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

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.

Difficult Removal of a Stuck Chemoport Catheter of a Paediatric Patient in Post-Coronavirus Disease (COVID-19) Era - Management Strategies and Literature Review

ABSTRACT

A chemoport is widely used in paediatric oncology population. Removal is a relatively easy procedure, but difficulty can be encountered in case the catheter is densely adherent to the vascular wall. It is a rare complication and is associated with long indwelling duration and acute lymphoblastic leukaemia (ALL). Forceful traction can lead to vascular injury and high morbidity. Herein, we report a 7-year-old girl with precursor B ALL who had delayed chemoport removal due to the coronavirus disease (COVID-19) pandemic. The removal process was difficult, as the catheter was adherent to the right innominate vein. Out of panic, the surgeon pulled it out forcefully. Fortunately, the catheter and its fragment were successfully retrieved completely and the child was discharged the next day. The management strategy varies and ranges from minimally invasive to open surgery. Leaving a stuck chemoport catheter in situ can be a bailout method or part of conservative management.

The stuck haemodialysis catheter-a case report of a rare but dreaded complication following kidney transplantation

BACKGROUND

Tunnelled cuffed haemodialysis catheters are at increased risk of incarceration or becoming 'stuck' via fibrotic adhesion to the central veins when left in situ for prolonged periods of time. Stuck catheters cannot be removed using standard techniques such as bedside dissection of the cuff. Whilst there are several strategies published for the removal of these incarcerated lines, there is no consensus on the best approach. Here we present a challenging case of a stuck haemodialysis catheter in the acute post transplantation period.

CASE PRESENTATION

A 66-year-old female on haemodialysis presented for kidney transplantation with a tunnelled-cuffed haemodialysis catheter in situ for five years. Following transplantation, removal of the line was unsuccessful despite dissection of the cuff, with traction causing a choking sensation with tracheal movement. Eventually, the line was removed without complications utilising sequential balloon dilatation by interventional radiology and the patient was discharged without complications.

CONCLUSIONS

This case serves as a timely reminder of the risks of long-term tunnelled haemodialysis catheters and as a caution towards proceeding with kidney transplantation in those with long-term haemodialysis catheters in situ. Greater nephrologist awareness of interventional radiology techniques for this challenging situation will help to avoid more invasive strategies. The risks of a stuck catheter should be included in the discussions about the optimal vascular access and transplantation suitability for a given patient.

A technique to retrieve an internalised embedded central venous catheter

BACKGROUND

Central venous catheters may become embedded due to the formation of adhesions between the indwelling catheter and the vein wall.

CASE PRESENTATION

A 49-year-old patient with bacteraemia was referred for retrieval of an embedded internalised central venous dialysis catheter. Recently the catheter had been surgically ligated at the venotomy site internalising the intravascular catheter component, which precluded antegrade ballooning through the catheter hub. Seldinger technique was used to access the catheter lumen within the left internal jugular vein and through and through access was established across the catheter. Retrograde endoluminal balloon dilation was performed to disrupt adhesions and free the catheter. The catheter was snared over the wire and removed from the right femoral vein.

CONCLUSION

This case report outlines an effective, minimally invasive retrieval method in a rare case of an embedded internalised central venous catheter.

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.

Layered Sheath-Assisted Dissection and Retrieval of Stuck Port Catheters: A Single-Center Experience

Chemoports are often required for oncological patients requiring repeated blood draws and long-term drug therapy. However, complications such as dislodgement, fracture, thrombosis, and venous occlusion may occur if the ports remain unremoved when not in use. Nonetheless, existing techniques require multiple accesses or release of the stuck catheter tip to retrieve the catheter, making the procedure inconvenient. We present our experience with a technique using the Bard Denali inferior vena cava filter retrieval kit to remove a stuck or fractured chemoport catheter through a single vascular access. The technique was performed in two female patients with satisfactory results (complete retrieval of broken chemoports) and an event-free follow-up period. The entire procedure was completed within 15-30 minutes with fluoroscopic time under two minutes. The technique allows for better case management by simplifying the procedure, reducing radiation, and improving workflow efficiency in the operating room.

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.

[Endoluminal balloon dilatation of impacted central venous catheter-Case report and literature review]

BACKGROUND

The long-term application of tunneled central venous catheters leads to the development of firm adhesions between the wall of the vein and the catheter, which makes removal of the catheter difficult or impossible. The treatment options in such cases include abandonment of catheter parts or an open surgical approach up to sternotomy. At present, procedural alternatives are available, which include endovascular techniques such as the use of laser energy and endoluminal dilatation.

