The stuck central venous catheter: beware of potential hazards

S. Mahadeva, A. Cohen* and M. Bellamy

Intensive Care Unit, St James’s Hospital, Beckett Street, Leeds LS9 7TF, UK*Corresponding author

Accepted for publication: May 30, 2002


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Many complications of attempted central venous access have been described, most related to insertion. Larger and stiffer catheters are being used more often for dialysis or massive transfusion. This case report details how one catheter was damaged during the insertion of a second catheter. The problem was discovered when the catheter could not be removed, and was subsequently removed after dissection. The reason for the difficult removal and the likely consequences of excessive force are illustrated.

Br J Anaesth 2002; 89: 650–2

Keywords: complications, catheter damage; equipment, catheters; monitoring, physiological


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Percutaneous insertion of central venous catheters (CVCs) is routine hospital practice. Complications of this procedure have been well documented. Most arise from problems encountered during insertion (cardiovascular side-effects and bleeding) and during maintenance (infection, thrombosis and mechanical risks).1 One of the mechanical complications of CVC use is breakage, with the risk that the distal remnant is dislodged as an embolism while a stuck catheter is being removed.2 We describe an unusual cause of this complication in a fairly common clinical scenario.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
MF, a 48-yr-old female patient with chronic myeloid leukaemia, was admitted with sepsis several weeks after a bone marrow stem cell transplant. Ultrasound scanning of her upper thorax and neck revealed thrombosis in both the right internal jugular and subclavian veins, because of previous catheter insertion for multiple courses of chemotherapy. On the day of admission a 20 cm long, 8.5 Fr, quadruple-lumen CVC (Vygon, Cirencester, UK) was placed in the left internal jugular (LIJ) vein by a Seldinger technique and under ultrasound guidance. The catheter was inserted up to the 15 cm mark, with the remaining proximal portion external to the patient. The position was checked in the usual manner by a chest radiograph (Fig. 1). Seven days later, we decided to replace the existing CVC because of a suspicion of line-related sepsis. Using the same technique, the left subclavian vein was easily cannulated but the guide wire met resistance after advancing several centimetres. A further two attempts were made in a similar manner, with similar results and the procedure was abandoned. Central venous access was obtained without difficulty via the right femoral vein.



View larger version (142K):
[in this window]
[in a new window]
 
Fig 1 Antero-posterior chest x-ray. The left internal jugular cannula is visible.

 
Some time later, the nurse caring for the patient reported difficulty removing the LIJ catheter. Resistance was met after 13 cm of the catheter had been withdrawn, with 2 cm of the catheter still within the vascular lumen. Gentle traction was applied to no avail. Close inspection after the entry site had been extended to 1 cm suggested that the catheter had been partially sheared and that complete fracture was imminent. An emergency cut-down procedure was performed along the site of the LIJ vein; the catheter remnant was identified and was found to be connected to the body of the catheter by one remaining intact lumen of the original four. The remnant was secured with an artery clip and was successfully removed (Figs 2 and 3); the incision site was sutured. After removal it was seen that the cause of the catheter being stuck was the ridge caused by the fracture in the external material of the line becoming stuck in the vessel wall on removal (Fig. 4).



View larger version (36K):
[in this window]
[in a new window]
 
Fig 2 Photograph of left internal jugular catheter after removal. The distal tip became disconnected after secure application of the artery clip during removal.

 


View larger version (45K):
[in this window]
[in a new window]
 
Fig 3 The distal section of left internal jugular catheter. It is possible to see the individual internal lumen (one of four), now fractured.

 


View larger version (53K):
[in this window]
[in a new window]
 
Fig 4 Line drawing representing the internal jugular vein cut longitudinally. It is possible to see the puncture in the vessel wall, the tip of the partially fractured CVC within the lumen and the fracture stuck across the gap. One of the four internal lumens remains intact. Traction on the external part of the line would have resulted in venous embolization.

