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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 182-184

Delayed cardiac migration of totally implantable central venous access catheter


Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Web Publication9-Apr-2014

Correspondence Address:
Shailesh Solanki
Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0513.130223

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  Abstract 

Chemo ports (or totally implantable venous devices) are increasingly being used for venous access for chemotherapy in cancer patients, especially in the pediatric age group. They improve the quality of life of children requiring long-term chemotherapy. Despite the advances made in the design, material of the catheter and the technique of insertion, various complications are associated with their use. Cardiac embolization of such a catheter is a life-threatening complication. We report, cardiac migration of a chemo port catheter 6 months post-insertion and discuss the diagnosis and management of this rare complication.

Keywords: Cardiac migration, complications of implantable venous device, totally implantable venous access device


How to cite this article:
Solanki S, Babu M N, Gowrishankar B C, Ramesh S. Delayed cardiac migration of totally implantable central venous access catheter. Clin Cancer Investig J 2014;3:182-4

How to cite this URL:
Solanki S, Babu M N, Gowrishankar B C, Ramesh S. Delayed cardiac migration of totally implantable central venous access catheter. Clin Cancer Investig J [serial online] 2014 [cited 2020 Apr 1];3:182-4. Available from: http://www.ccij-online.org/text.asp?2014/3/2/182/130223


  Introduction Top


The introduction of implantable venous devices has revolutionized the care and quality of life of patients with cancer. Implantable port consists of a single lumen (or double lumen) reservoir hub attached to a catheter. The reservoir hub is implanted in the subcutaneous tissue of the chest wall and catheter tunneled to the accessed vein. The distal end is positioned in the superior vena cava, whereas the proximal end is connected to the port reservoir. These totally implantable ports offer several advantages over partially implantable systems: Low infection rates and unrestricted freedom in patients' physical activities. [1],[2] Device-associated complications include infection, catheter obstruction and deep venous thrombosis are well-described. In the present case, we discuss an infrequent, but serious non-infectious complication associated with totally implantable devices. 6 months after insertion, the whole catheter migrated spontaneously into the right ventricle.


  Case Report Top


The present case report is about a 2-year-8-month-old female child diagnosed with left adrenal neuroblastoma stage IV underwent chemo port placement [Figure 1]. Districath implantable port axial into right internal jugular vein by a percutaneous technique. Catheter position was confirmed radiologically post insertion. She then received 10 courses of chemotherapy through the chemo port without any complications. During the 11 th course of chemotherapy, there was no backflow of blood on reservoir chamber aspiration and a subcutaneous swelling developed at chemo port site on flushing. X-ray chest [Figure 2] revealed migration of the whole catheter into cardiac chamber. The catheter was retrieved from the right ventricle [Figure 3] with the help of a goose neck snare introduced via right subclavian vein under fluoroscopic guidance (by an interventional cardiologist). Right femoral vein access failed due to thrombosis. The infusion chamber was also removed and the child later underwent another chemo port placement for further chemotherapy.
Figure 1: Totally implantable venous access device. Showing port chamber with tubing attached via metallic connector

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Figure 2: Migrated, detached whole catheter in cardiac chamber and infusion chamber with a metallic hub on the right chest wall

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Figure 3: Retrieval of the catheter under fluoroscopic guidance with the help of a vascular snare via the subclavian vein (percutaneous technique)