METHODS

This article describes the successful application of endoluminal dilatation for removal of ingrown central venous catheters in three patients, which had impacted in the superior vena cava and brachiocephalic vein. A 5 Fr (Cordis, Santa Clara, CA, USA) sheath was inserted into one lumen through the severed end of the double lumen catheter. Subsequently, a balloon catheter was inserted into the other lumen to prevent retrograde bleeding or air embolism. Under fluoroscopy a guidewire (0.018, Terumo Medical Corporation, Somerset, New Jersey, USA) was introduced via the sheath to beyond the tip of the hemodialysis catheter into the right atrium. Finally, an angioplasty balloon was inserted (4 × 80 mm) via the guidewire and the complete catheter was sequentially inflated with a pressure of 4 atm. It was then possible to pull out the catheter with no difficulty.

RESULTS

This technique resulted in the removal of the central venous catheters in all three patients, without any relevant complications or resistance.

CONCLUSION

By dissolving adhesions between the catheter and the vein wall, endoluminal balloon dilatation constitutes a reliable and safe technique for the extraction of impacted central venous hemodialysis catheters and may thus help to avoid further invasive surgical procedures.

Removal of central venous port-catheter by the combination of interventional radiological procedures

We encountered a patient with an infection related to an implanted central venous port-catheter that necessitated removal of the system. As the catheter had tightly adhered to the venous wall, removal was impossible with standard methods. After trial and error, we used a guiding catheter that was advanced over the implanted catheter to detach the fibrin sheath on the implanted catheter that had adhered to the vessel wall. At that time, a pull-through technique was used. After we succeeded in detaching the adhesion with the guiding catheter, we were able to withdraw the implanted catheter.

Why do subcutaneous ports get stuck? A case-control study

PURPOSE

We sought to identify clinical features associated with difficult subcutaneous port removals in children.

METHODS

Ports placed between April 2014 and September 2017 at our institution were prospectively tracked for difficult removals. A case-control analysis was performed. Patients with ports that were difficult to remove (stuck; cases) were compared to biological sex and age-matched controls in a ratio of 1:3. Logistic regression determined the association between case/control status and clinical features adjusting for biological sex and age as covariates. A multivariable analysis was performed to identify independent associations.

RESULTS

57 stuck ports (28 extreme [10 endovascular intervention] and 29 moderate) and 171 controls were analyzed. Stuck ports were associated with a diagnosis of acute lymphoblastic leukemia (86% cases versus 22.2% controls; p < 0.001) and a longer placement duration (median 2.6 years [interquartile range (IQR) 2.5-2.6] versus 0.8 years [IQR 0.5-1.4]; p < 0.001). On univariate analysis, procedural and device features associated with stuck ports included subclavian access (71.9% cases versus 48.5% controls; p = 0.0126), a polyurethane versus silicone catheter (96.5% cases versus 79.9% controls; p = 0.001), and a rough catheter appearance at removal (92.6% cases versus 9.4% controls; p < 0.0001). A diagnosis of ALL and duration of line placement were associated with having a stuck port on multivariate analysis.

CONCLUSION

Polyurethane central venous catheters placed for the two-year treatment of acute lymphoblastic leukemia may become difficult to remove. This constellation of factors warrants more extensive preoperative discussion of risk, endovascular backup availability, and scheduling for longer operating room time.

Endovascular treatment of the stuck hemodialysis catheter: A report of two cases and literature review

A considerable number of patients present with stuck CVC after long-use of CVC, which is thought to result from the adhesion of the fibrous sheath, formed over the CVC, to the vessel or atrial wall. The removal of these catheters is a difficult and risky procedure. Hong reported a minimally invasive technique through endoluminal balloon dilation, which successfully breaks the adhesions and expands the vein, thus allowing for an easy removal of the CVC. The authors present two cases of a variant method of Hong's technique, and provide a literature review on stuck catheters. Our experience is that balloon angioplasty dilation is a safe and practical option. We highlight the role of experienced interventional nephrologists or radiologists in the management of this complication as endovascular treatment is the first line treatment.

