Abstract
Fibrin sheath formation is a leading culprit of central venous catheter malfunction. The complete removal of fibrin sheaths is an essential component of maintaining catheter patency, preventing future restenosis, and decreasing the risk of bloodborne infections. Treatment of fibrin sheaths includes pharmacologic therapy, balloon angioplasty, catheter exchange, and mechanical stripping. In this article 3 cases are reviewed, 2 patients had long-term hemodialysis catheter malfunction and 1 had complications related to a chest port. On imaging, superior vena cava stenosis, occlusion, and/or filling defect were identified for all patients, as well as findings suggesting the presence of fibrin sheath. Description of these cases detail a new technique for fibrin sheath removal utilizing the ClotTriever System (Inari Medical, Irvine, CA), which is a mechanical thrombectomy device used for the treatment of deep vein thrombosis. This technique allowed for complete removal of the fibrin sheath via a minimally invasive interventional procedure which did not require access through the central venous catheter lumen.
Keywords: Fibrin sheath, Central venous catheterization, Catheter obstruction, Dialysis catheter malfunction, Superior vena cava syndrome, ClotTriever System
Introduction
Over 5 million central venous catheters (CVCs) are placed in the United States each year. CVC-associated complications include infection, thrombosis, fibrin sheath formation, and central venous stenosis, and longer-term CVC use is generally believed to increase the risk of these events. Long-term CVCs are commonly used for patients receiving hemodialysis, immunotherapy, or chemotherapy, among other conditions, and their use is rising [1]. Fibrin sheath formation is a primary cause of CVC malfunction, with up to 50% of hemodialysis patients experiencing fibrin sheath-related catheter dysfunction [2].
Fibrin sheath can begin to form immediately after CVC placement, however, it takes several weeks for a true fibrin sheath to develop [3]. A fibrin sheath is an agglomeration of glycoproteins that coat the outside of the catheter and form a tight complex structure over time [4]. When a CVC is inserted into the vein, the body reacts to the presence of foreign material through activation of the coagulation cascade. The initial agglomeration of cells and protein begins at the puncture site, continually adhering to the catheter over time towards the distal catheter tip [3]. An inflammatory response to catheter-associated vessel wall trauma further perpetuates this process [4]. After several weeks, the thrombus and fibrin that initially lined the exterior of the catheter are replaced with a tight structure of collagen, fibroblasts, epithelial cells, and smooth muscle cells [3]. CVC malfunction typically occurs once the fibrin sheath grows to the tip of the catheter and causes obstruction.
If a CVC is removed due to fibrin sheath-induced malfunction and the fibrin sheath is not removed completely with the catheter, it can take months to years for the body to clear the sheath on its own [3]. Thus, the longevity of fibrin sheaths may contribute to an increased risk of developing central venous stenosis and bacteremia post-CVC usage [5]. Likewise, catheter-related fibrin sheath formation may contribute to obstruction and central venous stenosis, which occurs in 20%-40% of hemodialysis patients with CVCs. In more severe cases, central venous stenosis can lead to central venous occlusion, or superior vena cava (SVC) syndrome [3]. Therefore, to help prevent both restenosis and infection in patients suffering from fibrin sheath-related CVC malfunction, it is a priority to demonstrate an effective, minimally invasive technique for complete fibrin sheath removal when access through the associated CVC is not possible. The following 3 case reports describe the utilization of the ClotTriever System (Inari Medical, Irvine, CA), a mechanical thrombectomy device used for the treatment of deep vein thrombosis (DVT), to extirpate fibrin sheath material in patients with CVC complications when access through the aggravating CVC was not possible.
