Surgical retrieval of transected umbilical vein catheter in an extremely preterm neonate

Abstract

Umbilical catheters are used in the care of critically ill neonates for intravenous treatment. It is generally considered a safe procedure, although complications can occur. Of these, catheter breakage and intravenous migration are rare but potentially life-threatening events. Due to the low frequency of which these events occur, obtaining detailed descriptions of removal techniques can pose a challenge. Here, we describe a case of a broken umbilical vein catheter and the surgical retrieval of the retained fragment. We also present a thorough literature search of cases of broken umbilical catheters and the method by which they were removed.

Background

Umbilical vein catheters (UVCs) and umbilical arterial catheters (UACs) are extensively used in the care of critically ill neonates who require central venous access for intravenous medication, fluid treatment and blood sampling. Although generally safe, complications arise in 13.3%–20.3% of UVC placements.^{1 2} Catheter breakage is a rare and unfortunate complication which can result in the migration of the catheter and embolus formation, ultimately leading to severe complications.^{3 4} Retrieval of embolised foreign bodies in neonates can prove difficult. In the English literature, a few cases of broken umbilical catheters have been reported. Here, we describe a case of a broken UVC in an extreme preterm neonate and the surgical retrieval of the retained catheter fragment. Furthermore, we review the literature for cases of broken umbilical catheters and describe how others have managed this complication.

Case presentation

A gestational age of 27 weeks, extremely preterm male infant with a birth weight of 1290 g was born by caesarean section to a mother with preterm premature rupture of membranes. The neonate was admitted to the neonatal intensive care unit (NICU), and a 3.5 Fr UVC (VYGON, Polyvinyl Chloride Umbilical Catheter) was placed for parenteral nutritional support and drug infusion. Correct placement at the junction of the inferior vena cava and the right atrium was verified by ultrasound.

Due to developing signs of infection, the UVC was discontinued on day 3 as per clinical guidelines.⁴ During removal, the catheter accidentally broke. Bedside localisation and extraction were attempted but halted due to further migration of the catheter into the umbilical vein and bleeding from the manipulation.

Investigations

In an effort to localise the ruptured catheter, a babygram was taken. The catheter was localised with the peripheral end just below the umbilical level and the central part in the right atrium at Th 5–6 level (figure 1). Due to the superficial position of the catheter and in order to minimise the risk of further central migration, prompt surgical intervention was planned.

Figure 1.

Horizontal babygram image showing a catheter (marked by arrows) with the central end in right atrium and the peripheral end just under abdominal fascia at the umbilical level, where an artery forceps is used to mark the location.

Treatment

Informed consent was obtained from the patient’s parents, and the neonate was urgently sedated, intubated and transferred to a surgical theatre. Under general anaesthesia, a 1.5 cm transverse supraumbilical incision was made and carried down through the fascia. The umbilical vein was identified and clamped centrally with a bulldog vascular clamp. The umbilical vein was accessed through a longitudinal cut down. The catheter was located and retrieved in its entirety using forceps without any complications. The procedure was performed by an experienced paediatric urologist.

Outcome and follow-up

Successful complete retrieval of the embolised foreign body was confirmed by visual inspection of the catheter fragment and a repeat babygram. The total procedure time was 15 min with no blood loss. The boy was discharged, thriving from the neonatal unit at 2 months of age.

Discussion

Umbilical catheters are well-established for managing infant care in the NICU. Complications are known to arise at insertion, manipulation and on removal.

Umbilical catheter rupture is a rare but feared complication. Catheter transection can occur due to removal with scissors or scalpels if the catheter has been sutured to the skin; hence, banding in bridge must be preferred.⁵ It can also rupture due to application of excessive force when withdrawing the catheter. Migration of the umbilical catheter fragment poses a risk of infection, embolisation, arrhythmias and vascular perforation, among others.^{1 3 6}

In some cases, embolised catheters were not acknowledged until several months after discontinuation,^{7 8} which emphasises the importance of visual inspection of the catheter upon removal and ultrasound or X-ray-verified removal of the complete catheter in cases of doubt.

