1
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Zhou H, Wang B, Pan J, Qiu C, Yu X, He Y, Zhu Q, Yu L, Wu Z, Li D, Zhang H. Percutaneous snare-retrieval of intracardiac thrombus under fluoroscopic and transesophageal echocardiography guidance: case report and systematic review. Front Cardiovasc Med 2023; 10:1127131. [PMID: 37229221 PMCID: PMC10203901 DOI: 10.3389/fcvm.2023.1127131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Intracardiac foreign bodies (IFB) are rare clinical conditions. There are now several reports on the percutaneous retrieval of IFB under fluoroscopy. However, some IFB are not radiopaque, and retrieval requires combined fluoroscopic and ultrasound guidance. We report the case of a bedridden 23-year-old male patient with T-lymphoblastic lymphoma treated with long-term chemotherapy. Ultrasound examination diagnosed a huge thrombus in the right atrium near the opening of the inferior vena cava which affected the patency of his PICC line. Ten days of anticoagulant therapy did not modify the thrombus size. Open heart surgery was not feasible because of the patient clinical condition. Snare-capture of the non-opaque thrombus was done from the femoral vein under fluoroscopic and ultrasound guidance with excellent outcomes. We also present a systematic review of IFB. We found out that percutaneous removal of IFBs is a safe and effective procedure. The youngest patient who received percutaneous IFB retrieval was 10 days old and weighed only 800 g, while the oldest patient was 70 years old. Port catheters (43.5%) and PICC lines (42.3%) were the most commonly found IFBs. Snare catheters and forceps were the most commonly used instruments.
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Affiliation(s)
- Huaji Zhou
- Department of Vascular Surgery, The NO.1 People’s Hospital of Pinghu, Jiaxing, China
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bing Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Pan
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinyu Yu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qianqian Zhu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lei Yu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Muacevic A, Adler JR, Sayyed R. Untying the Knot: A Rare Case of Formation of a Life-Threatening Intracardiac Knot Following the Placement of a Temporary Transvenous Pacemaker. Cureus 2022; 14:e33188. [PMID: 36726882 PMCID: PMC9886405 DOI: 10.7759/cureus.33188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/02/2023] Open
Abstract
The implantation of a temporary pacemaker lead is a very common procedure performed in most hospitals and is known to be relatively safe, but there can be serious complications in rare circumstances. Reported complications including arrhythmias, infection, thromboembolic phenomena, and perforation of the vessel or the heart are all extensively described. However, an unusual and life-threatening complication that is not frequently discussed is the formation of intracardiac knots. We present a case of a rare complication of a temporary pacemaker placement with the formation of a knot in the distal lead requiring expert technique for removal.
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3
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Sakamoto S, Irishio M, Nakatani Y, Kataoka T, Fukuda D. Successful Extraction of Guidewire Entrapped in the Tricuspid Valve Leaflet Using a Laser Sheath. JACC Case Rep 2022; 6:101676. [PMID: 36704058 PMCID: PMC9871204 DOI: 10.1016/j.jaccas.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/28/2022] [Accepted: 10/13/2022] [Indexed: 11/10/2022]
Abstract
Right ventriculography is a necessary step for implantation of leadless pacemaker and is considered a safe procedure. However, an inappropriate manipulation of the guidewire can lead to serious complications. We present a case where the guide-wire was entrapped in the tricuspid valve, and its successful extraction using a laser sheath. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Shogo Sakamoto
- Department of Cardiovascular Medicine, Bellland General Hospital, Naka-ku, Sakai, Osaka, Japan,Address for correspondence: Dr Shogo Sakamoto, Department of Cardiovascular Medicine, Bellland General Hospital, 500-3 Higashiyama, Naka-ku, Sakai, Osaka 599-8247, Japan.