Case report 1
A 64-year-old female with a history of end-stage renal disease (ESRD) on hemodialysis 3 days a week presented following a fall at home with a malfunctioning tunneled dialysis catheter secondary to a right atrium (RA) mass and line-associated blood infection. This patient was admitted for line sepsis, the tunneled dialysis catheter was removed, and she was placed on a 3-4-day line holiday before insertion of a nontunneled external jugular vein (EJ) dialysis catheter. However, the new catheter also malfunctioned with concern for fibrin sheath or central stenosis. The patient did not present with any arm, facial, or upper body swelling that would indicate SVC syndrome. Subsequent chest computed tomography (CT) demonstrated an SVC filling defect alongside the CVC leading to the RA mass (Fig. 1) which was compatible with residual fibrin sheath from the removed tunneled catheter. Because the old catheter had been removed prior to fresh venous access for placement of the non-tunneled catheter, there was no access through the lumen of the fibrin sheath which precluded percutaneous transluminal angioplasty (PTA) and tissue plasminogen activator (TPA) infusion as options for treatment.
Fig. 1.
Axial postcontrast computed tomography image of the chest at the level of the superior vena cava demonstrating the nontunneled central venous catheter alongside a filling defect (red arrow) with concern for residual fibrin sheath following tunneled catheter removal. This extended into the right atrium to cause the appearance of a mass.
Therefore, the patient was brought to the interventional radiology suite for SVC angiography and thrombectomy with fibrin sheath removal and repeat nontunneled dialysis catheter replacement. Monitored anesthesia care was provided by a licensed anesthesiologist for the duration of the case. Ultrasound guidance was utilized to obtain access to the left internal jugular vein (IJ) with a 21-gauge micropuncture needle and a 10-French sheath was placed. Contrast was injected directly through the left IJ sheath and digital subtraction angiography (DSA) of the left brachiocephalic vein, SVC, and RA was performed. An evident filling defect was confirmed along the right lateral aspect of the proximal SVC that is compatible with the location of known intravascular mass or thrombus. An Amplatz wire was placed across the lesion and through the right atrium and inferior vena cava (IVC) to the iliac vein level.
To better characterize the abnormality, a Visions intravascular ultrasound (IVUS) probe (Philips, San Diego, CA) was inserted through the left IJ sheath and advanced across the lesion. IVUS showed a significant filling defect within the superior portion of the SVC extending into the RA (Fig. 2). The filling defect had a cross-sectional appearance of circular echogenic structure with a central lumen, compatible with residual fibrin sheath. Hypoechoic material was noted around the fibrin sheath likely due to more acute thrombus.
Fig. 2.
(A–D) Sequential images (proximal to distal) demonstrating filling defects within the superior vena cava and right atrium alongside the intravascular ultrasound catheter. The distal most image, (D) demonstrates a circular structure with central lumen (red arrow), compatible with fibrin sheath cast about the prior tunneled central venous catheter.
The existing right EJ hemodialysis catheter was retracted back into the confluence of the right brachiocephalic vein to prevent entanglement with the ClotTriever device and IVUS imaging was repeated to confirm the structure identified was indeed a fibrin sheath. Next, through the left IJ access, serial dilation was performed before insertion of the 13 French ClotTriever sheath under fluoroscopic guidance. The ClotTriever catheter was inserted over the wire and the basket advanced distal to the filling defect visualized on IVUS, and deployed in the SVC (Fig. 3). The distal tip of the ClotTriever device remained safely on the Amplatz wire in the lower IVC. The coring element and basket were deployed and retracted to perform mechanical thrombectomy and extirpation of intravascular material using fluoroscopic guidance. A single-pass made with the device facing in the direction of the thrombus yielded chronic appearing fibrotic material compatible with fibrin sheath (Fig. 4). In addition, small amounts of acute thrombi were removed.
Fig. 3.
Fluoroscopic image demonstrating the ClotTriever collection basket (red arrow) deployed in the superior vena cava. Existing right external jugular vein nontunneled catheter retracted to avoid entanglement in the ClotTriever device.
Fig. 4.
Chronic fibrotic material removed via mechanical thrombectomy utilizing a single pass of the ClotTriever catheter.
Subsequently, post-thrombectomy IVUS was performed through the left IJ sheath and demonstrated complete resolution of the intravascular filling defect, due to fibrin sheath, in the SVC and RA (Fig. 5). Post thrombectomy venogram was also obtained through the left IJ sheath and showed resolution of the filling defect (Fig. 6).
