Intravenous catheter fragments: endovascular retrieval

Abstracts

OBJECTIVE: Central venous access is an increasingly frequent procedure and intravenous catheter fractures and fragments embolization, although being rare, correspond to the most common intravascular foreign bodies. This study purpose is to show our experience in the removal of these foreign bodies, employing endovascular techniques. MATERIALS AND METHODS: Retrospective analysis of ten consecutive cases in the last five years, including patients with ages ranging from 9 months to 67 years. RESULTS: The procedure was successfully performed in all the cases by means of different techniques and with no complication. Most common fragments lodgement sites were: right atrium, superior vena cava and left pulmonary artery. The retrieval of these foreign bodies by means of endovascular techniques is a relatively simple procedure when compared to the surgical alternative, and has been safely and successfully performed in countless patients. The available devices have proven quite effective and, among them, the loop snare is the most versatile. CONCLUSION: The high success rate with few complications reported, even in children, allows us to say that, whenever possible, percutaneous extraction of intravascular foreign objects should be performed. Notwithstanding, familiarization with the several techniques available is essential, allowing combinations and modifications according to each situation.

Vascular access ports; Foreign bodies; Embolism

OBJETIVO: A colocação de cateter para acesso venoso central é uma prática médica cada vez mais comum, sendo a fratura e embolização de fragmentos do cateter raras, porém correspondem aos corpos estranhos intravasculares mais comuns. O objetivo é demonstrar nossa experiência na retirada desses corpos estranhos intravasculares utilizando técnicas endovasculares. MATERIAIS E MÉTODOS: Análise retrospectiva dos últimos cinco anos permitiu a avaliação de dez casos consecutivos, com a idade variando entre nove meses e 67 anos. RESULTADOS: O procedimento foi realizado com sucesso em todos os casos, por diferentes técnicas, sem complicações. Os locais mais comuns de alojamento dos fragmentos foram átrio direito, veia cava superior e artéria pulmonar esquerda. A retirada desses corpos estranhos por técnicas endovasculares é procedimento relativamente simples quando comparado à alternativa cirúrgica, tendo sido utilizada com segurança e sucesso em inúmeros pacientes. Os dispositivos disponíveis mostraram-se bastante eficazes, sendo o laço o mais versátil. CONCLUSÃO: A alta taxa de sucesso com poucas complicações relatadas, mesmo em crianças, permite a afirmação que os corpos estranhos intravenosos devem ser extraídos por técnicas percutâneas sempre que possível. Contudo, a familiarização com as diversas técnicas é fundamental, permitindo combinações e modificações, adaptando-as à situação do caso.

Vias de acesso vascular; Corpos estranhos; Embolia

ORIGINAL ARTICLE

Intravenous catheter fragments: endovascular retrieval^*

Gustavo Andrade^I; Romero Marques^I; Norma Brito^I; Ângelo Bomfim^I; Douglas Cavalcanti^II; Carlos Abath^I

^IMD, Interventional Radiologists at Angiorad

^IIVascular Surgeon at Angiorad

^{Mailing address}

ABSTRACT

OBJECTIVE: Central venous access is an increasingly frequent procedure and intravenous catheter fractures and fragments embolization, although being rare, correspond to the most common intravascular foreign bodies. This study purpose is to show our experience in the removal of these foreign bodies employing endovascular techniques.

MATERIALS AND METHODS: Retrospective analysis of ten consecutive cases in the last five years, including patients with ages ranging from 9 months to 67 years.

RESULTS: The procedure was successfully performed in all the cases by means of different techniques and with no complication. Most common fragments lodgement sites were: right atrium, superior vena cava and left pulmonary artery. The retrieval of these foreign bodies by means of endovascular techniques is a relatively simple procedure when compared to the surgical alternative, and has been safely and successfully performed in countless patients. The available devices have proven quite effective and, among them, the loop snare is the most versatile.

CONCLUSION: The high success rate with few complications reported, even in children, allows us to say that, whenever possible, intravascular foreign objects percutaneous extraction should be performed. Notwithstanding, familiarization with the several techniques available is essential, allowing combinations and modifications, according to each situation.

Keywords: Vascular access ports; Foreign bodies; Embolism.

INTRODUCTION

The placement of central venous access is an increasing practice in medicine and embolization of these catheters or fragments is rare, representing only about 1% of complications^(1–3). Despite this low incidence, the great number of central venous accesses makes them responsible for the great majority of intravascular foreign bodies⁽¹⁾.

The present study objective is to demonstrate our experience in the removal of intravascular foreign bodies by means of endovascular techniques in the last five years (ten patients).