| | - Moritoshi Irishio
- Department of Cardiovascular Medicine, Bellland General Hospital, Naka-ku, Sakai, Osaka, Japan
| | - Yoshihiro Nakatani
- Department of Cardiovascular Medicine, Bellland General Hospital, Naka-ku, Sakai, Osaka, Japan
| | - Toru Kataoka
- Department of Cardiovascular Medicine, Bellland General Hospital, Naka-ku, Sakai, Osaka, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Abeno-ku, Osaka, Japan
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Gonzalez LS, Coghlan C, Alsatli RA, Alsatli O, Tam CW, Kumar SR, Thalappillil R, Chaney MA. The Entrapped Pulmonary Artery Catheter. J Cardiothorac Vasc Anesth 2022; 36:4198-4207. [PMID: 35843773 DOI: 10.1053/j.jvca.2022.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Laura S Gonzalez
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Colleen Coghlan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Raed A Alsatli
- Department of Anesthesiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ola Alsatli
- Kenneth Jansz Medicine Professional Corporation, Burlington, Ontario, Canada
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Shreyajit R Kumar
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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5
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Cohen SM, Gold AK, Augoustides JGT. Removal of a Knotted Swan Ganz Catheter in the Superior Vena Cava After Heart Transplant-Revisiting A Rare Complication of Pulmonary Artery Catheter Placement. J Cardiothorac Vasc Anesth 2022; 36:4221-4222. [PMID: 35882580 DOI: 10.1053/j.jvca.2022.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Samuel M Cohen
- Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Andrew K Gold
- Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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Sekiguchi K, Takano H. Knot formation of a guidewire during subclavian venous catheterization: A case report. Radiol Case Rep 2022; 17:3923-3926. [PMID: 36032201 PMCID: PMC9399890 DOI: 10.1016/j.radcr.2022.07.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 07/14/2022] [Indexed: 11/28/2022] Open
Abstract
Central venous catheters are used for a variety of purposes, including emergency care, parenteral nutrition, and chemotherapy, but their insertion can cause mechanical complications such as malposition, arterial puncture, and pneumothorax. Here, we describe a rare case of guidewire knot formation during subclavian vein catheterization. A 70-year-old woman presented to our facility for central venous port placement for chemotherapy after surgical resection of a retroperitoneal liposarcoma. The left subclavian vein was selected and punctured under ultrasound guidance, and a guidewire was introduced. However, strong resistance prevented both advancement and withdrawal of the guidewire. Radiograph revealed a knot like shadow near the tip of the guidewire. After placement of a central venous port in the opposite site, the knotted guidewire was surgically removed. Intraoperatively, the guidewire was found to penetrate the vein and form a knot on the outside of the posterior wall. Although the guidewire was able to be removed, a postoperative chest x-ray revealed a left pneumothorax, which required 10 days of treatment. If a knot forms in a guidewire during catheterization, surgical removal is recommended because forcible pulling can damage the vessel. In conclusion, guidewire knot formation is a very rare complication, but physicians performing central venous catheterization should be aware of it, and this report describes how to prevent and manage it.
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7
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Mima H, Enomoto S, Tamaki Y, Miyake M, Kondo H, Tamura T. Percutaneous removal of a knotted Swan-Ganz catheter. Cardiovasc Interv Ther 2021; 37:595-596. [PMID: 34748156 PMCID: PMC9197905 DOI: 10.1007/s12928-021-00822-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/30/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Hibiki Mima
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Soichiro Enomoto
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan.
| | - Yodo Tamaki
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Makoto Miyake
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Hirokazu Kondo
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
| | - Toshihiro Tamura
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, Nara, 632-8552, Japan
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8
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Kim SJ, Jeon HJ, Ho IG, Ihn K, Han SJ. Spontaneous knotting of an antegrade continent enema catheter. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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9
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Facanali CBG, Paixão VS, Sobrado CW, Facanali MR. Spontaneous Knot Formation in a Central Venous Catheter. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932354. [PMID: 34525010 PMCID: PMC8450428 DOI: 10.12659/ajcr.932354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient: Male, 63-year-old
Final Diagnosis: Spontaneous knot formation in central venous catheter
Symptoms: Central venous catheter whit any flow • associated with pain at the insertion site of the access
Medication: —
Clinical Procedure: Central venous catheterization
Specialty: General and Internal Medicine • Surgery
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Affiliation(s)
| | | | - Carlos Walter Sobrado
- Department of Gastroenterology, University of São Paulo, School of Medicine, São Paulo, SP, Brazil
| | - Marcio Roberto Facanali
- Department of Gastroenterology, University of São Paulo, School of Medicine, Santos, SP, Brazil
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Arboleda Salazar R, Rodriguez Delgado D, Perosanz Silvo C, Eixeres Esteve A. Removal of a Knotted Pulmonary Artery Catheter Using a Percutaneous Tracheostomy Set. J Cardiothorac Vasc Anesth 2021; 36:1123-1126. [PMID: 33563529 DOI: 10.1053/j.jvca.2021.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 11/11/2022]
Abstract
Placement of a pulmonary artery catheter is not a risk-free technique. Related incidents include ventricular arrhythmias, air embolisms, pulmonary artery perforation, infections, or catheter thrombosis. Herein the authors report a rare complication-the intracardiac knotting and its successful extraction using a percutaneous tracheostomy set in a hemodynamically compromised patient after a heart transplant.
