INTRODUCTION:Central venous catheter placement is common in medical practice today. Although it is a relatively simple procedure, it potentially has serious complications including: myocardial infarction; arrhythmia; valvular, cardiac or venous perforation; or pulmonary embolism. Other complications include infections, in-situ fracture, fragmentation, and embolization. A case of embolization of an entire catheter that remained asymptomatic for 17 years is presented.
CASE PRESENTATION:A case of 58 year old Caucasian male with a past medical history of very-severe chronic obstructive pulmonary disease (COPD), cor pulmonale, Crohn’s disease and psoriasis, presented with shortness of breath. He had history of several intubations for respiratory failure and central line placements for venous access in the past. On admission, his chest radiograph revealed a catheter in the superior vena cava extending into the right atrium. Previous radiographs were reviewed which revealed that the catheter had been present for the past 17 years in the exact same location. Echocardiograms were also reviewed, retrospectively, which confirmed the presence of a catheter. The patient was critically ill on this admission secondary to acute-on-chronic respiratory failure. The presence of the embolized catheter did not contribute to his clinical condition and therefore no attempt was made to retrieve and remove the retained catheter. He died shortly after admission secondary to end-stage-lung disease.
DISCUSSIONS:The first case of central venous catheter embolization was described in 1954. Catheter embolization or fragmentation usually occurs as a result of cutting the fixation suture, catheter material fatigue or patient movement. These catheters/fragments migrate in the blood stream lodging in the vena cava, right atrium, right ventricle, the main pulmonary artery, or one of its branches. Mortality reportedly depends on the duration and the site of lodgment of the foreign body. According to a study, mortality was highest when the foreign body was lodged in the right heart; less when lodged in the vena cava; and least when lodged in the pulmonary artery. Our case is unique for a number of reasons:1. We suspect that entire catheter might have embolized as the catheter design in those days was different. The catheters were inserted directly through a large bore needle. Afterwards it was connected to an adapter containing a hub for syringe or IV tubing connection. The catheter was uniform width and could easily migrate through the needle or venipuncture site.2. Patient remained asymptomatic despite the presence of the catheter in the right atrium.3. The presence of a retained catheter for 17 years. The longest reported time a retained catheter fragment remained asymptomatic was for 11 years. Although literature supports aggressive foreign body removal, there is also literature supporting conservative management in asymptomatic patients. The decision to extract these should be individualized based on the patient’s condition, the location, and the potential risks. The patient under discussion was cared for by other physicians prior to this admission and it is unclear if they were aware of the catheter’s presence. However the retained catheter did not, evidently, cause any clinical signs or symptoms for seventeen years.
CONCLUSION:Central venous catheter placement requires skill and experience, and one should be cautious during its insertion and removal. One must also have a high index of suspicion for foreign bodies while interpreting radiographs. Documentation of the devices during insertion and removal should be included in medical records.
DISCLOSURE:Anil Gogineni, None.