1 Division of Nephrology, Department of Medicine and 2 Department of Radiology, Taipei Veterans General Hospital, and 3 Faculty of Medicine, National Yang-Ming University School of Medicine, Taiwan
Keywords: double-lumen catheter; intravascular catheter fragment; percutaneous retrieval
Introduction
Double-lumen haemodialysis catheters are commonly used for temporary venous access in end-stage renal failure patients who require urgent haemodialysis but who do not have mature vascular access. However, catheter dysfunction, such as thrombosis and infection, is not uncommon. Because the replacement of a non-functional double-lumen catheter into a new site exposes patients to greater risk of mechanical complications, guide wire exchange of the catheter is an alternative technique to reduce risk, as long as no exit-site or tunnel infection is present [1]. Here, we report a case of accidental migration of a double-lumen catheter fragment into the internal jugular vein during a guide wire exchange. Immediate retrieval of the fragment was successful by way of a percutaneous transfemoral venous approach. Both surgical removal of the intravascular catheter fragment and prolonged hospitalization after surgery were avoided.
Case report
A 60-year-old woman presented to the emergency room of Taipei Veterans General Hospital with uraemia due to end-stage renal failure. Physical examination revealed her blood pressure to be 215/111 mmHg, pulse 74 beats/min, and respiration 20 breaths/min, with pale conjunctivae and basal rales over both lower lung fields. Laboratory data showed a haemoglobin concentration of 7.3 gm/dl; blood urea nitrogen, 129 mg/dl; creatinine, 9.6 mg/dl and potassium, 7.1 mEq/l. Chest X-ray revealed cardiomegaly and pulmonary congestion. Acute haemodialysis was initiated later. Because of the lack of a permanent vascular access, a double-lumen catheter (Arrow International Inc., Reoding, PA, USA) was inserted via the femoral venous approach. However, persistent oozing developed at the insertion site of the femoral vein catheter following haemodialysis and the catheter was removed the following day. Another double-lumen catheter was inserted via the right internal jugular vein using the external landmark-guided technique [2]. Nine days later, a left forearm arteriovenous polytetrafluoroethylene graft was created. By day 12, thrombosis developed within the jugular vein haemodialysis catheter causing inadequate blood flow during dialysis. An exchange of catheter over a guide wire was attempted at the bedside by the physician. The mid-portion of the double-lumen catheter was cut 2 cm above the skin exit site and a guide wire was then introduced through the anterior portion of the catheter. Unfortunately, the patient was very irritable during the procedure and the catheter fragment accidentally slipped and embedded itself under the neck skin. Immediate portable chest X-ray revealed a catheter fragment located in the central venous system of the neck (Figure 1). Emergent sonography further showed that the catheter fragment had dislodged itself entirely and entered into the right internal jugular vein. Thereafter, non-surgical retrieval of the catheter fragment through the percutaneous transfemoral venous route was immediately performed by a radiologist (S.S.T.) with a 6 Fr. gooseneck snare catheter (Microvena corporation, White Bear Lake, MN, USA) and a 14 Fr. vascular sheath. The floating free end of the catheter fragment was snared and pulled down through the superior vena cava, inferior vena cava and right external iliac vein under fluoroscopic guidance (Figure 2A
). Finally, the catheter fragment and retrieval set were put into the sheath and then withdrawn from the right femoral vein as a unit (Figure 2B
). The patient was very tolerant and no major complications were observed during or after the procedure. One day after the catheter fragment was removed, the patient was discharged uneventfully.
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Discussion
This report presented an iatrogenic catheter fragment in the central venous system. Fatal complications previously reported in the literature [35] include broken CVP catheters, metal guide wires, pacemaker electrodes, port-A fragments and vascular stents. Removing catheter fragments from the great vessels as soon as possible is necessary because the reported complications have been potentially life-threatening. Such complications have included septicaemia, multiple pulmonary emboli and abscess formation, arrhythmia, perforation of the great vessels or the heart, and sudden death [6]. Non-surgical removal of an intravascular steel guide wire fragment was first reported by Thomas et al. in 1964 [7]. Nowadays, percutaneous retrieval of an intravascular foreign body has become a relatively common procedure in interventional radiology. If a catheter fragment is free-floating (i.e. completely intravascularly), a percutaneous retrieval technique is the method of choice. However, if the fragment still remains anchored at the point of skin entry or outside the vessel, surgical cutdown may be preferred as a first approach [6]. In our case, ultrasonography disclosed that the catheter fragment had completely migrated into the internal jugular vein. Therefore, percutaneous retrieval was chosen in preference to surgical exploration and a gooseneck snare was used in our case. This non-operative technique is now available for removing catheter fragments in all catheter laboratories. Its advantages are its simplicity and safety. Moreover, surgical retraction, with its accompanying risks, should be avoided where possible.
Temporary venous catheters are commonly used for acute angioaccess in patients with end-stage renal failure needing urgent haemodialysis but who have no available mature access. However, catheter dysfunction such as thrombus formation is commonly encountered. Placement of a new catheter at another site is occasionally necessary but increases the chance of morbidity substantially during the procedure. Exchange of the catheter over a guide wire is a simpler technique if there is no evidence of tunnel or exit-site infection [1]. Insertion-related mechanical complications are minimized if physicians adopt the proper procedure. In our case, the attempt to introduce the guide wire through the double-lumen catheter fragment in an irritable patient led to the above-mentioned serious complication. Therefore, avoiding cutting off the double-lumen catheter and ensuring adequate sedation for irritable, uncooperative patients is mandatory. Moreover, the proper procedure for a guide wire exchange of double-lumen catheters by skilled physicians, or trainees under close supervision, cannot be over-emphasized. In case a double-lumen catheter fragment is dislodged in the internal jugular vein, we recommend that the percutaneous retrieval technique be considered first. This removes the potential risks of surgery and anesthesia, and also provides a simple and safe alternative for the management of such a fatal complication.
Teaching point
Extreme caution should be exercised in guide wire exchange of a non-functional, thrombotic catheter, and the double-lumen catheter should not be cut off for guide wire insertion. We recommend percutaneous retrieval by the gooseneck snare technique as the treatment of choice for a broken haemodialysis catheter fragment dislodged into the internal jugular vein.
Notes
Correspondence and offprint requests to: Der-Cherng Tarng, MD, Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital No. 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. Email: dctarng{at}vghtpe.gov.tw
References