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Anand Reddy,* Anondo Stangl,† and Brian Radbill‡
*Department of Nephrology, Mount Sinai School of Medicine, New York, †Department of Radiology, Mount Sinai School of Medicine, New York City, New York, and ‡Department of Nephrology, Mount Sinai School of Medicine, New York City, New York
ABSTRACT Despite efforts to curtail central vein catheter use for dialysis catheters are frequently used in the treatment of end-stage renal disease (ESRD). In 2006, 82% of patients in the USA initiated dialysis via a catheter. The overall of tunnelled cuffed catheter (TCC) use was 35% greater in 2005 compared with 1996. Dialysis catheter tip fracture is a rare and potentially serious complication. Herein, we present the case of an incidental ﬁnding of a retained catheter fragment from a fractured TCC in the right atrium. Fragment retrieval (via snare technique) and subsequent placement of a new central venous catheter are outlined.
Well-functioning, long-term vascular access remains the Achilles’ heel of hemodialysis (HD) and is essential to providing efﬁcient dialysis therapy. Vascular access is a major cause of morbidity and mortality (1) in endstage renal disease (ESRD), accounting for the majority of hospitalizations (2) and 14% of all ESRD expenses (an estimated $1 billion annually) (1). There are three main types of longterm vascular access: native arteriovenous ﬁstula (AVF), arteriovenous graft (AVG) and central vein catheter (CVC), typically a tunnelled cuffed catheter (TCC). Originally hailed as a viable alternative to the arteriovenous graft (AVG), TCCs have been associated with as much as a threefold increased mortality rate as compared to AVFs (3,4). Sepsis-related death is 100 times greater in dialysis patients than in the general population, with infection-related death and all-cause mortality highest in those with TCCs (5). Approximately 20% of patients dialyzed through a TCC develop osteomyelitis, septic arthritis, and endocarditis and often die, regardless of whether or not the infected catheter is removed (6,7). In addition to infection-related complications, a several-fold increase in cardiovascular risk has also been associated with catheter use (5). The cost of placing a TCC is approximately $13,000, and that of
Address correspondence to: Anand Reddy, One Gustave L.Levy Place, Mount Sinai School of Medicine, New York, NY 10029, Tel.: +1-212-241-8002, Fax: +1-212-987-0389, or e-mail: firstname.lastname@example.org. Seminars in Dialysis—Vol 23, No 5 (September–October) 2010 pp. 536–539 DOI: 10.1111/j.1525-139X.2010.00756.x ª 2010 Wiley Periodicals, Inc. 536
treating one TCC-related episode of bacteremia is as high as $45,000 (5). Case Report A 35-year-old caucasian woman presented with a history of ESRD on HD via a right internal jugular vein CVC. Other past medical history included a 22-year history of insulin-dependent diabetes mellitus (IDDM) complicated by gastroparesis, peripheral vascular disease, ischemic cardiomyopathy status-post AICD and a vocal cord lesion requiring a prior tracheostomy. Patient presented to the emergency department because of shortness of breath attributed to difﬁculty managing her tracheostomy. Her initial physical examination and bloodwork were unremarkable except for elevated blood urea nitrogen and creatinine and a potassium of 5.6 mEq ⁄ l. Routine chest X-ray revealed mild pulmonary congestion, right internal jugular CVC, and what appeared to be a catheter fragment in the cardiac silhouette (Fig. 1A and B). CT scan conﬁrmed the presence of a foreign body (Fig. 1C), most likely a fractured catheter tip, in the right atrium. After discussion with the patient and the interventional radiology team regarding potential risks and beneﬁts of catheter tip retrieval, the catheter fragment was successfully removed by percutaneous snare technique under ﬂuoroscopy guidance through a femoral approach (Fig. 2A–E). The catheter tip fragment and the indwelling CVC, which was exchanged at the time of the procedure, were sent for pathology. It was later revealed that the fragment was part of a
RETAINED FRACTURED CATHETER FRAGMENT
Fig. 1. Imaging studies (A) CXR lateral view; (B) CXR PA; (C) CT scan.