 
No immediate complications arose from this procedure but the patient died with overwhelming sepsis a week later.


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Shearing or fracturing is a recognized complication of CVC use. One centre reports an incidence of 2.5% over a 5 yr period; however, these incidents were all in neonates.2 Causes that have been described include shearing by the introducer needle during insertion,2 high pressure within the catheter caused by bolus infusions,2 fracturing of the external portion by the patient’s body movements (mostly infants),3 during removal of a stuck catheter (mostly by fibrin sheath formation around the catheter),4 and weakening of the catheter tip by movements of the tricuspid valve and right ventricular motion3 or mechanical forces between the clavicle and first rib.5 In our case, shearing of the LIJ catheter was probably caused by repeated cannulation attempts from the introducer needle in the left subclavian vein, both from the cutting edge of the needle and by blunt trauma from the metallic guide wire. The tip of the LIJ catheter was in the appropriate position for this to have occurred (Fig. 1). In view of this experience, we feel that cannulation of a central vein on the same side as an existing CVC requires caution. When inserting a new CVC the operator should be aware of the position of the tip of an existing CVC in relation to the site of cannulation. Furthermore, resistance to the passage of the introducer needle or guide wire, as we experienced, should be an absolute contraindication to further attempts at cannulation before the other cannula is removed.

Various methods of dealing with a sheared or fractured CVC have also been explored. Most authors advise against applying tension. In contrast, slow gentle traction (up to 36 h!) has been used with some success,6 but usually in cases with intact CVCs that have become entangled in fibrin sheaths. Cutaneous cut-down followed by distal venotomy to remove stuck catheters that have not fractured completely has been described previously as safe, simple and easily performed at the bedside.4 Once complete fracture with subsequent embolization has occurred, however, more complicated approaches have been used, including radio logical loops, snares and coils, and occasionally surgical exploration as a last resort.2 Hence, once shearing of a catheter is suspected, we advocate very cautious handling of the CVC. In particular we believe our case highlights that forceful traction on any stuck catheter should be avoided and a cause sought as soon as possible.

In summary, we have described an unusual cause of shearing of a CVC. In critically ill patients, changing a CVC is a common procedure if the existing catheter is possibly infected. Careful handling and immediate bedside attention can prevent more serious sequelae, such as embolization of a fragmented catheter tip. Clinicians should be aware of this previously unreported hazard of CVC use.


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Arenas-Marquez H, Anaya-Prado R, Barrera-Zepeda LM, Gonzalea-Ojeda A. Complications of central venous catheters. Curr Opin Clin Nutr Metab Care 2001; 4: 207–10[ISI][Medline]

2 Trotter C, Carey BE. Tearing and embolisation of percutaneous central venous catheters. Neonatal Netw 1998; 17: 67–71

3 Khilnani P, Toce S, Reddy R. Mechanical complications from very small percutaneous central venous Silastic catheters. Crit Care Med 1990; 18: 1477–8[ISI][Medline]

4 Ng PK, Ault MJ, Fishbein MC. The stuck catheter: a case report. Mt Sinai J Med 1997; 64: 350–2[ISI][Medline]

5 Ramsden WH, Cohen AT, Blanshard KS. Case report: central venous catheter fracture due to compression between clavicle and first rib. Clin Radiol 1995; 50: 59–60[ISI][Medline]

6 Gladman G, Sinha S, Sims DG, Chiswick ML. Staphylococcus epidermidis and retention of neonatal percutaneous venous catheters. Arch Dis Child 1990; 65: 234–5[Abstract]





This Article
Abstract
Full Text (PDF)
E-Letters: Submit a response to the article
Alert me when this article is cited
Alert me when E-letters are posted
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Search for citing articles in:
ISI Web of Science (1)
Disclaimer
Request Permissions
Google Scholar
Articles by Mahadeva, S.
Articles by Bellamy, M.
PubMed
PubMed Citation
Articles by Mahadeva, S.
Articles by Bellamy, M.