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11
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A difficult entanglement: Guidewire entrapment within the submitral apparatus following transseptal access. HeartRhythm Case Rep 2020; 6:819-822. [PMID: 33204613 PMCID: PMC7653466 DOI: 10.1016/j.hrcr.2020.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Wiens EJ, Seifer CM, Khoo C. Inadvertent Removal of a Right Ventricular Pacemaker Lead by a Knotted Transvenous Pacing Wire. Indian J Crit Care Med 2019; 23:102-103. [PMID: 31086456 PMCID: PMC6487609 DOI: 10.5005/jp-journals-10071-23126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report an unusual complication of permanent pacemaker (PPM) implantation in a patient with a temporary transvenous pacemaker (TVP) in situ, in which the TVP lead formed a knot around the newly-placed right ventricular (RV) lead, complicating TVP removal. The case underscores the fact that suboptimal TVP lead placement, such as looping in the RV, can result in complications during implantation of a permanent pacemaker.
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Affiliation(s)
- Evan J Wiens
- Department of Internal Medicine, Max Ready College of Medicine, University of Manitoba, Winnipeg MB, Canada
| | - Colette M Seifer
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Clarence Khoo
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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13
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Tan VH, Ching CK, Wong KCK. Clinical approach to the knotting diagnostic quadripolar catheter during zero-fluoro electrophysiological study. Clin Case Rep 2019; 7:926-929. [PMID: 31110716 PMCID: PMC6509920 DOI: 10.1002/ccr3.2123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/10/2019] [Accepted: 03/06/2019] [Indexed: 11/15/2022] Open
Abstract
We report a case of electrophysiology catheter knotting when inserted without fluoroscopic guidance followed by technique to unravel the knot via ipsilateral femoral vein. We advocate caution when manipulating catheters using minimal/zero fluoroscopic technique and having a low threshold to screen under fluoroscopy when encountering difficulties during catheter insertion.
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Affiliation(s)
- Vern Hsen Tan
- Cardiology DepartmentChangi General HospitalSingapore CitySingapore
| | - Chi Keong Ching
- Cardiology DepartmentNational Heart Center SingaporeSingapore CitySingapore
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14
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Yoon KS, Kim JA, Hong JI, Kim JH, Park SY, Choi SR. A double-knotted pulmonary artery catheter with large loop in the right internal jugular vein: A case report. KOSIN MEDICAL JOURNAL 2018. [DOI: 10.7180/kmj.2018.33.2.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Knotting of a pulmonary artery catheter (PAC) is a rare, but well-known complication of pulmonary artery (PA) catheterization. We report a case of a double-knotted PAC with a large loop in a patient with hepatocellular carcinoma (HCC) undergoing liver transplantation, which has been rarely reported in the literature. A PAC was advanced under pressure wave form guidance. PAC insertion was repeatedly attempted and the PAC was inserted 80 cm deep even though PAC should be normally inserted 45 to 55 cm deep. However, since no wave change was observed, we began deflating and pulling the balloon. At the 30-cm mark, the PAC could no longer be pulled. Fluoroscopy confirmed knotting of the PAC after surgery (The loop-formed PAC was shown in right internal jugular vein); thus, it was removed. For safe PA catheterization, deep insertion or repeated attempts should be avoided when the catheter cannot be easily inserted into the pulmonary artery. If possible, the insertion of PACs can be performed more safely by monitoring the movement of the catheter under fluoroscopy or transesophageal echocardiography.