Stuck fragment of totally implantable central venous access ports during removal: risk factor analysis in children

Background

Totally implantable central venous access ports (TICVAPs) have increasingly been used in pediatric patients because they provide reliable venous access. However, many complications associated with TICVAPs have been reported. Here, we aimed to analyze the risk factors of stuck fragment of TICVAPs during removal in children and recommend the appropriate periods of use or exchange.

Methods

We retrospectively reviewed the medical records of 121 patients, including 147 cases of TICVAP insertion, between January 2010 and July 2020.

Results

Among these, 98 cases in 72 patients involved of TICVAP removal, with 8 patients having had incomplete TICVAP removal resulting in a stuck fragment of the catheter in the central venous system (Group S). All Group S patients were male and had acute leukemia, and their TICVAPs were used for chemotherapy. Compared with the complete removal group (Group N), stuck fragment in Group S were significantly found in patients diagnosed with acute leukemia than those with other diagnoses (p < 0.001). Indwelling duration and body weight change during TICVAP indwelling were significantly longer and larger in Group S, respectively (p < 0.001). In multivariate logistic regression analysis, indwell duration (odds ratio [OR], 1.13; 95% confidence interval [Cl] 1.02–1.37, p = 0.10), body weight change during indwell (OR, 1.00; 95% Cl 0.83–1.18, p = 0.97), and platelet count at TICVAP insertion (OR, 0.98; 95% Cl 0.95–0.99; p = 0.48) showed an increased trend of risk for a stuck catheter.

Conclusions

We suggest prophylactic catheter exchange before indwell duration of 46 months (area under the curve [AUC], 0.949; 95% Cl 0.905–0.993) and body weight change up to 9.9 kg (AUC, 0.903; 95% Cl 0.840–0.966) to prevent a catheter from becoming stuck, especially in children with rapidly growing acute leukemia. Management of a stuck fragment remains controversial in asymptomatic patients, and we suggest careful, close observation rather than aggressive and invasive treatment.

Minimally invasive procedure for removal of infected ventriculoatrial shunts

BACKGROUND

Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances.

METHODS

We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution.

RESULTS

We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved.

CONCLUSION

Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.

Endoluminal dilatation technique to remove stuck hemodialysis tunneled catheter: A case report from Indonesia

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The phenomenon of the ‘stuck’ catheter in the central vein, where significant traction or additional maneuvers are required to remove the catheter, is not frequently reported in spite of the vast usage of these catheters worldwide.

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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.

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Endoluminal dilatation technique is a minimally invasive percutaneous technique that appears safe and straightforward and can be performed in any interventional suite while allowing preservation of venous access.

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Consider endoluminal dilatation technique as a treatment option.

Background

Tunneled CVC is being increasingly used worldwide as a mean of vascular access for hemodialysis. Among these, one of the emerging complications is that of the “embedded” or stuck catheter. There have been registered cases of vasomotor collapse, non-ST-elevation myocardial infarction (NSTEMI), avulsion of the vena cava, damage to the tricuspid valve having fatal consequences, and breakage of the CVC (Lodi et al., 2016).

Case presentation

A 63-year-old female with mature AV fistula came to the clinic for removal of a tunnelled 15 fr double lumen dialysis catheter (Medical Components, Harleysville, Pensylvania) that had been inserted into the left internal jugular vein 15 months prior to this visit. In the OR, our surgical attempt to remove the catheter failed. The first few dilation procedures were performed using 0.035-inch guidewire and balloon catheters. The technique was subsequently modified as follows. In this case we use a 6 × 60 mm Scoreflex balloon. Endoluminal dilation was repeated along the length of the catheter up to the cuff. Once the catheter has been removed, pressure was applied using sterile gauze to aid hemostasis. The procedure was successful without any observed complication.

Conclusion

Endoluminal dilatation technique is considered as the easiest and safest technique to remove hemodialysis catheter. Our case is the first stuck hemodialysis catheter reported in Indonesia and probably the first case that happen and treat with endoluminal dilatation technique in our country.

An easy way to remove a stuck hemodialysis catheter

The replacement of tunneled hemodialysis catheters (CVCs) is a common procedure. In some cases, the CVC cannot be removed from the central vein because of tight adhesions to the surrounding fibrin sheath. A tight fibrin sheath leads to firm adherence between the catheter and the central veins or right atrial wall. Such stuck catheters cannot be removed from the central vein using standard methods. We present here a case demonstrating the successful removal of such a stuck CVC using the reverse Seldinger method.