Fig. 5.
Post-thrombectomy intravascular ultrasound images of the right atrium (RA) and superior vena cava (SVC) demonstrate complete resolution of previously seen echogenic filling defects with normal vessel lumen.
Fig. 6.
Post-thrombectomy digital subtraction angiography demonstrating complete resolution of previous superior vena cava and right atrium filling defects after one device pass.
Finally, the existing right EJ nontunneled dialysis catheter was replaced over a guidewire for a new non-tunneled hemodialysis catheter under fluoroscopic guidance and secured in place. The tip of the catheter was placed at the superior cavoatrial junction and tested for patency by vigorous aspiration and flushing. Heparin was given throughout the procedure to aid in anticoagulation and was monitored closely via frequent activated coagulation time (ACT) testing. Minimal blood loss was noted and no intraprocedural complications occurred. The total duration of the procedure was 45 minutes with 3 minutes of fluoroscopy.
Case report 2
A 48-year-old male with a history of diabetes, hypertension, and ESRD on dialysis presented to the hospital with complaints of right sided facial and arm swelling and difficulty swallowing 1 week status post-tunneled dialysis catheter replacement at an outpatient facility. Outside records demonstrated that the catheter had initially been replaced over a wire, but due to continued malfunction the access was abandoned and a fresh catheter was placed with repeat venous access at a new site. This patient was admitted for possible SVC syndrome. An upper extremity ultrasound was conducted to rule out DVT. The ultrasound was negative for DVT and the vessels were widely patent. A chest CT scan was conducted and showed a tunneled right IJ dialysis catheter in place with tip termination in the proximal RA, lower SVC stenosis, and venous collaterals in the chest (Fig. 7).
Fig. 7.
(A–E) Axial and coronal computed tomography images of the chest demonstrating superior vena cava filling defect and occlusion inferior to the azygous vein confluence. Early mediastinal and chest wall venous collateralization was noted. The red arrows are pointing to the SVC filling defect in various planes and views.
The patient was subsequently scheduled for an SVC venogram with possible stent placement, angioplasty, removal of embolic intravascular material, and tunneled dialysis catheter exchange in the interventional radiology suite. General anesthesia care was provided to the patient via a licensed anesthesiologist. An Amplatz guidewire (Boston Scientific, Marlborough, MA) was passed through the existing right tunneled dialysis catheter and advanced centrally. After blunt dissection the catheter was removed and a sheath was advanced over the wire through the existing tunnel into the right brachiocephalic vein. Hand injection of contrast and DSA venogram showed complete occlusion of the SVC just beyond the confluence of the brachiocephalic vein with minimal collateral flow (Fig. 8). IVUS was performed over the wire which confirmed the complete occlusion of the SVC and showed additional heterogeneous hyperechoic intrinsic intravascular material likely related to fibrin sheath and thrombus (Fig. 9).
Fig. 8.
Initial venogram of the right brachiocephalic vein, superior vena cava, and right atrium demonstrating complete occlusion of the proximal superior vena cava.
Fig. 9.
Initial intravascular ultrasound images of the superior vena cava demonstrating complete occlusion with echogenic material likely due to fibrin sheath and/or chronic thrombus. The green circle represents the boarder of the superior vena cava.
Due to the extensive clot and possible fibrin sheath identified via IVUS, the ClotTriever system was utilized to remove the intravascular material. Serial dilation of the existing CVC track was conducted followed by insertion of a 13F ClotTriever sheath under fluoroscopic guidance. The ClotTriever device was then advanced over the wire and deployed past the clot burden location as noted on IVUS in the distal SVC. The device was retracted across the lesion to perform mechanical thrombectomy and extirpation using fluoroscopic guidance. A total of 3 passes were made with the device coring element opening facing varying directions. With this technique, a fibrin sheath cast in addition to acute and chronic clots were removed (Fig. 10). Hand-injected DSA venogram demonstrated improved flow through the SVC with severe residual stenosis (Fig. 11).
Fig. 10.
