Catch the Cath or Not? A Hamletic Dilemma after 10 Years

Abstract

In the last few years, a tremendous advancement has been made in the therapeutical management of several diseases with an increasing need for parental drug administration. To avoid repeated venous insertions and the patient’s anxiety related to these procedures, it is now common practice to insert a catheter to leave it in place for a longer time. However, these procedures may generate some complications, such as failure of insertion, embolization, and infection. Different noninvasive techniques have been proposed and used for the retrieval of lost or misplaced foreign objects. Here, we presented a case of the lost fragmented catheter in a young female who underwent a central venous catheter insertion 10 years ago, incidentally detected during an echocardiographic examination. Here, we presented a case of a lost fragmented catheter in a young female who underwent a central venous catheter insertion 10 years before.

INTRODUCTION

Therapeutic parenteral drug administration is now widely used,[1] especially for patients undergoing chemotherapy. This practice is increasing given the growing number of patients candidates for long-term therapy, the extension of indications, and pharmacological innovations that lead to the use of novel parental formulations.[2] To facilitate the delivery of infusion therapies and improve patient discomfort, as well as the anxiety associated with repeated venous insertions, it is current practice to insert a venous catheter that can be left in place for long periods.[3] The technological improvement of the available devices, the insertion techniques, and the postimplantation management make this practice widely accepted by patients, especially those who do not experience complications.[3] The most commonly central venous catheters (CVCs) used for long-term therapies include surgically implanted cuffed tunneled CVCs, subcutaneously implanted ports (e.g., port-a-cath), peripherally inserted CVCs, and percutaneous noncuffed or tunneled catheters.[2]

However, despite the technical improvement of devices and implant procedures, the use of CVCs remains burdened by mechanical, infectious, and thrombotic complications, especially in cancer patients who may have additional risk factors.[3] Some of these risks are still not well defined and may lead to particular cases that might represent a therapeutic challenge, as the case here reported.

CASE REPORT

A 32-year-old female was admitted to our cardiology unit because of acute heart failure after an emergency cesarean section at the 8^th month of gestation. A diagnosis of peripartum cardiomyopathy with moderate systolic dysfunction was made and the appropriate therapy was started according to the current guidelines. She had a history of acute myeloid leukemia (AML) about 13 years ago, requiring hospitalization, with a bone marrow autotransplantation, chemotherapy, and subsequent allogeneic bone marrow transplantation. The echocardiographic examination and admission showed a hyperechogenic, grossly linear, and partially floating formation in a parasternal short-axis section at the level of the great vessels, at the bifurcation of the pulmonary artery [Figure 1a and b, white arrow]. Within the limits of the ultrasound technique, an attempt was made to follow its course along the pulmonary branches. This formation was further investigated with a second-level technique using a high-resolution chest computed tomography (CT) scan. CT scan revealed a linear formation straddling the bifurcation of the pulmonary artery [Figure 1d, black arrow], mainly projecting to the left, with a craniocaudal and lateromedial course up to the level of the seventh dorsal vertebra [Figure 1c, black arrow].

Figure 1.

(a) Short-axis echocardiographic section showing a hyperechogenic, grossly linear, and partially floating formation (white arrow) at the level of the great vessels, at the bifurcation of the pulmonary artery. (b) Modified short-axis echocardiographic section was performed to follow the course of the floating formation (white arrow) along the pulmonary branches. (c) Sagittal computed tomography (CT) scan view showing a cranio-caudal and lateromedial course up to the level of the seventh dorsal vertebra of a residual catheter. (d) Axial CT scan view showing the catheter straddling the bifurcation of the pulmonary artery with a minimum distance of 6 mm between the tip of the central venous catheter and the visceral pleura of the left lung (black arrow)

This accidentally detected finding might be most likely attributed to a CVC positioned during her previous hospitalization because of AML, standing in situ for more than 10 years. The patient did not develop any symptoms related to this foreign body during her hospital stay. To our knowledge, this is the longest permanence time reported in the literature for an abandoned CVC.[4] Notably, the catheter migrated toward the pleura with a minimum distance of 6 mm between the tip of CVC and the visceral pleura of the left lung [Figure 1c, black arrow].

DISCUSSION

In the last few decades, the number of mini-invasive procedures is increasing in cardiology as well as in other medical specialties. Thus, the number of procedure-related events requiring system removal because of failure or infection, is also increasing. For device-related complications, the extraction techniques have improved and several reports have been already published in the field with the endovascular approach more used.[5,6,7] For CVC and other types of catheters, beyond conventional surgery, different mini-invasive[8,9] or novel surgery techniques[10] have been proposed. Our case is intriguing due to the position and the long-lasting. We did not find reports in the literature with shorter distances from the tip of CVC to the pleura. The abandoned CVC is potentially risky for the patient; the depth reached and the proximity to the pleura make a periodic follow-up of paramount importance. The long persistence in this position makes its removal dangerous, given the thin walls of the pulmonary arterioles. The case is a challenge: What decisions to make about it? Is it more appropriate to leave the body in place despite the patient’s young age or to perform an attempt of removal? In the latter case, what would be the best strategy? We asked first for an interventional cardiologist consultation that was aware of the position and the long-lasting, with a higher risk of bleeding and complications. Thus, we decided on a cardiothoracic surgical consultation. The surgeons proposed an open chest surgery at intermediate-high risk because of the proximity to the pleura and long persistence. Once discussed, the available therapeutical options and each risk/benefits ratio, the patients, taking into account the absence of symptoms, the long-standing of the catheter, and the risk of the proposed procedures, decided on a clinical follow-up.

In the literature, procedure-related complications involving the loss or the unsuccessful or incomplete removal of intravascular objects have been widely described. In the last decades, several mini-invasive techniques for retrieval of lost or misplaced foreign objects have been developed, and the removal of almost every foreign object has become possible. However, our case is rare and tricking, and despite the final therapeutical approach chosen, the hamletic dilemma on the best treatment remains open!

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.