The fibroblastic sleeve, the neglected complication of venous access devices: A narrative review

The presence of a vascular access device (or of any intravascular foreign body) inside the bloodstream is often associated with the formation of a connective tissue sleeve around the catheter (often named-erroneously-"fibrin sleeve"). Such sleeve is usually a physiological phenomenon with little or no clinical relevance, but its pathogenesis is still unclear, so that it is frequently confused with venous thrombosis; also, its relationship with other major catheter-related complications, such as venous thrombosis and bloodstream infection, is uncertain. This narrative review tries to convey in a systematic form the current knowledge about pathogenesis, incidence, clinical manifestations, diagnosis, and management of this phenomenon.

Solutions to stuck tunneled cuffed catheters in patients undergoing maintenance hemodialysis

OBJECTIVE

To study and discuss treatments for stuck tunneled cuffed catheter in patients undergoing maintenance hemodialysis.

METHOD

Retrospectively analyzing clinical data of 13 patients with stuck tunneled cuffed catheter in the Kidney Disease Center of the First Affiliated Hospital, College of Medicine, Zhejiang University in the period between September 2012 and October 2018. All patients failed to remove hemodialysis catheters by regular technique. The stuck catheters were treated by thoracotomy, endoluminal percutaneous transluminal angioplasty with blunt dissection or embedded and left in situ.

RESULTS

In 13 patients, one was successfully treated by thoracotomy, one failed to remove the catheter by regular technique and blunt dissection, and the stump of the catheter was clamped and buried in the subcutaneous fascia of the neck, and the other 11 were treated by endoluminal percutaneous transluminal angioplasty with blunt dissection. The average time of catheter removal procedure is 25 min, the overall success rate is 92.3%, and the success rate of percutaneous transluminal angioplasty is 100%.

CONCLUSION

Thoracotomy is an efficient way to treat stuck catheter but is limited by its high risk and complications. Leaving part of catheter in situ may increase the risk of central vein stenosis. Comparing to the former two, endoluminal percutaneous transluminal angioplasty is a safe, efficient, and practical way for stuck catheters and should be recommended as the first choice.

Tunnelled Haemodialysis Catheter Removal: An Underappreciated Problem, Not Always Simple and Safe

BACKGROUND

Optimal care of patients treated with a central tunneled catheter (CTC) as vascular access for hemodialysis requires a number of procedures. One of them is CTC removal, usually carried out using mostly the cut-down method (CDM) and the traction method (TM). The procedure seems to be simple and safe; however, occasionally, serious complications may occur. To eliminate the risk of such events, we have introduced a modified cut-down method (MCDM).

METHODS

The study included the analysis of retrospective results of 143 CTC removal procedures, 76 of which were performed using the standard cut-down method (CDM), and in 67 cases, the modified cut-down method (MCDM) was applied.

RESULTS

As minor side effects occurred in patients treated with both methods with comparable frequency, serious complications were observed only in the CDM patients group.

CONCLUSIONS

In our opinion, the new MCDM procedure is the simplest and safest method of CTC removal.

Complicated Surgical Removal of an Adherent Port-a-Cath After 11 Years of Implantation

A 65-year-old woman with a medical history significant for anal cancer was referred by her primary care physician for a port-a-cath removal. The port was placed prior to treatment of squamous cell carcinoma of the anus, 11 years prior to this scheduled removal. She received chemotherapy and radiation in accordance with the Nigro protocol, treating the anal cancer to complete resolution. During port removal, a fibrous capsule was dissected and the port was removed from the left upper breast border along with proximal portion of the catheter. Significant difficulty was found in removing the remaining catheter despite sustained traction and guidewire insertion. Fluoroscopy revealed an intravascular adhesion of the catheter tip in the superior vena cava, which could not be freed. In order to prevent vascular injury, the adhesed portion of the distal catheter was left in place with three large surgical clips placed distally. This case highlights the very rare complication of complete vascular adherence of the terminal catheter tip and extended port intracorporeal time as a risk factor for adhesion. This case also highlights the importance of timely permanent central venous catheter removal following completion of its intended regimen.

