Port-A Catheter Fracture: A Potential Lethal Iatrogenic Complication Identified on PET-CT

Transcription

1 Port-A Catheter Fracture: A Potential Lethal Iatrogenic Complication Identified on PET-CT Hung-Jen Hsieh 1, Kun-Han Lue 1, Bee-Song Chang 2, Chih-Hao K. Kao 1, Shu-Hsin Liu 1, Pan-Fu Kao 1 1 Department of Nuclear Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan 2 Department of Thoracic Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan We present a case of esophageal cancer underwent 18 F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) on purpose of tumor surveillance. The patient is clinically asymptomatic. The FDG PET is negative for tumor recurrence. However, careful inspection of the CT and scout image revealed rupture of Port-A catheter with remote migration- a potential lethal iatrogenic complication. Such probability must be kept in mind shall it be recognized and handled in time. Although uncommon [1], Port-A catheter fracture is serious. It can be fatal and cause complications such as sepsis, pulmonary thromboembolism, and cardiac consequences [2]. Nuclear medicine physicians should be alert to such probability and familiar with associated imaging findings. Case Report A 46-year-old man suffered from progressive difficult swallowing for one year, associated with postprandial nausea Key words: Port-A catheter, thrombo-embolism, pinchoff syndrome, PET-CT Ann Nucl Med Sci 2009;22:47-51 Introduction In contemporary clinical medicine, Port-A catheters are common devices encountered in daily practice. They are usually inserted on purpose of periodic injection of chemotherapeutic agents. Since 18 F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) has a growing role in the field of oncology, many oncological patients referred to PET studies bear Port-A catheters. Received 7/29/2008; revised 8/18/2008; accepted 8/20/2008. For correspondence and reprints contact: Hung-Jen Hsieh, M.D., Department of Nuclear Medicine, Buddhist Tzu Chi General Hospital. 707 Section 3, Chung Yang Road, Hualien 970, Taiwan. Tel: (886) ext. 2020, hsiehhj@tzuchi.com.tw Figure 1. A 46-year-old man had squamous cell carcinoma of middle third of esophagus at status post operation and concurrent chemotherapy and radiotherapy. The present FDG PET-CT study for tumor surveillance was essentially normal except for curvilinear mild uptake in the anterior mediastinum and epi-gastric region due to reconstruction surgery (arrowheads).

2 Hsieh HL et al Figure 2. Inspecting the fused PET-CT images, however, unusual radio-opacity was noted in several continuous transaxial slices tracing back from the left upper lung field, left pulmonary artery, to the pulmonary trunk and right ventricle outlet (2a-e, arrows) and corresponding to the catheter fragment detached away from the Port-A reservoir in situ (2f, arrow). It is noteworthy that the usual passage of Port-A catheter in the superior vena cava is absent. No abnormal FDG accumulation is demonstrable along the route of the dislodged Port-A catheter. Figure 3. The dislodged segment of Port-A catheter can be depicted by mindful inspection of scout image (arrows), which reminds us that scout image sometimes contains clinically important information. and vomiting. Review the history, the patient had heavy consumption of tobacco, alcohol and betel nut for more than twenty years. Physical examinations did not revealed particular findings. Panendoscopy and biopsy proved esophageal squamous cell carcinoma with nearly complete obstruction of the middle third of esophagus. Serial staging procedures showed stage IV (T3N1aM0) disease. He received esophagectomy and gastric tube reconstruction surgery, followed by concurrent chemoradiation therapy. The post-treatment course was uneventful. One year later, FDG PET-CT was arranged on purpose of tumor surveillance. No definite abnormal FDG uptake is demonstrable in the whole body scan except for curvilinear Figure 4. Percutaneous intravascular foreign body retrieval was performed by right femoral vein puncture (Seldinger s method). A 4-Fr RC-1 catheter was used to move the fractured port-a fragment from the left ascending pulmonary artery into the inferior vena cava (IVC). A 2.5-cm snare was then used to remove the port-a fragment (arrows) intact from the IVC. Ann Nucl Med Sci 2009;22:47-51 Vol. 22 No. 1 March