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  Discussion Top


Chemo ports (totally implantable devices) are widely used world-wide for pediatric oncology patients requiring long term chemotherapy. The complications with implantable devices are least compared with other central venous access methods. The complications can be classified as early and late. Early complications include hematoma, arterial puncture or injury, venous rupture, hydrothorax, hemothorax, chylothorax, pneumothorax, air embolism, malpositioning and catheter breakage that results in its migration. Late complications include catheter-related infection, catheter occlusions or thrombosis, catheter fracture and migration. [3],[4] Migrations happen less than initial malpositionings. [5] Catheter fracture and dislocation is an uncommon but life-threatening complication with an estimated rate of 0.1%. [6] Trotter reported an incidence of 2.5% over a 5 years period in neonates. [7] The embolized catheter fragment may travel to the right atrium, ventricle, or even into the pulmonary artery. Perforation of caval vein and migration of the catheter tip into the lung or mediastinal structures has also been observed. [8] Different mechanisms that lead to fracture and migration of the catheter have been described and include shearing by the introducer needle during insertion, bolus infusion, body movements, weakening of the catheter tip and mechanical compression between clavicle and the first rib. [5],[7]

In the index case, catheter migration was spontaneous as no plausible cause can be asserted. Blood aspiration and saline injection are standard safety tests to be undertaken before administration of drugs. Local pain or subcutaneous swelling at the site of port flushing are signs of malfunction or malposition and should be investigated. Rarely, it may present as an intracardiac foreign body with fever and/or arrhythmias. A catheter fragment in the heart may remain asymptomatic for years. [9] Percutaneous retrieval methods through a femoral vein or subclavian vein approach, using vascular snares are usually suitable and successful for most patients. Nevertheless, a catheter embedded in the myocardium may need a thoracotomy or median sternotomy for removal. [10]


  Conclusion Top


Catheter migration is a rare but life-threatening complication of implantable venous access devices. Intracardiac migration may remain asymptomatic or may cause arrhythmia and cardiac arrest, hence should be considered as emergency once diagnosed. The catheter can be retrieved mostly by percutaneous technique with the help of a vascular snare, but may sometimes require an open sternotomy/ thoracotomy. The importance of aspiration and saline flushing before any drug administration through ports cannot be overemphasized. Lastly, any implanted catheter should be removed once its purpose is fulfilled.

 
  References Top

1.Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-5.  Back to cited text no. 1
[PUBMED]    
2.Barbetakis N, Asteriou C, Kleontas A, Karvelas C. Migration of a fractured totally implantable venous access catheter into the right ventricle. Tuberk Toraks 2011;59:103-4.  Back to cited text no. 2
[PUBMED]    
3.Miller JA, Singireddy S, Maldjian P, Baker SR. A reevaluation of the radiographically detectable complications of percutaneous venous access lines inserted by four subcutaneous approaches. Am Surg 1999;65:125-30.  Back to cited text no. 3
    
4.McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V, Mallory DL. Accurate placement of central venous catheters: A prospective, randomized, multicenter trial. Crit Care Med 1993;21:1118-23.  Back to cited text no. 4
    
5.Bach A. Complications of central venous catheterization. Chest 1993;104:654-5.  Back to cited text no. 5
[PUBMED]    
6.Di Carlo I, Cordio S, La Greca G, Privitera G, Russello D, Puleo S, et al. Totally implantable venous access devices implanted surgically: A retrospective study on early and late complications. Arch Surg 2001;136:1050-3.  Back to cited text no. 6
    
7.Trotter C, Carey BE. Tearing and embolization of percutaneous central venous catheters. Neonatal Netw 1998;17:67-71.  Back to cited text no. 7
    
8.Hackert T, Tjaden C, Kraft A, Sido B, Dienemann H, Buchler MW. Intrapulmonal dislocation of a totally implantable venous access device. World J Surg Oncol 2005;3:19.  Back to cited text no. 8
    
9.Van Den Akker-Berman LM, Pinzur S, Aydinalp A, Brezins M, Gellerman M, Elami A, et al. Uneventful 25-year course of an intracardiac intravenous catheter fragment in the right heart. J Interv Cardiol 2002;15:421-3.  Back to cited text no. 9
    
10.Kapadia S, Parakh R, Grover T, Yadav A. Catheter fracture and cardiac migration of a totally implantable venous device. Indian J Cancer 2005;42:155-7.  Back to cited text no. 10
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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