As stated by Ruiz et al,⁹ time is of essence when planning the retrieval of an intravascular foreign body in a neonate, since severe complications can occur at any time. In our case, the time from catheter fracture to intervention was under 2 hours, thereby minimising the risk of proximal migration. In the case by Patel et al,¹⁰ delayed intervention resulted in catheter migration towards the heart and, therefore, the need to change the procedure from a minor surgical intervention to a more intricate endovascular procedure. Delayed removal of an UAC has in some cases been reported to cause rapidly progressing ischemia of extremity muscles.^{11 12}

In table 1, we present a thorough literature search of cases in the English literature of fractured umbilical catheters and the chosen method of retrieval. A structured reference review of the included studies was conducted, and additional articles were found and included.

Table 1.

Distribution of umbilical vein and artery retained catheters and extraction procedures

	Number of open procedures	Number of endovascular procedures	Number of other procedures	Gestational age range	Birthweight range	References
UVC	2	17*	0	24–40 weeks	600–3652 g	5 8–10 18–30
UAC	10	4*	2†	26–40 weeks	637–4000 g	7 11 12 14 18 20 29 31–39

A more detailed table is to be found in the online supplemental appendix.

*Endovascular loop snare was used in 20 cases, while endovascular forceps was used in one case.

†One catheter was not removed, while the other was pulled out using forceps.

A total of 35 cases were found. To our knowledge, our report is the most extensive literature search on the subject.

In the presented cases, various methods of retrieval have been described, including endovascular techniques; snare technique, wire and balloon catheters, pigtail catheters and open surgical procedures; laparotomy, open surgery and aortotomy, among others. Of these, the snare endovascular technique is the most frequently used, according to our research. The snare technique was used in 45.7% of the cases, but the method of choice has depended on infant size and clinical status, position of the catheter fragment, available equipment, expertise and risk of fragment-associated complications. The type and rigidity of the embolised catheter is also important when choosing the method of retrieval.¹³ In some cases, leaving the fragment in situ until the clinical status of the infant improved was chosen.¹⁴ In a literature study from 2012 comparing the retrieval of iatrogenic intravascular foreign bodies in 574 cases of both adult and paediatric patients, the snare technique was also found to be the most frequently used.¹⁵ Yet, no formal clinical guide to management of a fractured umbilical catheter exists.

Of the 35 cases, that we have found, gender of the infants was female in 9 of the cases and not specified in 7 of the cases. In the remaining 19 cases, the infants were male. This may be explained by the fact that the male gender is also predisposed to premature birth;¹⁶ hence, more male neonates will need placement of an umbilical catheter.

In our case, open access to the umbilical vein through a supraumbilical incision enabled retrieval of the UVC. This was possible due to the location of the fragment. The catheter fragment was lodged peripherally in the umbilical vein, which enabled retrieval through open access with a minor incision. When the integrity of a vein is disrupted through surgery, there is always a risk of infection, bleeding and formation of a vascular air embolism¹⁷, and this should be considered when attempting such an approach.

Learning points.

• To minimise the risk of catheter breakage, never use excessive force when withdrawing the umbilical vein catheter (UVC), and care must be taken when using a scalpel or scissors in the process of removal.

• The preferred method for UVC fixation is ‘banding in bridge’, which minimises the risk of endovascular catheter migration.

• Prompt diagnosis and retrieval of embolised umbilical catheter fragments are necessary to avoid further migration and potential vascular complications.

• In case of embolised umbilical arterial catheter (UAC), it is important to monitor limbs for signs of ischaemia.

• Endovascular extraction techniques are most prevalent in the literature, but open extraction is also a possibility if the catheter end still resides peripherally.

Ethics statements

Patient consent for publication

Consent obtained from parent(s)/guardian(s)