MATERIALS AND METHODS

In the period between 1999 and March 2004, a group of ten consecutive patients with ages ranging between 9 months and 67 years (Table 1) received central venous access devices. All the procedures for placement of the catheter were performed by surgeons without imaging guidance.

The catheter fracture usually occurs during its insertion, but we had one case during a catheter removal (Table 1 – patient 8; Figure 3). Once the fracture was noticed and confirmed by a chest X-ray, the patient was immediately referred to our service of interventional radiology in an emergency character.

RESULTS

All the procedures were performed in an angiography facility and under anesthesia. By means of a percutaneous femoral venous puncture (right or bilateral), a 8F introducer (French) permitted the handling of the different materials required for the procedure. A 5F catheter and an exchange guide-wire (260 cm) were conducted until the guide-wire was positioned adjacent to the catheter fragment (foreign body). Then, the 5F catheter was removed and the desired device — basket (Figure 1) or loop snare (Figure 3) — was introduced on the guide-wire. At that moment, the intravenous foreign body was captured by the device, and then grasped and removed.

In all of the cases, the procedures were technically successful, with no complications. None of the procedures has taken more than 40 minutes, between puncture and retrieval.

In two patients (Table 1 – patients 5 and 9; Figures 2 and ⁴), due to the absence of a free end of the fragment, its initial mobilization by means of a pig-tail catheter was necessary, bringing the fragment to a more favorable position and allowing its removal by means of a loop snare (Snare Amplatz; Microvena, White Bear Lake, MN).

DISCUSSION

Fracture of central venous access catheter is a rare although serious complication that may lead to thromboembolism, sepsis, cardiac arrhythmia, pericardial effusion, myocardial lesion and bacterial endocarditis. Unretrieved intravascular foreign bodies may cause severe or life-threatening complications in up to 71% of patients⁽¹⁾, with mortality ranging between 24% and 60%⁽⁴⁾. Notwithstanding some patients remain completely asymptomatic, the risk of such complications always makes removal desirable.

The percutaneous retrieval of intravascular foreign bodies is a relatively simple process, when compared to the surgical alternative, and has proven to be a safe and effective procedure for countless patients, including children and preterm neonates^(1–11). The most usually reported incident occurring during this procedure is cardiac arrhythmia that is always of transitory nature and related to intracardiac manipulation. These fragments usually can be atraumatically and successfully removed, the loop snare being recognized as the most effective and preferred device for this purpose^(1–13). Initially, our group opted for the basket (Figure 1) when industrially produced loop snares were not available. Since 2000, when they become available, it has been easy to note a change preference (Table 1) and currently the loop snare is our first option (Figure 3).

Most common fractured catheters lodging sites are the right atrium, the superior vena cava and the left pulmonary artery^(1–4), the two first ones being most frequently observed in this series (Table 1). We have always been utilizing a 5F diagnostic catheter and a long guide-wire to reach the intravascular foreign body and then, by means of the guide, placing the device (loop snare or basket) into the position desired. Once the fragment is captured and, for being flexible and foldable, it may be removed through the 8F introducer sheath. When the fragment is lodged in a distant position (^{Figure 4}) or with both extremities in contact with the vessel wall (Figure 2), it is very difficult or even impossible to capture it only with a loop snare. In this case, a 5F pig-tail catheter may be employed to enfold the fragment and bring it to a better position (Figures 2 and ⁴). With these approaches we were able to successfully remove all the fragments, but, if necessary, other techniques may be employed.

The interventional techniques for intravascular foreign bodies extraction have undergone significant changes over the years. Presently there is an array of devices available, like loop snares, baskets, balloons, forceps, molded catheters, directable guide-wires and magnets. All these devices have proved quite effective in certain situations, the loop snares being the most versatile ones^(1–13). The loop is at a right angle to the catheter (90°) and there is an array of snares sizes for an ideal adjustment to the vessel⁽¹²⁾.

CONCLUSION

The high rate of success and the low rate of complications, even in children, allow us to affirm that intravascular foreign bodies must be extracted whenever possible by means of percutaneous techniques. For this purpose, the availability of materials as well as the familiarization of the operating physician with the various techniques and materials are fundamental, permitting combinations and modifications to adapt them to the situation. Notwithstanding, sometimes creativity is an essential skill.

REFERENCES

Received May 25, 2005.

Accepted after revision September 2, 2005.

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*

Study developed at Angiorad – Grupo de Radiologia Intervencionista, Recife, PE, Brazil.

Publication Dates

• Publication in this collection
  17 Aug 2006
• Date of issue
  June 2006

History

• Accepted
  02 Sept 2005
• Received
  25 May 2005