3 PET/CT Port-A catheter fracture ientified on PET-CT radioactivity accumulation in the anterior mediastinum, spatially corresponding to the site of gastric reconstruction (Figure 1). However, the CT images showed an intra-thoracic radio-opaque track later proved to be a dislodged Port- A fragment. The radio-opacity could be traced through the right ventricular outlet, pulmonary trunk, left pulmonary artery, and left upper lung field (Figure 2a-2e). This was more clearly depicted on the scout image (Figure 3). The patient is clinically asymptomatic, but the Port-A catheter did not work when we checked it. According to the PET-CT findings, percutaneous foreign body retrieval (Seldinger s method) was scheduled and performed smoothly (Figure 4). The patient received regular clinical follow-up thereafter and remained disease-free till article submission. Discussion Central venous port catheters are usually set on purpose of periodic administration of chemotherapy for the treatment of various malignancies. Port-A catheter fracture with fragment dislodgement occurs in approximately 0.2% ~ 1% of port catheter implantation [1-3]. The dislocated catheter fragments have been found mainly in central veins, including subclavian vein, superior vena cava, inferior vena cava, right atrium, right ventricle, and pulmonary artery. Port-A catheter fracture is often asymptomatic [2]. However, serious complications such as infection, pulmonary embolism, arrhythmia, cardiac arrest and cardiac perforation occasionally pursue [4-6]. The probable causes of Port-A catheter dislodgment include improper catheter position, angulation or distortion of the anastomosis between port and catheter, severing of the catheter during insertion procedure, and fatigue of the catheter [7]. The pinch off syndrome is the most common cause- due to the catheter wear secondary to tearing and scissoring effect between the clavicle and first rib during shoulder movement [8]. It might be prevented by accessing the internal jugular vein alternatively or by implantation of the port catheter more laterally via the subclavian approach. Repeated high-pressure injection such as an attempt to disobstruct thrombosed catheter should be avoided since it also leads to catheter fracture [4]. Percutaneous retrieval of intra-vascular foreign bodies has become a frequently applied technique since its first description at more than three decades ago. In many cases, it has been proved to be a safe, effective and accessible procedure [9-11]. Many devices have been designed to retrieve various types of intravascular foreign bodies, including snares, loops, forceps, baskets, over sheaths and balloon catheters, etc.. The success rate for percutaneous intravascular foreign body retrieval is high, as good as nearly 100% [12]. Unable to retrieve the foreign bodies has been associated with absence of a free end, small pieces of fragments entrapped in the thrombosed vessel or deeply in peripheral branch, or escaped items outside the vessel walls. Malfunction of the catheter may be the first and only indicator of Port-A catheter dislocation [1], which is the case in our patient. The FDG PET may have no hint of abnormal FDG uptake, which is also demonstrated in our patient. However, with the increasing use of central venous catheters, nuclear medicine physicians are more frequently than ever confronted with the problem of catheter fractures. Without careful inspection of the CT information, such potential lethal finding is likely to be overlooked. A linear radio-opaque track that appears outside the usual route such as subclavian veins, jugular veins (in setting of central venous catheter), and superior vena cava should arouse the suspicion of catheter dislocation. The probability of Port-A catheter fracture should be kept in mind because its severe consequence is preventable and it can be identified as early as the prompt evaluation of CT scout image. References 1. Kock HJ, Pietsch M, Krause U, Wilke H, Eigler FW. Implantable vascular access system: experience in 1500 patients with totally implanted central venous port system. World J Surg 1998;22: Surov A, Jordan K, Buerke M, Persing M, Wollschlaeger B, Behrmann C. Atypical pulmonary embolism of port catheter fragments in oncology patients. Support Care Cancer 2006;14: Koller M, Papa MZ, Zweig A, Ben-Ari G. Spontaneous leak and transection of permanent subclavian catheters. J Surg Oncol 1998;68: Ballarini C, Intra M, Pisani Ceretti A, et al. 2009;22:

4 Hsieh HL et al Complications of subcutaneous infusion port in the general oncology population. Oncology 1999;56: Monreal M, Davant E. Thrombotic complications of central venous catheters in cancer patients. Acta Haematol 2001;106: Gowda MR, Gowda RM, Khan IA, et al. Positional ventricular tachycardia from a fractured mediport catheter with right ventricular migration--a case report. Angiology 2004;55: Liu JC, Tseng HS, Chen CY, Chern MS, Chang CY. Percutaneous retrieval of 20 centrally dislodged port-a catheter fragments. Clin Imaging 2004;28: Hinke DH, Zandt-Stastny DA, Goodman LR, Quebbeman EJ, Krzywda EA, Andris DA. Pinch-off syndrome: a complication of implantable subclavian venous access devices. Radiology 1990;177: Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Non-surgical retrieval of a broken segment of steel spring guide from right atrium and inferior vena cava. Circulation 1964;30: Yedlicka JW Jr, Carlson JE, Hunter DW, Castaneda- Zuniga WR, Amplatz K. Nitinol gooseneck snare for removal of foreign bodies: experimental study and clinical evaluation. Radiology 1991;178: Wu JR, Hsu JH, Chang TT, Dai ZK, Lu CC, Wu DK. Nonsurgical percutaneous retrieval of dislodged Port-A catheter from pulmonary artery in children. Jpn Heart J 2002;43: Dondelinger RF, Lepoutre B, Kurdziel JC. Percutaneous vascular foreign body retrieval: experience of an 11-year period. Eur J Radiol 1991;12:4-10. Ann Nucl Med Sci 2009;22:47-51 Vol. 22 No. 1 March

5 PET/CT Port-A catheter fracture ientified on PET-CT pinch-off 2009;22: (03) hsiehhj@tzuchi.com.tw 2009;22: