Clinics of Oncology
ISSN: 2640-1037 Volume 5
Case Report
Percutaneous Transvenous Removal of A Venous Access Port Catheter Fractured And
Migrated Into The Left Pulmonary Artery
Aydın Aslan1 and Ferit Aslan2*
1
Department of Radiology, Yuksek İhtisas University Medicalpark Ankara Batıkent Hospital , Ankara, Turkey
2
Department of Medical Oncology, Yuksek İhtisas University Medicalpark Ankara Batıkent Hospital , Ankara, Turkey
*
Corresponding author:
Ferit Aslan,
Department of Medical Oncology, Yuksek İhtisas
University, Medicalpark Ankara Hospital,
Ankara, Turkey ,09056100, Tel: 0312) 666 80 00;
Fax :(0212) 227 34 77;
E-mail: feritferhat21@gmail.com
Received: 26 Oct 2021
Accepted: 11 Nov 2021
Published: 16 Nov 2021
J Short Name: COO
Copyright:
©2021 Aslan F. This is an open access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and
build upon your work non-commercially.
Citation:
Keywords:
Port catheter; Fractured and migrated; Percutaneous
removal; Gooseneck snare
1. Abstract
Patients having chemotherapy usually undergo placement of a totally implantable venous access port (TIVAP) with high patient
satisfaction and low complication rates. Although properly placed
and carefully used, some complications can be introduced in the
early and late period. Among the delayed complications, a fractured and migrated catheter into the pulmonary artery is rarely seen
and sometimes generates a life-threatining situation. The migrated
part can be safely and effectively retrieved by percutaneous transvenous way with a gooseneck snare system. we report a very rare
case of TIVAP catheter fractured and migrated of distal part into
the left pulmonary artery and its removal via percutaneous transvenous route
2. Introduction
In patients with cancer, long-term central venous path is often needed for periodic administration of chemotheraphy, blood intake
for testing and sometimes vasculary way for contrast enhanced
imaging techniques [1, 2]. For this purpose, a totally implantable
venous access port (TIVAP) catheter was first introduced Niederhuber et al. in 1982 with present used type usually implanted subcutaneous tissue in the chest wall [3]. Because of their low rates
of extravasation and infection, TIVAP has been widely accepted
and used worldwide with high patient satisfaction, longer service
life and easier care [4]. Nowadays, TIVAP has become an essenclinicsofoncology.com
Aslan F, Percutaneous Transvenous Removal of A Venous
Access Port Catheter Fractured And Migrated Into The
Left Pulmonary Artery. Clin Onco. 2021; 5(5): 1-3
tial need for many chemotheraphy protocols in malignancies with
improving the patients’ quality of life [5]. Although its routinely
used, complications including venous thrombosis, extravasations,
dislocation, obstruction, catheter leakage, and local or systemic
infections can be seen up to 15% of patients in early (<30 days)
and late stage (>30 days) after implantation [3]. Among these delayed complications, a fractured and migrated port catheter into the
pulmonary artery is seen very rare and constitutes life-threatening
situation leading mostly thromboembolic events or embolization
of the vessels [6]. Therefore, removal of this migrated catheter part
should be recommended as soon as possible when this hazardous
and emergency situation established.
Here, we report a very rare case of TIVAP catheter fractured and
migrated of distal part into the left pulmonary artery and its removal via percutaneous transvenous route.
3. Case Report
A 56 year old woman with T2N0M0 infiltrative ductal carcinoma
of breast underwent modified radical mastectomy in March 2015.
One month after the surgery, a TIVAP placement was performed in
another instutition on the right chess wall via right subclavian vein
(SV). A chest radiography showed the TIVAP located at the correct
position and no catheter kinking was seen in the vessel entrance
(Figure 1a). So she had been applied several planned schedule chemotherapy via this TIVAP. After the end of planned chemotherapy,
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Volume 5 Issue 5 -2021
she was followed-up for 3 months in the first two years and once
in per year after then. In the previous annual control in April 2019,
there was a catheter twisting between the first rib and clavicle (Figure 1b) compatible with pinch-off syndrome. The patient was told
that the catheter is needed to be removed but patient refused it. In
January 2020, patient came to control with no clinical symptom
and a chest x-ray was performed. On the chest radiography, catheter fracture from the former twisting site and distal part migration
into the left pulmonary artery was observed (Figure 1c). Because
the patient had no clinical sypmtom, no-added computed tomography (CT) imaging was performed and both the proximal port
Case Report
catheter and the migrated distal part were planned to remove. The
remnant catheter and reservoir were taken by surgically under local anesthesia. For the migrated distal part, we inserted a 6F sheath
into the right femoral vein by ultrasound (US)-guided percutaneous puncture. The migrated catheter part was subsequently captured
near the proximal free part and moved into the sheath in the right
femoral vein using a 6F Amplatz GooseNeck Snare Kit (Figure 1d
and 1e). Then, the migrated fragment was removed successfully
with venous sheath (Figure 1f). Venous puncture area was compressed a few minutes manually. There was no complication during
these procedure.