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15
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Nawale JM, Patil SN, Nalawade DD, Borikar NA, Sonawane BS, Chaurasia AS. Successful percutaneous retrieval of unusually knotted temporary pacemaker lead. Indian Pacing Electrophysiol J 2018; 18:148-149. [PMID: 29477309 PMCID: PMC6090000 DOI: 10.1016/j.ipej.2018.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/09/2018] [Accepted: 02/21/2018] [Indexed: 11/25/2022] Open
Abstract
Implantation of temporary pacemaker lead is commonly performed procedure and is usually safe, but can sometimes develop rare and serious complication like intracardiac lead knotting which may require challenging retrieval techniques. We report a case of successful percutaneous retrieval of unusually knotted right internal jugular venous temporary pacing lead via left femoral transvenous approach using snare over a long sheath after cutting the electrode proximally and thus avoiding any surgical intervention.
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16
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Hong B, Park H, Yoon Y, Jung C, Kim YH, Lim CS. Interventional Removal of Knotted Pulmonary Artery Catheter: A Case Report. J Intensive Care Med 2017; 33:322-324. [PMID: 28946777 DOI: 10.1177/0885066617733933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 60-year-old female patient underwent emergency cadaveric liver transplantation. During the insertion of the pulmonary artery catheter (PAC) through the left innominate vein, advancement of the catheter was not successful and a knot occurred. An interventional radiologist performed antegrade rigid wire insertion into the PAC and succeeded in loosening the knot in the vessel. We report the successful removal of a knot through intervention without additional invasive procedures in a hemodynamically unstable patient with a coagulopathy.
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Affiliation(s)
- Boohwi Hong
- 1 Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Jung-gu, Daejeon, Korea
| | - Hyunwoo Park
- 1 Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Jung-gu, Daejeon, Korea
| | - Yeomyung Yoon
- 1 Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Jung-gu, Daejeon, Korea
| | - Choonho Jung
- 1 Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Jung-gu, Daejeon, Korea
| | - Yoon Hee Kim
- 1 Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Jung-gu, Daejeon, Korea
| | - Chae Seong Lim
- 1 Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Jung-gu, Daejeon, Korea
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Zhou L, Muthucumaru M, Tan K, Lau K. Transjugular retrieval of a knotted peripherally inserted central venous catheter (Epicutaneo-Cava catheter) in a neonate. BJR Case Rep 2016; 2:20150327. [PMID: 30459970 PMCID: PMC6243363 DOI: 10.1259/bjrcr.20150327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 02/22/2016] [Accepted: 03/09/2016] [Indexed: 12/04/2022] Open
Abstract
Knotting of intravascular catheters has been well described, and all such cases documented in the literature have occurred during catheter insertion. Knot formation has not been reported during the removal of a peripherally inserted central venous line (Epicutaneo-Cava 2 French 24 gauge) in a neonate. The mechanism of knotting in our case is not fully understood. This case emphasizes the value of plain radiography in detecting the presence of a knot in the line, and is being presented to raise the awareness about knot formation if undue resistance is felt during line removal. Early recognition of this rare but serious complication may avoid line fracture and potential fragment embolization.