Chronic tube-shaped fibrin like material removed with ClotTriever system; findings consistent with fibrin sheath cast.
Fig. 11.
Post-thrombectomy digital subtraction angiography images demonstrating improved flow with diminished intravascular filling defect, but with severe residual stenosis.
Next, SVC stenosis was treated with PTA using an Atlas 16 mm x 40 mm high-pressure balloon (BD, Franklin Lakes, NJ). Balloon was inflated to nominal pressure of 6 ATM for 3 minutes. Afterward, venography (Fig. 12) and IVUS (Fig. 13) demonstrated a widely patent SVC.
Fig. 12.
Post-thrombectomy and percutaneous transluminal angioplasty venogram of right brachiocephalic vein, superior vena cava, and right atrium showing all vessels are widely patent. Venogram conducted under digital subtraction angiography with hand injection of contrast.
Fig. 13.
Intravascular ultrasound image of the superior vena cava following thrombectomy and angioplasty demonstrating a widely patent vessel with resolution of previous filling defect.
Finally, under fluoroscopic guidance and using the existing wire access a new 23 cm tunneled dialysis catheter was placed with the tip ending in the proximal RA. The catheter was aspirated and flushed to ensure patency and secured with a suture and Tegaderm Chlorhexidine Gluconate Dressing (3M, St Paul, MN). Heparin was given throughout the procedure to aid in anticoagulation and was monitored closely via frequent ACT testing. The total duration of the procedure was 1 hour and 27 minutes with a fluoroscopy time of 5 minutes, and 6 seconds. There was minimal blood loss and no intraprocedural complications were noted.
Case report 3
A 73-year-old female with a past medical history including diabetes mellitus, hypertension, hyperlipidemia, and endometrial cancer presented as an outpatient for facial and neck swelling on the right side and port malfunction. The patient had a chest port on the right side that was placed over a year prior. A chest CT with contrast was obtained outpatient showing severe SVC stenosis versus occlusion below the azygos confluence and well-established venous collateral flow (Fig. 14). Recommendation for revascularization of the SVC was made based on the patient's imaging and clinical presentation of SVC syndrome and the patient was scheduled for SVC recanalization.
Fig. 14.
(A and B) Axial (A) and coronal (B) computed tomography images of the chest through the superior vena cava demonstrating stenosis with venous collateral flow.
No access was possible through the lumen of the catheter due to the presence of an internalized port. Therefore, the patient was scheduled for an SVC venogram, possible thrombectomy, angioplasty, stenting, and chest port replacement in the interventional radiology suite. General anesthesia care was provided to the patient via a licensed anesthesiologist. Initially, 2 venous access sites were obtained using ultrasound guidance to better characterize the proximal and distal extent of the stenosis and allow potentially more convenient stent deployment from the common femoral vein. A 6 French sheath was placed in the right IJ and an 8 French Pinnacle Destination Guiding sheath (Terumo Interventional Systems, Somerset, NJ) was placed coaxially within a 10 French sheath in the right common femoral vein.
The 8 French sheath tip was guided from the common femoral vein and placed within the lower SVC. DSA of the SVC was conducted by hand injecting contrast simultaneously through the upper and lower access site sheaths to obtain a venogram. The venogram showed complete occlusion of the mid-SVC at the tip of the existing port catheter just below the azygos vein confluence (Fig. 15). Moreover, the azygos vein was enlarged with retrograde flow and prominent collaterals to the inferior vena cava. Next, a 90 cm angled NaviCross Support catheter (Terumo Interventional Systems, Somerset, NJ) and regular stiffness GlideWire (Terumo Interventional Systems, Somerset, NJ) were advanced through the right common femoral vein access to recanalize the SVC. With mild difficulty, the lesion was crossed, and the wire was captured using a gooseneck snare from the IJ access and the wire was externalized. The GlideWire was then exchanged for an Amplatz guidewire for added support.
Fig. 15.
Initial superior vena cava venogram demonstrating severe stenosis with collateral flow through an enlarged azygous vein.