different catheter than the indwelling CVC (Fig. 3), which was found to be intact. Discussion Here we described a case of a retained catheter fragment incidentally discovered in the right atrium of an ESRD patient with a history of multiple prior CVCs successfully removed percutaneously via a snare technique. In addition to pulmonary embolization (8–10), other potential serious complications of dialysis catheter tip fracture may include: myocardial rupture, valvular perforation, pulmonary artery rupture, infective endocarditis, and pulmonary abscess. The fractured catheter component may lodge anywhere distal to its original location including the vena cava, right atrium, right ventricle, and pulmonary artery, depending on the size and weight of the broken segment (11). Removal of the foreign body by a nonsurgical percutaneous approach is possible in most cases. This can be done using snares, hooked guide wires, Fogarty balloon catheters, or Dormia baskets (12). Central venous catheter fracture has primarily been reported in patients with central venous access devices used primarily for the administration of chemotherapy. These catheters are commonly inserted in the subclavian
vein and fracture is attributed to chronic mechanical friction and shear forces on the catheter as it passes between the clavicle and the ﬁrst rib (4,13). The ‘‘pinchoff’’ sign, characterized by a kink or narrowing of the catheter at this position, is an early warning sign for impending catheter fracture at that site (4). This type of mechanical friction and catheter stenosis may be avoided by choosing an internal jugular vein approach, which is better, suited for cuffed tunneled hemodialysis catheters but not for long term implanted chemotherapy devices (10). Early indications of catheter fracture are not well described. In a few case reports, associated symptoms ⁄ ﬁndings included intermittent catheter malfunction, resistance to ﬂuid administration, pain during dialysis treatment, chest pain and palpitations, all of which are relatively nonspeciﬁc (10,14,15). The majority of case reports are asymptomatic. Our patient did present with shortness of breath but this was directly attributable to difﬁculties with her tracheostomy. During a recent hospital admission, the patient developed an episode of ventricular tachycardia; however, given the patient’s history of reduced LV function and prior dysrhythmia requiring AICD placement, we do not feel this was related to the presence of the retained catheter fragment. In our patient it was not clear why the catheter fractured but most likely as various reports have shown that
Reddy et al.
Fig. 2. (A–D) Percutaneous transvenous snare technique of intracardiac catheter fragment retrieval removal approach.
aware of all potential problems (however rare) and recognize the need for a multidisciplinary approach in managing vascular access complications and failure. References
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Fig. 3. Catheter fragment and catheter after removal.
vascular catheter could be afﬁxed to the wall of the superior vena cava or the atrium (16–21). Tradional methods of catheter removal not only cause vascular or atrial avulsion but may also result in catheter breakage with resultant retention of the broken fragments (16,17). Recently a novel new Laser sheath technique was applied to remove the retained catheters which shown catheter withdrawal without any risk of catheter fracture (22). Unfortunately, as we have learned all too well, the dialysis access catheter is a double-edged sword. With the frequent use of cuffed catheters it is important to be
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18. Hassan A, Khaffa M, Al-Akira M, Lord R, Davenport A: Six cases of retained central venous haemodialysis access catheters. Nephrol Dial Transplant 21:2005–2008, 2006 Links 19. Liu T, Hanna N, Summers D: Retained central venous haemodialysis access catheters. Nephrol Dial Transplant 22:960–961, 2007 20. Thein H, Ratanjee SK: Tethered hemodialysis catheter with retained portions in central vein and right atrium on attempted removal. Am J Kidney Dis 46:35–39, 2005 Links 21. Foley PT, Carter RM, Uberoi R: Endovascular removal of long-term hemodialysis catheters. Cardiovasc Intervent Radiol 30:1079–1081, 2007 22. Carrillo RG, Garisto JD, Salman L, Merrill D, Asif A: A novel technique for tethered dialysis catheter removal using the LASER sheath. Semin Dial 22:688–691, 2009