Totally percutaneous endoluminal ballooning of stuck hemodialysis catheters: One-year experience of a referral center

The stuck catheter is an uncommon but dreaded complication of dialysis line placement. It always finds the operator unaware and often requires procedure modification or reschedule. Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from wall adhesions. The purpose of the current study was to present a totally percutaneous variation of endoluminal stuck catheters ballooning, along with our experience in terms of safety and feasibility. A major difference presented in respect to previous techniques is that this modification does not require isolation of the distal line stump at the venous entry point by tissue dissection, thus reducing procedural time and difficulty. We presented a case series of five lines that were ballooned by navigating low-profile material directly from the cutaneous exit of the lines, with optimal results (100% success). The findings of this investigation provide additional evidence with respect to the safety and effectiveness of endoluminal ballooning of Tesio lines and offer a new variation of endoluminal ballooning which we found easy to perform, safe, and effective.

Endovascular extraction of entrapped long-term central feeding catheter: Case series

Long-term tunneled central venous catheters are widely used in several clinical indications, that is, hemodialysis, chemotherapy, and total parenteral nutrition. However, central venous catheters are associated with a number of complications, including catheter occlusion and sepsis, which may necessitate earlier catheter removal. In most cases manual traction is sufficient to remove the catheter. Nevertheless, in some cases severe adhesions, formed between the catheter and the vessel wall, complicate simple catheter removal. We present four cases of entrapped long-term central venous catheters and describe methods (e.g. endoluminal balloon dilatation and wire snare) performed by experienced cardiologists at high-volume center to remove them. We claim that permanent central venous catheters removal procedures may be unpredictable and hazardous. Therefore, entrapped central venous catheters should be extracted by experienced operators in specialized high-volume centers.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

Endoluminal dilatation for embedded hemodialysis catheters: A case-control study of factors associated with embedding and clinical outcomes

BACKGROUND

With the increasing frequency of tunneled hemodialysis catheter use there is a parallel increase in the need for removal and/or exchange. A small but significant minority of catheters become embedded or 'stuck' and cannot be removed by traditional means. Management of embedded catheters involves cutting the catheter, burying the retained fragment with a subsequent increased risk of infections and thrombosis. Endoluminal dilatation may provide a potential safe and effective technique for removing embedded catheters, however, to date, there is a paucity of data.

OBJECTIVES

1) To determine factors associated with catheters becoming embedded and 2) to determine outcomes associated with endoluminal dilatation.

METHODS

All patients with endoluminal dilatation for embedded catheters at our institution since Jan. 2010 were included. Patients who had an embedded catheter were matched 1:3 with patients with uncomplicated catheter removal. Baseline patient and catheter characteristics were compared. Outcomes included procedural success and procedure-related infection. Logistic regression models were used to determine factors associated with embedded catheters.

RESULTS

We matched 15 cases of embedded tunneled catheters with 45 controls. Among patients with embedded catheters, there were no complications with endoluminal dilatation. Factors independently associated with embedded catheters included catheter dwell time (> 2 years) and history of central venous stenosis.

CONCLUSION

Embedded catheters can be successfully managed by endoluminal dilatation with minimal complications and factors associated with embedding include dwell times > 2 years and/or with a history of central venous stenosis.

Application of Hong's technique for removal of stuck hemodialysis tunneled catheter to pacemaker leads

The term “stuck catheter” refers to situations where a central venous catheter cannot be removed from the central veins or right atrium using standard technique, usually due to development of a fibrin sheath leading to adherence to SVC or right atrial wall. Endoluminal dilatation is an interventional radiology technique that has been previously reported in the removal of stuck hemodialysis catheters, and to the best of our knowledge, this case describes the first application of the technique to remove a hemodialysis catheter that was adherent to SVC wall and transvenous pacemaker leads.

The Removal of a Stuck Catheter: An Alternative to Hong's Technique

The use of the tunneled central venous catheter (CVC) is steadily increasing worldwide as a means of vascular access for hemodialysis. The increased use of these devices, which often outlive the patients, and the extended time they are used are associated with more frequent complications. Among these, one of the emerging complications is that of the “embedded” or stuck catheter. This term refers to when the catheter cannot be removed after detaching the retention cuff. In medical literature, experiences with the removal of stuck catheters are described with the use of several different methods. Currently the most commonly used technique also considered the safest is “endoluminal dilation” also known as Hong's Technique, recently modified by Quaretti and Galli. Below, a new technique using a Vollmar ring is described for removing a stuck catheter as an alternative to Hong's technique, or after a failed attempt at using Hong's technique.

Outpatient removal of tunneled dialysis catheters by nephrology fellows in training at a Veterans Affairs Medical Center

BACKGROUND

Removal of tunneled dialysis catheters (TDC) usually occurs in dedicated procedure suites and is performed relatively rarely at the bedside. Scarce evidence exists in the literature to assess the safety and success of this procedure when performed during supervised academic training.

