Tunneled Catheters: How to Get Unstuck Thomas Vesely, M.D. Saint Louis, Missouri Disclosure Caymus Medical Cylerus, Inc. Phase One Medical W.L. Gore & Associates Definition : Stuck Catheter A tunneled venous catheter that cannot be removed after complete release of the subcutaneous cuff If this catheter cannot be removed then it s a stuck catheter Patient may experience chest pain when attempting to retract catheter cuff Catheters deeply inserted can be challenging to remove May need to make incision over cuff 1
do not do this retention sutures tied too tight WTF???? Use dilator to create a suture loop Secure but comfortable suture loop Secure but comfortable suture loop Fibrin Sheath Formation Fibrin sheath extracted from catheter exit site 2
Hemodialysis catheter retracted and injection of x-ray contrast tip of catheter pulled back cast of tip of catheter Formation of fibrin sheath around distal ends of catheter Development of Fibrin Sheath Catheter is covered with : 1. plasma proteins 2. platelets 3. thrombus 4. organized thrombus 5. collagen deposition 6. smooth muscle cells minutes days weeks entry into internal jugular vein internal jugular vein catheter exit site site of catheter cuff fibrin sheath Fibrin sheath extends from catheter exit site along entire length of the catheter Residual fibrin sheath adherent to wall of SVC after removal of catheter From Saad et al. J Vasc Intervent Radiol 2008: 19:890-896 SVC Fibrin sheath surrounding catheter Fibrous attachment to SVC wall SVC Catheter can become attached anywhere it contacts the wall of the blood vessel From : Forauer AR J Vasc Intervent Radiol 2003; 14:1163-1168 3
From: Atlas of Dialysis Vascular Access Tushar Vachharajani, MD If the catheter continues to work well then build-up of fibrin and thrombus may go undetected and lead to incorporation of catheter into wall of blood vessel Complex topology of left-sided catheters cuff vein entry site growth of catheter-adherent fibrous tissue at vein entry site Resistance when retracting catheter may be due to adhesions of fibrous tissue surrounding catheter Catheter attachment can occur at stenoses fibrin sheath attachment sites Disruption of fibrin sheath by removal of the catheter Catheter may become attached anywhere that catheter contacts wall of blood vessel 4
cuff Incidence of Stuck Catheters Under-recognized, under reported vein entry site embedded catheter Incidence of 4% Five patients out of 136 had embedded catheters Average duration catheter use : 24.7 months J Pediatr Surg 2003; 38:594-596 embedded catheter torn away from vein wall Six patients with embedded catheters in place for 3 5 years Nephrol Dial Transplant 2006; 21:2005-2008 Management of the Stuck Catheter Just pull harder. hemodialysis catheter 57 lbs of force to break catheter catheters broke near hub Weighted traction to remove stuck catheter 5
Options for Management of Stuck Catheter 1. Surgical ligation 2. Percutaneous techniques for removal a. Angioplasty balloon b. Snare c. Lead extraction tools Surgical Ligation of Stuck Catheter 1. Surgical exposure of vein entry site 2. Tie & occlude catheter with suture 3. Transect catheter 4. Close wound over stuck catheter 3. Thoracotomy Percutaneous Techniques for Removal of Stuck Tunneled Catheter Angioplasty balloon Snare AICD lead extraction tools Percutaneous Techniques for Removal of Stuck Tunneled Catheter Outpatient Surgery Center vs. Hospital Percutaneous Techniques for Removal of Stuck Tunneled Catheter Angioplasty balloon Snare AICD lead extraction tools Tear in mediastinum with acute hemorrhage 6
Stuck hemodialysis catheter enters left internal jugular vein Angioplasty balloon (6mm) inflated inside catheter lumen From: Hong JH J Vasc Access 2011; 12:381-384 Guidewire + angioplasty balloon catheter Inflation of 6mm diameter balloon in catheter J Vasc Intervent Radiol 2012; 23:1089-1093 Figure 1 Figure 3 Use of hemostats to occlude catheter lumens More aggressive angioplasty using 8mm balloon Ryan et al. J Vasc Intervent Radiol 2012; 23:1089-1093 Ryan et al. J Vasc Intervent Radiol 2012; 23:1089-1093 7
Plan B: Sheath Around Catheter Peel-Away Sheath Technique 1. Cut catheter 2. Tie suture around catheter 3. Advance 16 Fr. sheath over catheter DOI: 10.5301/jva.5000186 From Abigail Falk, MD Air Embolism Calculated air flow rate = 493 ml/sec through open 16 Fr. catheter with -5mmHg CVP V 2Δp γσk γfσl/d ρ L g g Modified Bernoulli's Equation solved for air flow velocity Use sidearm adapter to prevent air embolism tighten valve around balloon catheter Percutaneous Techniques for Removal of Stuck Tunneled Catheter Angioplasty balloon Snare AICD lead extraction tools Use of Endovascular Snares 8
Right Angle Snare Right angle snare is oriented at a 90º angle to catheter shaft Nitinol wire is resistant to deformation caused by vigorous manipulations Ensnare catheter embedded in chronic thrombus Curry Retrieval Snare Dotter Retrieval Snare catheter tip is free 6 Fr introducer sheath If tip of catheter is free Foley PT et al. Cardiovasc Intervent Radiol 2007; 30:1079-1081 snare around catheter tip snare 9
retract snare chronic thrombus retract snare Thrombus surrounding catheter tip If tip of catheter is not free for snaring loop guidewire around catheter Catheter tip embedded in vascular wall IVC approach from femoral vein snare end of guidewire McIntyre CW et al. Nephrol Dial Transplant 2003; 18:432-433 retract snare 10
Percutaneous Techniques for Removal of Stuck Tunneled Catheter Angioplasty balloon Snare AICD lead extraction tools Excimer laser sheath Summary Under recognized problem Incidence < 1% laser sheath embedded lead Management based on specific details of situation Recommendation : prophylactic exchange of catheter once a year? 11