Afterward, the old port and catheter were removed from the right chest and the pocket was flushed with vancomycin. A new catheter was tunneled under the right chest to the new IJ access site and a new port was placed in the existing pocket. The pocket was sutured closed using an absorbable suture and Dermabond (Ethicon, Cincinnati, OH) was placed on the skin. At this time the catheter remained externalized.
Subsequently, an Atlas 7 mm x 40 mm high-pressure balloon was advanced over the Amplatz wire to the area of complete occlusion and inflated twice to near burst pressure of 14 ATM for approximately 30 seconds. The balloon was removed, and an IVUS catheter advanced. IVUS imaging demonstrated continued complete occlusion of the SVC lumen with echogenic material likely to be chronic thrombus or fibrin sheath (Fig. 16).
Fig. 16.
(A–C) Initial intravascular ultrasound imaging showing complete occlusion of the superior vena cava and highly echogenic material likely to be chronic thrombus or fibrin sheath. The arrows are pointing to areas of increased echogenicity.
Mechanical thrombectomy of the SVC was conducted. Serial dilation of the right common femoral vein access was performed and a 13 French ClotTriever sheath was inserted under fluoroscopic guidance. Likewise, the right IJ sheath was upsized to a 12 French sheath. Once the sheaths were in place the ClotTriever catheter was advanced over the wire and deployed in the SVC with the superior aspect of the device externalized through the right IJ sheath access site (Fig. 17). The device was used to perform mechanical thrombectomy and en bloc extirpation of intravascular material under fluoroscopic guidance. As in prior cases, the ClotTriever basket was advanced past the area of clot burden utilizing what was visualized on IVUS to determine the ideal location. The ClotTriever catheter was retracted and advanced for a total of 3 passes with the device coring element opening facing various directions. Each pass resulted in the removal of chronic appearing thrombus from the SVC (Fig. 18). Post-thrombectomy venography revealed improved flow in the SVC but significant residual stenosis with retrograde flow in the enlarged azygous vein (Fig. 19).
Fig. 17.
This image shows the deployed ClotTriever catheter which was retracted across the superior vena cava, then collapsed and retracted across the right atrium and removed from the body.
Fig. 18.
Images of a small amount of chronic appearing thrombus or fibrinous material removed via thrombectomy using the ClotTriever system.
Fig. 19.
Post-thrombectomy venography demonstrating improved flow in the superior vena cava with significant residual stenosis with retrograde flow in the enlarged azygous vein.
Therefore, IVUS was used to evaluate vessel size and a 20 mm x 60 mm Abre venous stent (Medtronic, Minneapolis, MN) was advanced over the wire and deployed across the lesion utilizing the femoral venous access. After stent placement, angioplasty was performed with a 20 mm x 40 mm high-pressure balloon (Fig. 20). Poststent IVUS and venography demonstrated a widely patent SVC (Fig. 21). The azygous vein is no longer opacified with contrast implying a normal direction of flow.
Fig. 20.
Fluoroscopic image during superior vena cava stenting and angioplasty.
Fig. 21.
(A–D) Fluoroscopic (A and B) and intravascular ultrasound (C and D) images of the superior vena cava demonstrating patency and normal caliber post thrombectomy and percutaneous transluminal angioplasty. Fluoroscopic images show resolution of previously seen retrograde azygous flow.
Finally, the right IJ 12 French sheath was replaced with a 10 French peel-away sheath, and the externalized port catheter, previously tunneled under the skin, was measured, cut, and advanced through the peel-away sheath. The catheter tip terminated at the superior cavoatrial junction below the inferior aspect of the freshly placed SVC stent. Both access sites were closed with purse-string sutures and dressing. Heparin was given throughout the procedure to aid in anticoagulation and was monitored closely via frequent ACT testing. Minimal blood loss was noted and no intraprocedural complications occurred. The total duration of the procedure was 1 hour and 56 minutes with fluoroscopy time of 11 minutes and 42 seconds.
Discussion
The ClotTriever system was successful in complete residual fibrin sheath removal in 3 cases in which access through the lumen of the treated fibrin sheath was not possible. In these cases, this was achieved with short procedure durations and without embolization or other complications.
