Transcatheter Removal of Peripherally Inserted Central Catheter Adherent to the Ventricular Septum

Transcription

1 Original article Transcatheter Removal of Peripherally Inserted Central Catheter Adherent to the Ventricular Septum Keng Yean Wong 1, MMed(Paeds), FAMS, Teng Hong Tan 1, MMed(Paeds), MRCP (UK, Paeds), Yee Low 2, MBBS, FRCS (Edin), Seok Gek Tan 3 SRN, Bhavani Sriram 4, MBBS, MRCP (Lond) 1 Cardiology Service, Paediatric Subspecialties, KK Women s & Children s Hospital, Singapore 2 Department of Paediatric Surgery, KK Women s & Children s Hospital, Singapore 3 Diagnostic Imaging/Angiography Suite, KK Women s & Children s Hospital, Singapore 4 Department of Neonatology, KK Women s & Children s Hospital, Singapore Abstract We describe an unusual case of a young child with peripherally inserted central catheter (PICC) adherent to the ventricular septal wall 5 days following insertion. The impacted PICC was successfully retrieved using a transcatheter procedure. The technique describes the freeing of an intracardiac central line with closed ends. Keywords: axillary vein, loop, snare Introduction Peripherally inserted central catheters (PICC) are commonly used in neonates and infants needing long term intravenous access. Complications that can arise include infection, thrombosis, thrombophlebitis, cardiac perforation and tamponade, cardiac arrhythmias, fracture and embolisation, and impaction of the line 1 6. The retrieval of lines that have fractured and embolised has been well described We describe a method of removal of a PICC which became impacted in the ventricular septum of a child. History A 17-months-old girl with trisomy 21 (weight 7kg) was admitted for repair of a H-type anorectal malformation with anovestibular fistula. She had been previously treated for haemolytic uraemic syndrome and seizures, and subsequently for chronic left tibial osteomyelitis and bronchiolitis. Following surgical repair of the fistula, the venous access was difficult and a 24G silicon PICC was inserted via the left axillary vein. This was done with no difficulty and post insertion X-ray showed the tip of the line was across the tricuspid valve into the right ventricle. The line was pulled back 2cm and a repeat X-ray showed the line in an apparently satisfactory position in the right atrium. However there was difficulty in removing the line on the 5th post-operative day. An exploration of the line was performed by the paediatric surgeon. The PICC was exposed to the subclavian vein. However the line remained stuck and pulling the elastic line only stretched it further. The procedure was abandoned for fear of fragmenting the line. Fluoroscopy showed the line in the innominate vein and right atrium with its tip in the right ventricle. Echocardiogram showed a 12mm echogenic line tip adherent to the perimembranous and muscular area of the ventricular septum (Fig. 1, overleaf). 89

2 Original Article Fig.1. Echocardiogram (subcostal view) showing the tip of the peripherally inserted central catheter (arrow) adherent to the ventricular septum. RV, Right Ventricle; LV, Left Ventricle. Cardiac catheter procedure The child was brought to the angiographic laboratory. The right and left femoral veins were punctured percutaneously. A 4F pigtail catheter was passed via the left femoral vein into the right superior vena cava right atrial junction to hook on to the atrial portion of the PICC (Fig. 2). The PICC was pulled down towards the inferior vena cava junction but the pigtail loop opened up and the PICC remained anchored to the ventricular septum. A close loop was created with a double length Terumo wire with the Pigtail catheter hooked across the PICC. The distal end of the Terumo wire was directed into the inferior vena cava where it was snared with a Dormian Basket and pulled out through the sheath in the right femoral vein (Fig. 3).The PICC was now pulled down into the inferior vena cava using the closed loop (Fig. 4) while the PICC at the axillary end was fixed. The PICC was freed from its adherent position in the ventricular septum with the firm pulling tension. The complete Fig. 2. A 4F pigtail catheter was used to hook on to the atrial part of the peripherally inserted central catheter (arrow). As the catheter was only faintly radio-opaque, it is highlighted here with a black line. 90

