Embolization of a fractured central venous catheter placed using the internal jugular approach

Abstract

INTRODUCTION

Fracture and embolization of central venous catheters placed via the subclavian approach is well recognized, but fractured catheters placed via the internal jugular vein are extremely rare.

PRESENTATION OF CASE

A 65-year-old man presented with a catheter embolus after placement of a central venous port using the internal jugular approach undertaken to administer adjuvant chemotherapy for colon cancer with lung metastases. Goose neck and conformational loop snares were successfully used to percutaneously retrieve the severed catheter, which had migrated to the right ventricle.

DISCUSSION

Catheter fracture may occur even after placement via the internal jugular approach and may be underestimated because it is often asymptomatic. Interventional radiology techniques using goose-neck and conformational loop snares may be useful to retract an intravascular foreign body.

CONCLUSION

Imaging studies such as a chest X-ray are mandatory to check that the catheter tip is in the appropriate position during the entire follow-up period even if it was placed through the internal jugular vein.

1. Introduction

Catheter fracture with subsequent embolization is a rare late complication of central venous catheter placement. It has been reported most commonly with a catheter placed using the subclavian approach and is often preceded by the “pinch-off sign”, first described by Aikten and Minton.¹ To avoid this potentially serious complication, an internal jugular (IJ) approach has been advocated by some authors.^2–4. We report a patient with a fragmented catheter embolus to the right ventricle in which the catheter of a central venous port was placed using the IJ approach. Interventional radiology techniques using goose-neck and conformational loop snares were used successfully to remove the catheter fragment, which had migrated to the right ventricle.

2. Presentation of case

A 65-year-old man with a history of ascending colon cancer and synchronous metastases to both lungs underwent placement of a central venous port (Bard Port with Groshong Catheter, Bard Access Systems Inc., UT, USA) to receive adjuvant chemotherapy. The catheter of the central venous port was introduced via the right IJ vein without complications. He subsequently underwent 12 courses of FOLFOX treatment. Due to the high risk of recurrence, the port was left in place for possible future use after completion of the scheduled treatment. He underwent computed tomography (CT) scanning every three months as part of routine follow-up. At 508 days after placement of the central venous port, it was noticed on the CT scan that the central venous catheter had fractured at the entry site into the right IJ vein and the distal tip of the catheter had migrated to the inferior vena cava (Fig. 1).

Fig. 1.

(A) Coronal, (B) sagittal reconstruction of images from the CT scan. The proximal catheter (thin arrow) is severed at the entry site to the right internal jugular vein. The distal fragment (thick arrow) lies in the inferior vena cava.

The patient was brought to the interventional radiology department and emergency angiography performed. By the time he reached the angiography suite, the distal catheter fragment had migrated further to the right ventricle. The right ventricle was too small for the basket wire to get fully expanded, so a 15 mm goose neck wire (Amplatz Goose Neck Snare Kit, ev3, Inc., MN, USA) was used to move the catheter tip into the inferior vena cava, a more favorable position for retrieval using the snare device. It was then retrieved using a 45 mm conformational loop snare (EN Snare Endovascular Snare System, Merit Medical Systems. Inc., UT, USA). The electrocardiogram showed premature ventricular contractions during the procedure. The central venous port was removed subsequently. The patient tolerated the procedure well without any sequelae.

3. Discussion

This case report emphasizes two important features. First, catheter fracture is possible, even after using the IJ approach. Second, interventional radiology techniques using goose-neck and conformational loop snares are useful to extract an intravascular foreign body. Fracture and migration of a central venous catheter is known as a late complication that occurs in 0.5%–3% of patients and is sometimes associated with port removal, but can also occur spontaneously.^5–8 This complication is known to occur more commonly after a subclavian-approach is used to place the catheter. This has led some to recommend the IJ approach as the preferred method to avoid catheter “pinch off” which has been associated with subsequent embolization.

However, this rare complication can also happen with a catheter placed using the IJ approach. Previous similar reports showed a fracture in the proximal portion of the catheter placed using the IJ route.^9–11 The fracture was attributed to repeated compression of the catheter against the clavicle. The present case is unique in that the transection spontaneously occurred in the distal portion of the catheter, about 10 cm from the port, at the entry site into the IJ in the right neck. We speculated that it might be due to material weakness of the silicone catheter.

Interventional radiology techniques using a combination of goose-neck and conformational loop wires were useful. The migrated catheter can cause significant complications such as pulmonary embolism, cardiac perforation, or sepsis. Percutaneous retrieval of an intravascular foreign body is standard therapy.^8,12,13 Once a foreign body becomes endothelialized, it is usually impossible to remove percutaneously. Therefore in this patient, angiography and removal was carried out expeditiously. There was not enough room in the right ventricle for a basket snare or a 45 mm conformational loop snare to become fully expanded. A goose-neck snare was then used, the catheter fragment moved to the inferior vena cava, and a conformational loop snare used to extract it.

Spontaneous catheter fractures may be under-estimated. In one report 83% were asymptomatic.⁶ In the present case, the tunneled portion of the catheter was palpable up to the neck, and appeared normal. Heparin flush did not result in swelling at site of the injection port chamber nor pain in the shoulder which have been reported to be signs of catheter fracture and leak.^6,7,9,11,14 Some vascular access devices are not assessed after completion of scheduled treatment, which suggests that they may never be identified as damaged.

4. Conclusion

Catheter fracture may occur even after placement via the IJ approach, and interventional radiology techniques using goose-neck and conformational loop snares may be useful to retract an intravascular foreign body. X-ray follow up is mandatory because damaged or embolized central venous catheters are often asymptomatic.

Consent

Informed consent was obtained from the patient.

Conflicts of interest

None.

Funding

None.

Author contributions

Drs. Atsushi Shimizu, Alan Lefor, Manabu Nakata, Umehachi Mitsuhashi, Masahiro Tanaka and Yoshikazu Yasuda contributed with the study design, data collection, data analysis, and writing the paper.