappingofthe free-endsof thecatheter.Thus, thecatheterremnantcouldnotbehandledwiththe maneu-versofasnarecatheter.Theproximalendofthecatheter wasreleased withtheaid of a pigtaildiagnostic catheter and pulledout tothe superior vena cava. Thereafter the catheterremnantwassuccessfullyandeasilyremovedwith thehelpofasnarecatheter(Figs.2and3).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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