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Affiliation(s)
- Lindsay Zhou
- Department of Paediatric Surgery, Monash Medical Centre, Melbourne, VIC, Australia
| | | | - Kenneth Tan
- Department of Neonatology, Monash Medical Centre, Melbourne, VIC, Australia
| | - Kenneth Lau
- Department of Diagnostic Imaging, Monash Medical Centre, Melbourne, VIC, Australia
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Percutaneous retrieval of centrally embolized fragments of central venous access devices or knotted Swan-Ganz catheters. Clinical report of 14 retrievals with detailed angiographic analysis and review of procedural aspects. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2016; 12:140-55. [PMID: 27279874 PMCID: PMC4882387 DOI: 10.5114/aic.2016.59365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/21/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction Totally implantable venous access systems (TIVAS), Swan-Ganz (SG) and central venous catheters (CVC) allow easy and repetitive entry to the central cardiovascular system. Fragments of them may be released inadvertently into the cardiovascular system during their insertion or as a result of mechanical complications encountered during long-term utilization. Aim To present results of percutaneous retrieval of embolized fragments of central venous devices or knotted SG and review the procedural aspects with a series of detailed angiographies. Material and methods Between January 2003 and December 2012 there were 14 (~0.025%) successful retrievals in 13 patients (44 ±16 years, 15% females) of embolized fragments of TIVAS (n = 10) or CVC (n = 1) or of dislodged guide-wires (n = 2) or knotted SG (n = 1). Results Foreign bodies with the forward end located in the right ventricle (RV), as well as those found in the pulmonary artery (PA), often required repositioning with a pigtail catheter as compared to those catheter fragments which were located in the right atrium (RA) and/or great vein and possessed an accessible free end allowing their direct ensnarement with the loop snare (57.0% (4/7) vs. 66.7% (2/3) vs. 0.0% (0/3); p = 0.074 respectively). Procedure duration was 2–3 times longer among catheters retrieved from the PA than among those with the forward edge located in the RV or RA (30 (18–68) vs. 13.5 (11–37) vs. 8 min (8–13); p = 0.054 respectively). The SG catheter knotted in the vena cava superior (VCS) was encircled with the loop snare introduced transfemorally, subsequently cut at its skin entrance and then pulled down inside the 14 Fr vascular sheath. Conclusions By using the pigtail catheter and the loop snare, it is feasible to retrieve centrally embolized fragments or knotted central venous access devices.
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Fiala A, Glodny B, Lorenz IH. [Knotted Seldinger wire]. Anaesthesist 2015; 65:42-45. [PMID: 26661081 DOI: 10.1007/s00101-015-0119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 11/27/2022]
Abstract
Central venous catheters are usually positioned using the Seldinger technique with a guidewire. This article reports a case where the guidewire was inserted via the left subclavian vein with the landmark technique. The guidewire became kinked, pierced the vessel wall and became stuck forming several loops within the adjacent tissue of the vein. Several attempts were made to remove the guidewire by interventional radiology but were unsuccessful. Due to the critical condition of the patient an operation was considered too perilous and the guidewire was finally left in situ. No formation of local venous thrombosis could be detected.
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Affiliation(s)
- A Fiala
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstr. 36, 6020, Innsbruck, Österreich.
| | - B Glodny
- Universitätsklinik für Radiologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - I H Lorenz
- Universitätsklinik für Allgemeine und Chirurgische Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
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20
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Jugular Venous Catheterization: A Case of Knotting. Case Rep Med 2015; 2015:810346. [PMID: 26633975 PMCID: PMC4655031 DOI: 10.1155/2015/810346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/29/2015] [Accepted: 10/07/2015] [Indexed: 11/18/2022] Open
Abstract
A 79-year-old woman, diagnosed for cancer of the ovary, had a central catheter that was placed with difficulty through the right internal jugular vein intraoperatively. After oophorectomy, it was realized that the catheter was knotted. Thus, the central venous catheter was removed successfully using a traction technique in the operating room. Central venous catheter use may result in various complications, although it has been used as an invasive method for hemodynamic monitoring and fluid and drug infusion. Here, we present catheter knotting in a case with solutions for this complication, under literature review.
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Wang NN, Hatzakorzian R, Carvalho G, Waters P. Entrapment of a pulmonary artery catheter inside a knotted percutaneous sheath introducer. Can J Anaesth 2015; 62:663-4. [PMID: 25772702 DOI: 10.1007/s12630-015-0355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 02/24/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
- Ning Nan Wang
- Department of Anesthesia, Royal Victoria Hospital, McGill University Health Centre, Montreal, QC, Canada
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22
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Halenda GM, Godoy MM, Flores AF, Ngo PD. Removal of a knotted catheter lodged in an appendicostomy tract. J Pediatr Surg 2012; 47:412-4. [PMID: 22325404 DOI: 10.1016/j.jpedsurg.2011.11.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 11/15/2011] [Accepted: 11/16/2011] [Indexed: 10/14/2022]
Abstract
Knots are an unusual complication of catheterization procedures but have been reported in a variety of circumstances. Refractory constipation and colonic dysmotility disorders can be treated with a surgically created appendicostomy that is typically catheterized nightly to administer an antegrade colonic enema. We report a case of a catheter that formed a knot and became lodged in an appendicostomy. We describe the method used to remove the knot and make a recommendation to prevent this complication.
