(Chest. 2000;117:1209-1211.)
© 2000
American College of Chest Physicians
Retrieval of an IV Catheter Fragment From the Pulmonary Artery 11 Years After Embolization*
Srihari Thanigaraj, MD;
Ayyasamy Panneerselvam, MD and
John Yanos, MD
*
From the Cardiovascular Division (Dr. Thanigaraj), Washington University, St. Louis, MO; and the Department of Internal Medicine (Drs. Panneerselvam and Yanos), University of Missouri, Columbia, MO.
Correspondence to: Srihari Thanigaraj, MD, Cardiovascular Division, Washington University School of Medicine, 660 South Euclid Ave, Box 8086, St. Louis, MO 63110; e-mail: hari{at}cardsfellow.wustl.edu
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Abstract
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The use of a peripherally inserted central catheter (PICC) is
occasionally complicated by intravascular fracture and central
embolization of the catheter fragment. We present a patient in whom a
PICC fragment was retrieved from the pulmonary artery 11 years after
embolization following its incidental detection. Despite a history of
IV drug abuse and mitral regurgitation, this patient remained
asymptomatic and without complications. The catheter fragment was
retrieved since the patient was believed to be at risk for
endocarditis. This may be the longest duration reported of an embolized
catheter fragment that was successfully removed. As the natural history
of asymptomatic-retained central venous foreign bodies remains unclear,
the decision to remove them should be individualized. In selected
cases, these foreign bodies may be retrieved without complications even
several years after embolization.
Key Words: foreign body embolization • indwelling venous catheters • IV foreign bodies • peripherally inserted central catheters
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Introduction
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Indwelling
venous catheters are widely used for prolonged infusion therapy.
Intravascular fracture and embolization to distal vascular sites may
complicate their use. A case of central embolization of a catheter
fragment that was extracted 11 years later is presented and the related
literature is reviewed.
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Case Report
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A 40-year-old woman was hospitalized for IV antibiotic treatment
of right foot cellulitis. A PICC was placed through the right
antecubital vein for this purpose. Chest radiograph confirmed the PICC
position with its tip terminating in the superior vena
cava. Also noted on the chest radiograph was a catheter fragment in the
left pulmonary artery that had no continuity with the PICC positioned
in the superior vena cava (Fig 1
). The PICC was immediately removed, inspected, and found to be intact
up to the tip without any evidence of breakage.
Detailed history elicited from the patient revealed that she had
had a PICC placed at another hospital 11 years earlier. On its removal,
this catheter apparently could not be extracted in its entirety and its
proximal portion was found to be severed off. Attempts to localize the
broken catheter tip fragment were unsuccessful. This history was
verified with the hospital where she had the first PICC placed. The
patient failed to return for follow-up and did not advise other
physicians of this condition, as she remained asymptomatic. Apparently
this catheter fragment had embolized to the left pulmonary artery,
where it remained until discovered incidentally on the chest radiograph
performed at our institution.
The patient’s medical history was significant for IV drug abuse and
mitral valve prolapse with regurgitation. In view of her risk for
endocarditis and her prior history of pulmonary embolism (occurred
prior to the first PICC placement), it was decided to remove the
embolized catheter fragment. Using a percutaneous right femoral venous
approach, a 6F multipurpose catheter was advanced via the right heart
to the left pulmonary artery. A 15-mm Nitinol snare was advanced
through the multipurpose catheter, and the PICC fragment measuring 9 cm
was retrieved intact without complication (Fig 2
). A follow-up chest radiograph excluded any residual fragments
in the left pulmonary artery (Fig 3
). The postprocedural hospital course was uneventful, and the patient
was discharged in a stable condition on the fourth day of
hospitalization.
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Discussion
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Inadvertent fracture and fragment embolization of
indwelling venous catheters continues to occur despite the use of
meticulous techniques. Catheter fatigue from prolonged use contributes
to in situ fracture, fragmentation, and distal
embolization.1
The catheter fragments migrate
distally along the blood stream finally lodging in the vena cava,
right atrium, right ventricle, or the main pulmonary artery or
one of its branches. The final site of lodgment depends on their
length, weight, and the material stiffness.2
Centrally embolized foreign bodies may be associated with serious
complications, but the true complication rate is unknown due to the
lack of large studies. The possible complications include myocardial
perforation or necrosis culminating in tamponade, myocardial
infarction, valvular perforation, arrhythmia, and cardiac arrest. The
foreign body can act as a nidus for thrombus formation with resultant
pulmonary embolism. Infectious complications include endocarditis,
secondary infection of thrombus, mycotic aneurysm, and
pulmonary abscesses.2
3
4
Mortality depends on the duration
as well as the site of lodgment of the embolized foreign body.
According to one study, mortality was the highest when the foreign body
was lodged in the right heart, less when localized in the vena cava,
and least when lodged in the pulmonary artery.5
Our patient did not suffer any complication from the retained catheter
fragment for 11 years, despite her IV drug use, which increases the
risk of infectious complications. To our knowledge, this case may
represent the longest catheter fragment embolization that was then
successfully removed. There is one other case described in the
literature in which a patient with an embolized guidewire in the
pulmonary artery remained asymptomatic for 14 years, but extraction was
not attempted in this case as the guidewire was adherent to the
vascular wall.6
Interestingly, there were no adhesions in
our patient and the catheter fragment was retrieved easily.
Percutaneous retrieval can be done using loop snares, Dormia baskets,
hooked guide wires, and Fogarty balloon catheters.1
3
Before attempting percutaneous removal, angiography may be considered
to exclude thrombus2
that may predispose to pulmonary
embolism.1
Percutaneous extraction may be performed at a
low risk,3
but if extraction fails, surgical retrieval may
be necessary.
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Conclusion
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Centrally embolized foreign bodies may be associated with
serious complications. The true rate of complication is unknown due to
the lack of long-term follow-up data. In selected cases, it may be
possible to retrieve these foreign bodies at a low risk even several
years after embolization. The decision to extract such foreign bodies
should be individualized based on their location and the risk of
possible complications.
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Footnotes
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Abbreviation: PICC = peripherally inserted central
catheter
Received for publication May 25, 1999.
Accepted for publication October 15, 1999.
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References
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-
Grabenwoeger, F, Bardach, G, Dock, W, et al (1988) Percutaneous extraction of centrally embolized foreign bodies: a report of 16 cases. Br J Radiol 61,1014-1018[Abstract]
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Kadir, S, Athanasoulis, CA (1982) Percutaneous retrieval of intravas-cular foreign bodies. Athanasoulis, CA Pfister, RC eds. Interventional radiology ,379-397 WB Saunders Philadelphia, PA.
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Fisher, RG, Ferreyro, R (1978) Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. AJR Am J Roentgenol 130,541-548[Abstract]
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Blair, E, Hunziker, R, Flanagan, ME (1970) Catheter embolism. Surgery 67,457-461[ISI][Medline]
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Richardson, JD, Grover, FL, Trinkle, JK (1974) Intravenous catheter emboli: experience with twenty cases and collective review. Am J Surg 128,722-727[CrossRef][ISI][Medline]
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Reynen, K (1993) 14-year follow-up of central embolization by a guidewire. N Engl J Med 329,970-971[Free Full Text]
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Abstract
Introduction