PATIENTS AND METHODS

We conducted a retrospective chart review of all TDC removals performed on an outpatient basis by nephrology fellows under faculty supervision during a 5-year period at an academic Veterans Affairs Medical Center. Data were collected regarding patient demographics, basic laboratory studies, pertinent clinical information and procedure-related variables. We evaluated the safety, success and complication rate of this procedure.

RESULTS

We identified 72 TDC removals that met the above criteria. Mean age was 63 ± 10 years. All patients were male and hypertensive, 68% were diabetic and 69% were African-American. Overall, 88% of procedures were performed in end-stage renal disease (ESRD) patients, while the rest had needed temporary dialysis for acute kidney injury. Notably, 49 patients (68%) were taking one or more of aspirin, clopidogrel or warfarin at the time of TDC removal. Overall complication rate was low (&lt;2%). There was no increase in risk of bleeding, even in subjects receiving anti-platelet therapy; only one of the 49 patients (2%) had a minor bleeding complication.

CONCLUSIONS

Outpatient TDC removal by trainees was successful and safe in the vast majority of cases (99%). We propose that TDC removal skills should be actively pursued and acquired by all nephrology fellows. This would expand the scope of practice for future general nephrologists and facilitate timely patient care.

Mechanics of a stuck central venous catheter removal

Although a surgical removal of tunneled central venous catheter is usually simple, it can become complicated when the catheter is found to be stuck because of its adherence within a central vein. If a catheter is pulled too hard, it may fracture within a central vein in two pieces. In this report, we describe the mechanics of central venous catheter breakage and provide a solution that minimizes the possibility of catheter from breaking as it is pulled out from its stuck position within a central vein.

IR Approaches to Difficult Removals of Totally Implanted Venous Access Port Catheters in Children: A Single-Center Experience

PURPOSE

To identify factors associated with adherence of implanted venous access port catheters in children and describe technical strategies for removing "stuck" ports.

MATERIALS AND METHODS

A retrospective single-center review of port removals was conducted between 2003 and 2012. Cases were identified through radiology reports. Clinical details (eg, demographics, disease, port dwell time, interventional techniques) were obtained through patient charts. Cases were classified as difficult removals if there was documented adherence to soft tissues or vein, or simple removals if no difficulty was recorded. Difficult removals were categorized and graded on increasing invasiveness of techniques required. Successful removal was defined as complete removal of the port catheter. Difficult removals were compared with simple removals for factors associated with difficult removal. Of all removals (N = 1,306), 58 were classified as difficult removals (4%).

RESULTS

Using various techniques, 57 of 58 (98%) adherent port catheters were successfully removed. Factors identified with difficult removals included primary diagnosis of acute lymphoblastic leukemia (ALL) (78% vs 37%, P < .0001), age at insertion (3.7 y vs 5.4 y, P = .0019), and port dwell time (median 1,087 d vs 616 d, P < .0001).

CONCLUSIONS

Difficulty removing port catheters in children is uncommon. Port catheters can usually be removed successfully using various IR techniques ranging in invasiveness. There is an association of difficult removal with early age at insertion, ALL diagnosis, and long port dwell time. Awareness of these factors may help physicians inform parents of potential difficulties and plan the removal procedure.

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 Refinement of Hong's Technique for the Removal of Stuck Dialysis Catheters: An Easy Solution to a Complex Problem

Aim

A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety.

Methods

We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists.

Results

All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel.

Conclusions

Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus’ egg in this previously risky field.

The permanent catheter

An elderly woman receiving hemodialysis via a right brachiocephalic arteriovenous fistula presented to the clinic for elective removal of a tunneled hemodialysis catheter inserted 5 years ago. The catheter had not been removed earlier at the patient's request. Removal was now unsuccessful in the clinic. Exploration in the operating room revealed the innominate vein had fibrosed around the length of the catheter. The procedure was abandoned, catheter cut short and the remnant left in situ. This case serves as a reminder to exercise caution if there is difficulty in removing the catheter even after the cuff is dissected free, and to remove them once a working fistula or graft is available. Failing which, the patient bears an unnecessary risk of line infection, or as in this case, the catheter may unintentionally end up what its common misnomer "perm-cath" alludes to--becoming truly "permanent."