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23
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Roy GB, Cheriyan AA, Rymbai ML. How is that? Knotting of a peripherally inserted central venous catheter. Indian J Anaesth 2011; 54:272-4. [PMID: 20885890 PMCID: PMC2933503 DOI: 10.4103/0019-5049.65367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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24
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Rafie IM, Viswanathan G, Penny WJ. Transfemoral contralateral technique to retrieve knotted coronary artery catheter using Amplatz Goose Neck snare catheter. BMJ Case Rep 2010; 2010:2010/nov18_1/bcr1220092598. [PMID: 22798519 DOI: 10.1136/bcr.12.2009.2598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Performing coronary angiography in very older patients can prove a challenge due to vessels calcification and torturousity. Manipulation of coronary catheters to engage the artery ostium may result in over twisting and can result in complications ranging from a minor 'kink' to a complex 'knot'. The authors describe a novel method to retrieve the complex twisted coronary catheter using snare technique, after usual steps to remove the coronary catheter failed.
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Affiliation(s)
- Ihsan M Rafie
- Cardiology, University Hospital of Wales, Cardiff, UK
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25
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26
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Bonet NA, Samper FO, Loro Represa JM, Guillén RV. Anudamiento reiterado de un catéter de Swan-Ganz. Rev Esp Cardiol (Engl Ed) 2010; 63:869-70. [DOI: 10.1016/s0300-8932(10)70192-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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27
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Onan B, Oz K, Onan IS. Knotted Seldinger guidewire as a complication of Hickman catheter implantation. J Vasc Access 2010; 11:171-2. [PMID: 20175063 DOI: 10.1177/112972981001100218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Evans DC, Doraiswamy VA, Prosciak MP, Silviera M, Seamon MJ, Funes VR, Cipolla J, Wang CF, Kavuturu S, Torigian DA, Cook CH, Lindsey DE, Steinberg SM, Stawicki SP. Complications Associated with Pulmonary Artery Catheters: A Comprehensive Clinical Review. Scand J Surg 2009; 98:199-208. [DOI: 10.1177/145749690909800402] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Care for the critically ill patient requires maintenance of adequate tissue perfusion/oxygenation. Continuous hemodynamic monitoring is frequently utilized to achieve these objectives. Pulmonary artery catheters (PAC) allow measurement of hemodynamic variables that cannot be measured reliably or continuously by less invasive means. Inherent to every medical intervention are risks associated with that intervention. This review categorizes complications associated with the PAC into four broad groups — Complications of central venous access; complications related to PAC insertion and manipulation; complications associated with short- or long-term presence of the PAC in the cardiovascular system; and errors resulting from incorrect interpretation/use of PAC-derived data. We will discuss each of these four broad categories, followed by in-depth descriptions of the most common and most serious individual complications.
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Affiliation(s)
- D. C. Evans
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus (OH), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - V. A. Doraiswamy
- Department of Medicine, University of Arizona College of Medicine, Tucson, (AZ), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - M. P. Prosciak
- The Johns Hopkins Burn Center, Baltimore (MD), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - M. Silviera
- Department of Surgery, Section of Trauma/Critical Care, Temple University School of Medicine, Philadelphia (PA), U.S.A
| | - M. J. Seamon
- Department of Surgery, Section of Trauma/Critical Care, Temple University School of Medicine, Philadelphia (PA), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - V. Rodriguez Funes
- Research Unit, Hospital Nacional Rosales, El Salvador
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - J. Cipolla
- Regional Level I Trauma Center, St Luke's Hospital and Health Network, Bethlehem (PA) U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - C. F. Wang
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus (OH), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - S. Kavuturu
- Department of Surgery, Bronx Lebanon Medical Center, Bronx (NY), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - D. A. Torigian
- Department of Radiology, University of Pennsylvania Medical Center, Pennsylvania (PA), U.S.A
| | - C. H. Cook
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus (OH), U.S.A
| | - D. E. Lindsey
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus (OH), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - S. M. Steinberg
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus (OH), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
| | - S. P. Stawicki
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, Columbus (OH), U.S.A
- OPUS 12 Foundation, Inc., Columbus (OH), U.S.A
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29
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Katsikis A, Karavolias G, Voudris V. Transfemoral percutaneous removal of a knotted Swan-Ganz catheter. Catheter Cardiovasc Interv 2009; 74:802-4. [DOI: 10.1002/ccd.22201] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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30
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Kim HK, Choi JW, Lee JH, Lee AR. Knotting of a guidewire during internal jugular vein catheterization in an infant: A case report. Korean J Anesthesiol 2009; 57:531-534. [PMID: 30625920 DOI: 10.4097/kjae.2009.57.4.531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Central venous catheterization has been frequently used in pediatric patients in wide variety of conditions. Several authors have described about various complication of central venous catheterization in pediatric patients and reported complication rates of 3% to 6%. Knotting of guidewire as a complication of central venous catheterization has been reported in adult patients, but knotting of guidewire has not been reported in infants. Therefore we report an infant who experienced a knotting of guidewire during internal jugular vein catheterization which was successfully removed without any adverse events. We suggest that knot formation is possible in infants and there should be a high suspicion if resistance is felt at the time of catheter advancement.
