Stuck long-term indwelling central venous catheters in adolescents: three cases and a short topical review

A Stepwise Interventional Strategy for the Removal of Adherent Totally Implanted Central Venous Access Port Catheters

BACKGROUND

To evaluate the safety and effectiveness of a stepwise interventional strategy for the removal of adherent totally implanted central venous access port catheters, consisting of a guidewire support, antegrade coaxial separation, and retrograde coaxial separation with increasing technical complexity.

METHODS

This study has a retrospective design. Thirty-two patients who had failed routine removal of the port catheter and were then transferred to interventional radiology between November 2017 and December 2023 were reviewed. The technical success and complication rates were recorded.

RESULTS

All adherent catheters were successfully removed without catheter fragmentation, using guidewire support (n = 21), antegrade coaxial separation (n = 5), and retrograde coaxial separation (n = 6). The technical success rate was 100%, and no complications occurred.

CONCLUSIONS

The proposed stepwise interventional strategy successfully removed adherent port catheters, with good safety and high effectiveness. It appeared to reduce the incidence of catheter fracture during the removal of adherent totally implantable central venous access port catheters.

Removal of stuck tunnelled dialysis line requiring cardiopulmonary bypass and venous repair

Tunnelled central venous dialysis catheters can usually be removed easily. However, their removal can become rarely complicated requiring more invasive techniques. We report a case in which cardiopulmonary bypass and repair of great veins was required for safe removal. A 38-year-old female with end-stage renal failure and a 3-year-old Hickman line inserted into her right internal jugular vein was referred to our cardiac surgical unit following failed attempts of line removal by local vascular surgical team using open vascular surgical techniques. As a result, an MDT decision was made that it was safer to proceed to a cardiothoracic surgical approach rather than other techniques. Investigations showed significant calcification surrounding the line which was adherent to the venous wall. Removal of the retained catheter required median sternotomy and the use of cardiopulmonary bypass as the great veins had to be opened to free the line and allow complete removal. The line was successfully removed with its encircling calcified sheath, and the veins were closed primarily without needing a patch repair. The integrity of the great veins was maintained to meet the on-going need this young patient has for central venous access. The patient made an uneventful recovery. When other measures fail, sternotomy and cardiopulmonary bypass provide a safe option for complete removal of stuck central venous catheters with low risk to the patient.

Difficult removal of totally implantable venous access devices in adult patients: Incidence, risk factors, and management

BACKGROUND

Totally implantable venous access devices (TIVADs) have played an important role of medical oncology practice. However, operators sometimes encounter considerable difficulty when removing TIVADs. This study aimed to investigate the incidence of difficult TIVAD removal, determine associated risk factors, and investigate interventional radiology (IR) approaches to difficult removal.

METHODS

A total of 514 TIVAD removal procedures performed in a single-center between January 2014 and May 2021 were retrospectively analyzed to determine incidence of difficult removal and associated risk factors. IR approaches applied in difficult removal cases were also reviewed.

RESULTS

The incidence of difficult removal was 7.4% (38/514). In univariable analysis, indwelling duration, silicone catheter, and subcutaneous leakage of fluid were identified as significant risk factors for difficult removal. Multivariable analysis showed that indwelling duration per year (odds ratio (OR), 1.46; 95% confidence interval (CI), 1.28-1.67; p < 0.01) and subcutaneous leakage of fluid (OR, 6.04; 95% CI, 2.45-14.91; p < 0.01) were significantly associated with difficult removal. In the 38 difficult removal cases, 32 TIVADs could be removed using more dissection and traction than the standard removal method. In the other 6, TIVADs were successfully removed by using several IR techniques, including insertion of a guide wire (n = 1), dissection using an introducer sheath (n = 2), pushing with a dilator (n = 1), and pulling with a snare (n = 2).

CONCLUSION

Difficult TIVAD removal is uncommon. However, operators should expect it when removing long indwelling TIVADs and those with subcutaneous leakage. IR approaches to difficult removal are minimally invasive and can be useful.

The Stuck Catheter: A Hazardous Twist to the Meaning of Permanent Catheters

Introduction

Permanent central venous catheter use is associated with significant complications that often require their timely removal. An uncommon complication is resistant removal of the catheter due to adherence of the catheter to the vessel wall. This occasionally mandates invasive interventions for removal. The aim of this study is to describe the occurrence of this “stuck catheter” phenomenon and its consequences.

Methods

A retrospective review of all the removed tunneled hemodialysis catheters from July 2005 to December 2014 at a single academic-based hemodialysis center to determine the incidence of stuck catheters. Data were retrieved from a prospectively maintained computerized vascular access database and verified manually against patient charts.

Results

In our retrospective review of tunneled hemodialysis catheters spanning close to a decade, we found that 19 (0.92%) of catheters were retained, requiring endovascular intervention or open sternotomy. Of these, three could not be removed, with one patient succumbing to catheter-related infection. Longer catheter vintage appeared to be associated with ‘stuck catheter’.

Conclusions

Retention of tunneled central venous catheters is a rare but important complication of prolonged tunneled catheter use that nephrologists should be aware of. Endoluminal balloon dilatation procedures are the initial approach, but surgical intervention may be necessary.

A stuck haemodialysis central venous catheter: not quite open and shut!

Removal of tunnelled central venous catheters can become complex if left in situ for a prolonged period. We report a challenging case of a stuck tunnelled haemodialysis catheter, which required sternotomy with cardio-pulmonary bypass for retrieval. A 47-year-old female had failed attempts to remove the venous limb of a Tessio line on the ward. A cut down on the internal jugular vein and division of the fibrin sheath failed to release it. Synchronous traction was applied via a snare inserted through a femoral approach. On table trans-oesophageal echocardiogram showed the tip of the catheter traversing the tricuspid valve. At sternotomy with cardio-pulmonary bypass, the tip of the catheter was found attached to the septal leaflet of the tricuspid valve requiring release and repair. The management of stuck line has potential serious complications. Prophylactic catheter exchange should be considered to avoid complications.

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.

A Breakthrough Technique for the Removal of a Hemodialysis Catheter Stuck in the Central Vein: Endoluminal Balloon Dilatation of the Stuck Catheter

Background

Hemodialysis (HD) catheters can get stuck in the central vein after long-term use and their removal might become difficult especially in patients with fibrosed or occluded central veins. Herein, a breakthrough technique is reported for the easy removal of a stuck HD catheter from the central vein.

Case Report

Attempts were made to remove a tunneled double-lumen HD catheter from the central vein of a 74-year-old woman, only to find that the catheter was stuck. The patient was transferred to the operating room and a skin incision was made in the neck and the subcutaneous portion of the HD catheter was retrieved from the tunnel. Under fluoroscopy, a guide wire was inserted into one lumen of the HD catheter and advanced into the right atrium beyond the catheter tip. A 5 mm × 4 cm balloon angioplasty catheter was then inserted into the HD catheter lumen over the guide wire and advanced into the jugular vein junction of the HD catheter around the thoracic inlet. The balloon was inflated to its maximum dimension and pressure. This endoluminal dilatation of the HD catheter was continued by deflating the balloon and then pushing the angioplasty catheter 4 cm at a time towards the tip of the HD catheter in the right atrium. After a second balloon angioplasty catheter of 6 mm × 4 cm was used to expand the entire segment of the other lumen, the HD catheter was pulled out easily from the central vein without any resistance.

Comments

The endoluminal balloon dilatation of the HD catheter not only separates the stuck HD catheter from the adherent vein by breaking the adhesions between them, but also expands the vein simultaneously, thus enabling easy removal of the HD catheter.