Figure 1: (a) Chest x-ray after TIVAP implantation shows the correct position of it. (b) Approximately 3 years after implantation, a twisting of catheter
between the first rib and clavicle, compatible with pinch-off syndrome (arrow) was seen. (c) About 9 month later after (b) image, broken of the catheter
from former twisted area and migration of distal part into the left pulmonary artery was detected (arrow). Note the remnant catheter and port reservoir
(arrowhead). (d) With right femoral vein approach, the snare kit was moved to the dislodged catheter. (e) The migrated part was captured with snare
system. (f) The broken distal part of catheter removed successfully with venous sheath.
4. Discussion
TIVAP has been used in the oncology routine by increasing patient comfort and easing chemotherapy application since the early 1980s [7]. It enables more benefits than other non-implantable
systems with low infection rates and unlimited liberty in patients’
daily activities. TIVAP consists of a catheter attached to a usually chamber shaped reservoir that is implanted into subcutaneous
tissue on the chest wall. The catheter enters the central veins and
the tip of it ends in the atriocaval junction or in the right atrium.
Altough its proper implantation and careful use, approximately 5
to 15% of patiens have some complication in short- and long-term
[3, 8]. Most common early complications seen within the first 30
day include usually procedure-related troubles such as catheter
malpositioning, arterial injury and hematoma, pneumo-hemothorax or cardiac tamponade. In late-stage complications encountered after the 30 days from implantation include infection, catheter
thrombosis and stenosis or catheter fracture with extravasation,
mostly result with catheter withdrawal. Mainly two central venous
accesses are chosen for the TIVAP: the subclavian vein (SV) or the
internal jugular vein (IJV). Many reports support the preferential
use of the IJV with its low complication rate both in the early and
clinicsofoncology.com
late period after implantation [1, 5, 9]. However, few studies have
shown no differences in the incidence of complications between
this two venous placement [5, 10, 11].
Fractured of port catheter is another delayed complication usually
seen in delayed phase due to several mechanisms. Loose connection between the reservoir and catheter, mechanical damage of
catheter during tunneling or implantation and exhaustion fracture
because of sharp angle especially in the venous access site are the
most common causes [12]. In patients with TIVAP introduced via
SV, like our patient, the catheter part passing through the clavicle
and the first rib is also a fracture point called as pinch-off syndrome
[6]. In this situation, port catheter fracture usually happens during
catheter removal. Some studies reported that US-guided puncture
of the lateral site of SV near the axillary vein segment could avoid
this syndrome [13]. Choosing IJV access is another suggestion but
it should be kept in mind that catheter fracture can also occur less
commonly in the IJV route due to repetitive neck motions [14].
Migration of fractured catheter is a very rare complication. The
displaced catheter can move to the right ventricle and pulmonary
artery following flow direction, as in our case, leading to life-threatening conditions such as heart damage, pulmonary embolism
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and obstruction result with distal embolisation [3, 6]. Catheter
displacement should be suspected if infusion is not being easy or
there is distention around the catheter tract. But sometimes, patient
may be clinically asymptomatic and catheter migration into the
defined areas above can be identified on a routine chest x-ray, just
like in our patient. A chest radiography can be used to show the
TIVAP integrity and catheter position. Sometimes, CT of chest or
pulmonary CT angiography can be needed particularly in symptomatic patient showing right ventricle disfunction or thromboembolic event. Radiologic imaging has become very necessary not only
peri-procedural assessment and postoperative follow-up for detection of possible complications but also to plan intervention such
as removal of fractured and migrated catheter [15]. Early removal
of dislodged catheter is necessary to prevent pulmonary embolism
and distal embolisation. Thoracotomy was the principal technique
to retrieve the migrated fragment in the past but parallel to developments in technology, interventional transvenous techniques
with minimal invasive procedures are effectively used nowadays
[6, 16]. Endovascular snare systems, with the help of a guide wire
or pigtail can be used easily and reliably for the retrival of fractured catheter [17].
5. Conclusion
The fracture and migration of port catheter occasionally occur in
the late phase after TIVAP implantation. Pinch-off syndrome is one
of the reasons for broken catheters besides disordered connection
between port parts, mechanical damage and fatigue fracture because of sharp angle. Radiologic techniques have an important role
in both imaging during the intervention or follow-up and planning
intervention. Fractured part of the catheter can be easily and safely
removed with minimally invasive percutaneous transvenous route.
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