3 Transcatheter Removal of PICC Fig. 3. With the pigtail catheter (PT) hooked across the peripherally inserted central catheter, the Terumo wire (T) was advanced through the pigtail catheter and directed into the inferior vena cava where it was snared with a Dormian Basket (DB), thereby creating a close loop. Fig. 4. The close loop formed by the pigtail catheter and Terumo wire was used to free the peripheral inserted central catheter (arrow) from its adherent position in the ventricular septum. As the catheter was only faintly radio-opaque, it is highlighted here with a black line. length of the PICC was then withdrawn from the axillary end (Fig. 5, overleaf ). Discussion This is the first report of an impacted PICC due to adherence to the ventricular septum and retrieval by a transcatheter procedure. The catheter following insertion was initially too far in and an adjustment was made. The position of the PICC was confirmed with a check x-ray. Fine PICC are often difficult to visualise and radiocontrast may help to enhance its visibility. Movement of PICC is known to occur with arm movement; cephalic venous lines move away and axillary lines move towards the heart with arm adduction 12. The axillary approach is usually done with the arm abducted. It is possible in this patient that the line moved further forwards when the arm returned to its normal adducted position. It is unusual for a PICC inserted for 5 days to be impacted. The most common and likely site is in the arm due to thrombophlebitis of the small venous channels. The other site is consequent to mechanical pinching between the clavicle and the first rib. Movement of the shoulder in various positions did not change the PICC resistance to removal. The catheter was explored up to the subclavian vein and the catheter was visualised to be free in the lumen of the innominate vein and superior vena cava on the echocardiogram. The fixed echogenic linear shadow on the perimembranous ventricular septum and the resistance to the extracting force demonstrated that the catheter was firmly adherent to the wall of the septum. A possible explanation of this is that the catheter passed in between the commissure of the posterior and septal leaflet of the tricuspid valve. With limitation of tip motion, the PICC became adherent to the perimembranous septal wall and muscular septum. Removal of embolic fragments of central venous lines has been well described. In these situations the removal is done using snares, loops or 91

4 Original Article Fig. 5. The complete length of the peripherally inserted central catheter was withdrawn from the axillary end after it was freed from its adherent position in the ventricular septum. forceps catching onto the open ends of the line. However in our patient both ends of the line were anchored down and it was not possible to snare the line at its ends. The aim was to catch to the line near to its anchored position to allow maximal tension. It may be possible to capture the line on the side with a retrieval forceps or a Dormian Basket in the SVC innominate vein junction where the line is in a more confined space. The direction of force would be towards the axillary end and pulling at this position may snap the line or further elongate the elastic line without exerting enough tension to free the adherent end. The close loop allows safe and easy capture of the PICC with no open ends in the right atrium and is a mechanically efficient way of freeing the catheter. There is no direct tightening of a noose around the soft PICC material which may risk snapping the PICC on pulling. Vettukattil et al 13 described passing a guidewire through the central venous catheter to allow easier retrieval but this is not possible for this small caliber 24G PICC. Conclusion Impaction of a PICC due to adherence to the ventricular septum is uncommon. This reemphasizes the importance of verification of the catheter tip position post-insertion of PICC. The impacted catheter resisted attempts at removal peripherally. We describe a successful method of transcatheter retrieval which may be applied in a similar situation where the both ends of the line are anchored down. References 1. James L, Bledsoe L, Hadaway LC, A retrospective look at tip location and complications of peripherally inserted central catheter lines. J Intraven Nurs. 1993;16(2): Dubois J, Garel L, Tapiero B, Dubé J, Laframboise S, David M. Peripherally inserted central catheters in infants and children. Radiology. 1997;204(3): Garg M, Chang CCMerritt RJ, An unusual case presentation: pericardial tamponade complicating central venous catheter. Journal of Perinatology : Official Journal of the California Perinatal Association (4): Bivins MHCallahan MJ, Position-dependent ventricular tachycardia related to a peripherally inserted central catheter. Mayo Clinic Proceedings (4): Chow LM, Friedman JN, Macarthur C, et al., Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. The Journal of Pediatrics (2): Crowley JJ, Pereira JK, Harris LS, et al., Peripherally inserted central catheters: experience in 523 children. Radiology (3):

5 Transcatheter Removal of PICC 7. Chung KJ, Chernoff HL, Leape LL, et al., Transfemoral snaring of broken catheters from the right heart in small infants. Catheterization and Cardiovascular Diagnosis (3): Fuenfer MM, Georgeson KE, Cain WS, et al., Etiology and retrieval of retained central venous catheter fragments within the heart and great vessels of infants and children. Journal of Pediatric Surgery (3): Greenfield DH, McMullan GK, Parisi AF, et al., Snare retrieval of a catheter fragment with inaccessible ends from the pulmonary artery. Catheterization and Cardiovascular Diagnosis (1): Hsu YY, Wang CR, Yeoh HA, et al., Endovascular retrieval of an embolized central venous catheter in a neonate of very low birth weight. Ajr. American Journal of Roentgenology (1): Andrews RE, Tulloh RMRigby ML, Percutaneous retrieval of central venous catheter fragments. Archives of Disease in Childhood (2): Forauer ARAlonzo M, Change in peripherally inserted central catheter tip position with abduction and adduction of the upper extremity. Journal of Vascular and Interventional Radiology : Jvir. 11(10): Vettukattil JJ, Thomas ESalmon AP, Safe retrieval of impacted central venous line. Archives of Disease in Childhood (7):