Catheter-associated fibrin sheaths are a challenge faced by many interventionalists. To date, there are no recommendations for preventing fibrin sheath formation in patients with long-term CVC access. Some studies have been conducted utilizing prophylactic thrombolytic agents or systemic anticoagulation to help prevent fibrin sheath formation [5]. However, these studies have shown contradictory information, and further studies are needed. In the absence of prophylaxis, the frequent incidence of fibrin sheath formation and increased use of long-term CVCs, exacerbates this issue. Interventionalists have limited treatment options, particularly when complications arise due to fibrin sheath which was left behind after the malfunctioning CVC was removed. Leaving a fibrin sheath behind in a vessel can predispose the patient to catheter-associated systemic infections as the fibrin sheath is a medium for bacterial accumulation and growth [6]. Complete fibrin sheath removal may be of benefit to minimize further propagation, prevent infection, maintain vessel patency, and therefore, potentially improve long-term patient outcomes.
Currently, there are a few methods of correcting fibrin sheath-related catheter malfunction including pharmacologic and mechanical methods, but all the techniques assume there is continued access through the catheter that caused the sheath and therefore through the lumen of the fibrin sheath. Additionally, these techniques may only provide short-term relief of CVC malfunction and can be associated with risk of embolization. Pharmacologically, TPA can be injected and left to dwell inside the CVC to help break up the thrombus and fibrin sheath, essentially restoring the full functioning of the catheter. However, this technique is only useful in early-stage thrombosis and does little to help break up more organized fibrin sheaths as they contain a highly structure collagen matrix that does not dissolve with TPA [7]. In addition, a few mechanical methods of fibrin sheath removal have been demonstrated including balloon disruption of the fibrin sheath with PTA, catheter exchange, fibrin sheath snaring, and guidewire sheath disruption [8]. Although these methods may work in several cases, they are not without their drawbacks. Specifically, PTA and sheath snaring may lead to the release of portions or the entire fibrin sheath into systemic circulation posing a risk of pulmonary embolism [3]. PTA of fibrin sheaths has also been associated with more frequent catheter exchanges and malfunction [9]. Catheter exchange over a wire does not treat the fibrin sheath as it is usually adherent to the vessel wall and is not removed with the old catheter. The newly placed catheter may malfunction shortly after replacement as the old fibrin sheath grows to obstruct the new catheter tip [8]. Likewise, guidewire sheath disruption is only a short-term solution as only the fibrin sheath at the tip of the CVC is treated. The remainder of the sheath can continue to propagate to obstruct the catheter tip [7]. In this newly proposed method of fibrin sheath and catheter-associated thrombus extraction, there may be a greater risk of vascular injury, bleeding, and cardiac arrhythmia given larger bore access than other existing methods.
This case review demonstrates a method for fibrin sheath removal when access through the central lumen of the fibrin sheath is not available. In 2 cases, this access was not available due to the removal of the catheter causing the fibrin sheath (Cases 1 and 2) as can be seen often with infection, line holidays, or unrecognized fibrin sheaths. In a third case, the fibrin sheath lumen could not be accessed due to association with a chest port catheter (Case 3).
Conclusion
Removal of fibrin sheaths that reside on the external aspect of CVC can be challenging, particularly when access through the lumen of the fibrin sheath is not available. The use of ClotTriever system in these situations has proven useful in both fibrin sheath removal and recanalization of stenotic regions of the SVC as seen in these case reviews. Overall, further studies are recommended to document the usefulness and success of this technique in additional cases. A direct comparison between current fibrin sheath removal techniques and this novel method is also recommended to evaluate effectiveness, efficiency, cost, complications, and long-term patient outcomes.
Patient consent
Informed consent regarding the use of patient case data, excluding identifying factors, was obtained within the consent forms signed by the patient and physician prior to the procedure. Likewise, approval by the Silver Cross Hospital Internal Review Board was obtained for the completion of this case review series.
Footnotes
Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Feraz Rahman has received consulting fees from Inari Medical.
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