Removal of embedded central venous catheters

Retained intravascular catheter fragment at removal of implantable vascular access device: Incidence, risk factors, and outcomes

BACKGROUND

Retained intravascular catheter fragments (RICF) are a rare complication of implantable vascular access device (IVAD) removal for which there is limited understanding of aetiology. There is a varied approach to management among the currently published literature.

AIMS

The aim of this study was to establish incidence, risk factors, and outcomes for RICF after attempted removal of IVADs.

METHODS

A single institution retrospective review was undertaken of individuals ≤ 25 years undergoing removal of IVADs from October 2014 to June 2019. Risk factors for RICF were explored using univariable logistic and Cox regression analysis.

RESULTS

Six cases of RICF were identified among 654 line removal episodes (0.92% (95% CI 0.37-2%)) in patients aged 6-17 years (median 11, IQR 6-15 years). The main risk factor for RICF at removal was found to be line duration (OR 3.5/year, 95% CI 2.1-5.84, p < 0.0001). No RICFs occurred in lines indwelling for < 3 years. Five children with RICF ≤ 16 years were discussed with a paediatric cardiothoracic centre, and all were left in situ with 4 remaining asymptomatic. One had the fragment tip extruded through a wound, which required trimming. The other (17 years of age) developed an infected sinus for which partial removal with open excision followed by full removal with endovascular snare retrieval was performed by the adult vascular surgeons.

CONCLUSION

IVADs in-situ for longer than a three-year period are at greatest risk of RICF upon removal. Management with transfixion of line fragments to surrounding muscle seems prudent while invasive attempts at retrieval appear unwarranted.

Surgical retrieval of a guide wire lost during central venous catheterization in a dog

OBJECTIVE

To report a case of successful surgical removal of a guide wire lost during central venous catheterization.

CASE SUMMARY

A 28 kg, 4-year-old female neutered mixed breed dog presented to the primary care veterinarian with diabetic ketosis. During the process of central venous catheterization, the guide wire was accidently released and the entire length of the guide wire slipped into the jugular vein. Due to the absence of nearby interventional radiology facilities, surgical intervention was proposed. An ultrasound was used to determine that the guide wire was located in the caudal vena cava extending caudally into the right internal iliac vein. Rommel tourniquets were placed around the iliac vein cranial to the bifurcation of the common iliac vein into the external and internal iliac veins. A venotomy was performed in the right common iliac vein and the guide wire was grasped with hemostats and gently removed while alternately relaxing the cranial then caudal tourniquets. During anesthesia, ventricular premature contractions were noted that varied in frequency with the dog's positioning. Postoperative color flow Doppler ultrasound evaluation of the caudal vena cava, right common, internal and external iliac veins, and right femoral vein was normal with no evidence of thrombosis. Several days postoperative the dog's diabetic ketosis and ventricular premature contractions had resolved and color flow Doppler ultrasound evaluation was normal with no evidence of thrombosis.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first reported veterinary case of loss and subsequent surgical retrieval of a central venous catheter guide wire.

Complicated vascular access port removals: incidence, antecedents and avoidance

PURPOSE

Port removal is usually a straightforward procedure delegated to trainees. However, some port removals are complicated by central venous catheter (CVC) fragmentation, a challenge for even experienced surgeons. This study aimed to determine the incidence of, and risk factors for, complicated port removal in children.

METHODS

A single-centre study assessed the outcome of removal for all paediatric ports inserted from 1996 to 2012. Data were recorded detailing patient, insertion, device and removal characteristics. Risk factors for complicated removals were scrutinised using Chi-square tests; p < 0.05 significant.

RESULTS

Of 628 ports inserted from 1996 to 2012, 443 were subsequently removed at the same centre. 8/443 (1.8%) removals were complicated by CVC fragmentation, a median of 3.3 (2.4-3.9) years after insertion. Of complicated cases, 8/8 underwent formal neck dissection, 3/8 intravascular dissection, and 1/8 endovascular retrieval. 2/8 cases have retained intravascular CVC fragments. Risk factors for complication were CVC caliber <6Fr (p < 0.001) and use duration >2 years (p < 0.001).

CONCLUSION

Greatest care and senior supervision should be ensured when removing ports with CVC caliber <6Fr and/or >2 years since insertion. However, complications also occur with larger CVCs or after shorter durations. Therefore, the key to avoiding complicated port removal may simply be: preparation, preparation, neck preparation.

Retained central venous lines (CVLs) after attempted removal: an 11-year series and literature review

BACKGROUND

Central venous lines (CVLs) are frequently used in the management of many neonatal and pediatric conditions. Failure to remove the luminal part of the line (retained CVL) is rare. Consequently, there is lack of experience and consensus in its optimal management.

AIM

To document the incidence and management of retained CVLs in a tertiary pediatric surgical centre with access to interventional cardiology services. To review the literature and report efficacy/morbidity of attempted extraction of retained CVLs.

METHODS

Children with retained CVLs were identified from departmental morbidity and mortality records over an 11-year period. A literature search was performed in PubMed and Scopus to identify studies reporting retained CVLs (earliest date to 1 January 2012). This was supplemented by scanning bibliographies of retrieved articles.

RESULTS

The 11-year incidence of retained CVL was 0.3% (n=10; median duration in-situ 66.5 {range 47-146} months). The underlying pathology in 8 was cystic fibrosis. Antegrade transfemoral snare retrieval was successful in 6 of 7 attempts. In the remaining 3, a conservative approach was adopted following consultation with the family. None of the 4 with retained CVL developed complications (median follow-up 7.5 {range 1-53} months). The literature describes 38 pediatric index cases (including 10 from the current series). Seventeen (49%) were managed conservatively either intentionally or by default after failed endovascular removal attempt (n=4). No complications directly attributed to retained CVLs have been reported (median follow-up 40 {range 1-120} months). Reported morbidity associated with endovascular retrieval includes: procedural failure 30%, line embolization 8%, and intra-operative thrombo-embolism 8%.

CONCLUSION

Literature regarding management of retained CVLs is anecdotal. Although uncommon, the complication should feature in consent for removal of CVLs. Conservative management carries long-term risks of infection, thrombosis, and even migration, albeit unquantified over a child's lifetime. Endovascular retrieval is feasible with appropriate expertise.

Difficult extraction of long-term central venous catheters in children--case report

Although many publications address the complications associated with insertion of long-term, indwelling central venous catheters, there are only scattered reports of problems related to their removal. We report 4 cases of pediatric patients in whom the lines could not be pulled from the vein by standard methods, requiring 2 intraperiosteal clavicle resections with venorrhaphy, 1 femoral vein exploration and reconstruction, and 1 jugular venorrhaphy. Despite their relative biocompatibility, long-term silicone lines may become fixed in the vein. The rare and unpredictable occurrence of this problem may present the surgeon with unexpected intraoperative dilemmas. Before attempting localized extraction, surgeons should consider what venue, equipment, and anesthesia support may be required to successfully remove these catheters.