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Affiliation(s)
- Hee Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jong Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Ae Ryoung Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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31
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Valiño Hortas C, Tabeada Muñiz M, Vilanova Vázquez V, Pereira Loureiro MA. [Knotting of a pulmonary artery catheter (Swan-Ganz) tangled with a pacemaker cable]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:253-254. [PMID: 19537268 DOI: 10.1016/s0034-9356(09)70382-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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32
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Atrapamiento intravascular de un catéter de Swan-Ganz. ANGIOLOGIA 2009. [DOI: 10.1016/s0003-3170(09)15012-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kwon SC, Lyo IU, Shin SH, Park JB, Kim Y. Coil Knotting during Endovascular Coil Embolization for Ruptured MCA Aneurysm. A Case Report. Interv Neuroradiol 2008; 14:331-4. [PMID: 20557732 PMCID: PMC3396018 DOI: 10.1177/159101990801400315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 07/23/2008] [Indexed: 07/29/2023] Open
Abstract
SUMMARY Complications during coil embolization of cerebral aneurysms include thromboembolic events, hemorrhagic complications related to procedural aneurysmal rupture and parent vessel perforation, and coil-related complications. The present report describes a rare coil-related complication involving spontaneous coil knotting.
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Affiliation(s)
- S C Kwon
- Ulsan University Hospital; Republic of Korea
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34
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Hatim A, Belyamani L, Drissi M, Ibat D, Houssa A, Drissi Kamili N. [Knotting catheter in the superior vena cava: rare complication of Swan-Ganz]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2008; 27:761-762. [PMID: 18760892 DOI: 10.1016/j.annfar.2008.07.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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35
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Burzotta F, Romagnoli E, Trani C. Percutaneous removal of an embolized port catheter: Description of a new coaxial recovery technique including a case-report. Catheter Cardiovasc Interv 2008; 72:289-93. [DOI: 10.1002/ccd.21573] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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36
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de Jesus Peixoto Camargo J, Marcantonio Camargo S, Noguchi Machuca T, Wagner P. Intraoperative removal of a knotted Swan-Ganz catheter during lung transplantation. Interact Cardiovasc Thorac Surg 2008; 7:861-2. [PMID: 18653497 DOI: 10.1510/icvts.2008.181339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe the case of a 52-year-old man with end-stage emphysema who underwent a right-sided lung transplantation. During preoperative monitoring an apparently non-functioning Swan-Ganz catheter could not be removed through the insertion site - right internal jugular vein. Another Swan-Ganz catheter was successfully installed through the left internal jugular vein, pulmonary artery pressures could be recorded and the transplant was performed uneventfully. Then, the first catheter was inspected and superior vena cava palpation surprisingly revealed a knot at approximately 25 cm. The catheter was pushed to the azygous vein, proximal and distal controls were obtained and a venotomy was performed. The knotted side was sectioned and removed, while the remaining catheter was removed through the insertion site. Despite being rare, knotted intravascular devices have been increasingly reported. Removal with interventional radiology techniques can be accomplished in most instances, nevertheless, complex knots or knots fixed into cardiac structures require open removal. Since in our case the knot was detected intraoperatively, it was readily removed through the azygous vein. To the best of our knowledge, this is the first report to describe such a route of removal.
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Abstract
Few diagnostic modalities in medicine have been the subject of greater debate for as long after their inception as the pulmonary artery catheter. Placement of a Swan-Ganz catheter is associated with various complications, one of which is knotting. Complications of usage of these catheters are numerous and can have devastating effects. Knotting of Swan-Ganz catheters is a rare complication that can often be managed successfully using interventional radiological techniques. The case reported is a rare case of Swan-Ganz catheter knotting resulting from inserting an excessive length of Swan-Ganz catheter into the heart. Knotting can be prevented by following the principle rule in floating Swan-Ganz catheters by correlating the inserted length of pulmonary artery catheter (PAC) with the expected change in waveform.
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Affiliation(s)
- Hesham Ahmed
- Department of Trauma Surgery and Critical Care, Kings County Hospital Center, State University of New York–Downstate Medical Center, Brooklyn, New York
| | - Daniel Kaufman
- Department of Trauma Surgery and Critical Care, Kings County Hospital Center, State University of New York–Downstate Medical Center, Brooklyn, New York
| | - Michael E. Zenilman
- Department of Trauma Surgery and Critical Care, Kings County Hospital Center, State University of New York–Downstate Medical Center, Brooklyn, New York
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38
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Haut ER, Kamal MK, Reilly PM, Stavropoulos SW. Successful percutaneous retrieval of a swan-ganz catheter entrapped in an inferior vena cava filter. ACTA ACUST UNITED AC 2007; 62:1507-10. [PMID: 17563676 DOI: 10.1097/01.ta.0000235241.10599.d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Elliott R Haut
- Division of Trauma and Surgical Critical Care, Department of Surgery, The Johns Hopkins Medical Institution, Baltimore, Maryland 21287, USA.
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39
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Ranatunga DG, Richardson MG, Brooks DM. Percutaneous fluoroscopic removal of a knotted Swan?Ganz catheter in a patient with a persistent left-sided superior vena cava. ACTA ACUST UNITED AC 2007; 51:182-5. [PMID: 17419868 DOI: 10.1111/j.1440-1673.2007.01696.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Knotting of intravascular catheters is an uncommon but a well-recognized occurrence. The Swan-Ganz catheter (SGC) is the one that knots most commonly. A case of a knotted SGC is described in a patient with a persistent left-sided superior vena cava, and we propose that the presence of a left-sided superior vena cava is a risk factor for knot formation not previously reported. We review the published work on the risk factors for knot formation and on the techniques used to remove knotted SGC. We describe a technique using a gooseneck snare and Omni Flush catheter (Angiodynamics, Queensbury, NY, USA) to loosen and untie a knotted SGC.
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Affiliation(s)
- D G Ranatunga
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia.
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40
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41
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Bagul NB, Menon NJ, Pathak R, Platts A, Hamilton G. Knot in the Cava—An Unusual Complication of Swan–Ganz Catheters. Eur J Vasc Endovasc Surg 2005; 29:651-3. [PMID: 15878545 DOI: 10.1016/j.ejvs.2005.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2004] [Accepted: 02/15/2005] [Indexed: 10/25/2022]
Abstract
Complications associated with the use of the Swan-Ganz catheters including coiling and knotting of the catheter in the central venous system or in the chambers of the heart, often with disastrous consequences. We report a case of knotting of a Swan-Ganz catheter in the superior vena cava which necessitated surgical removal via the right internal jugular vein.
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Affiliation(s)
- N B Bagul
- Department of Vascular Surgery, Royal Free Hospital, Hampstead, London NW3 2QG, UK.
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42
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Menéndez Cuervo S, Campuzano artín S, Medina Villanueva A, Rey Galán C, Concha Torre A, Los Arcos Solas M. Nonsurgical removal of a knotted pediatric femoral vein catheter. J Pediatr 2004; 144:683. [PMID: 15127016 DOI: 10.1016/j.jpeds.2003.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sergio Menéndez Cuervo
- Unidad de Cuidados Intensivos Pediátricos, Hospital Central de Asturias, C/. Celestino Villamil s/n, Spain
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