Positional Ventricular Tachycardia from a Fractured Mediport Catheter with Right Ventricular Migration

Impact of mechanical stress on flexible tubing used for biomedical applications: Characterization of the damages and impact on the patient's health

Flexible tubing is a key part of a lot of medical devices used in hospital, but may be subjected to a lot of various mechanical stresses that can led to the failure or to complications for the patients. The nature and causes of these mechanical stresses were listed for peristaltic pump tubing, infusion set tubing and catheters. Their consequences in term of tubing damages and particular contamination were reported. The impact of the chemical nature of the tubing, of its size and also the impact of various parameters of the clinical acts were reviewed. Last the consequences for the patient's health were discussed.

The Mediport Paradox: Mediastinitis and Pericardial Effusion With a Misplaced Mediport

Totally implantable subcutaneous devices (TISDs) have become excellent options for patients requiring long-term chemotherapy, parenteral nutrition, and fluid replacement. As with all invasive devices and procedures, they come with their inherent risks, which may manifest immediately or at a later point in time. We present the case of a 74-year-old female with a history of hypertension, chronic obstructive pulmonary disease (COPD), ischemic stroke, breast cancer, and lung cancer who had mediport placement for chemotherapy administration. She received several infusions of pembrolizumab through her mediport and developed progressive dyspnea over four weeks. Upon evaluation at our institution, she was found to have a misplaced mediport with mediastinitis and pericardial effusion due to direct mediastinal exposure to immunotherapy. This case highlights the importance of systematic imaging review, regardless of suspected pathology, and encourages providers to have a low threshold to re-evaluate patients after device placement or immunotherapy commencement.

Detachment and embolization of totally implantable central venous access devices: diagnosis and management

BACKGROUND

Detachment and embolization (DE) is a rare complication of totally implantable central venous access devices (TIVADs). This study aimed to analyze clinical findings, etiology, and treatment options in DE of TIVADs.

METHODS

Patients who experienced DE between 2010-2019 were included. Indications, implantation techniques, time to diagnosis, patient complaints, diagnostic methods, rupture site, location of embolization, treatment methods, and chest X-rays prior to detachment were analyzed retrospectively.

RESULTS

DE of TIVAD was detected in 12(1.2%) patients. Eleven patients had breast cancer and one had colon cancer. Mean age at implantation was 45.3 ± 9.6(31-61.3) years. Seven (58%) patients were asymptomatic, four (33.3%) had TIVAD malfunction, and one (8.3%) had pain and swelling at port site after injection. Mean time from implantation to diagnosis was 1149.92(16-2795) days. The etiologies comprised Pinch-off Syndrome (POS) in eight (66%) patients, detachment directly adjacent to the lock mechanism in three (25%) patients, and probable iatrogenic injury during explantation in one (9%) patient. The most common site of embolism was the superior vena cava (25%). While the embolized fragment was removed percutaneously in 11 patients, medical follow-up was treatment choice for one patient.

CONCLUSIONS

DE is a rare complication with an incidence rate of 1.2% in this study. Since most patients were asymptomatic, chest radiography plays an important role in diagnosis. The most common cause was POS, and it can be prevented by inserting the catheter from lateral third of the clavicle during subclavian vein catheterization. The first-choice treatment was percutaneous femoral retrieval. However, if not technically possible, alternative treatment options are thoracotomy or follow-up with anticoagulant therapy.

Port-a-Cath fracture and migration in paediatric cancer patients: incidence and management at a tertiary care centre - a 15-year experience

INTRODUCTION

Port-a-Cath or chemoport provides prolonged central venous access for cancer patients requiring prolonged chemotherapy. Prolonged use of chemoport is associated with many complications. Dislodgement and migration of chemoport catheter is a rare and reportable complication with potentially serious consequences.

METHODS

The medical charts of 1222 paediatric cancer patients admitted to the Children's Cancer Center in Lebanon who had chemoports inserted for long-term chemotherapy were retrospectively reviewed. Descriptive analysis of data was conducted.

RESULTS

Chemoport fracture and migration were found in seven cases with an incidence of 0.57%. The duration of chemoport use before the event of dislodgement varied from 2 months to 102 months. Non-functioning chemoport was the most common presentation. Totally, six cases were managed successfully by loop snaring, three cases by paediatric cardiology team, and three cases by interventional radiology team. One case was managed surgically during chemoport removal.

CONCLUSION

Fracture and migration of chemoport catheter is a rare complication of uncertain aetiology and with potentially serious consequences. Percutaneous retrieval, done by experienced cardiologist or interventional radiologist, is the first choice for management of this complication as it is considered as a safe and effective approach.

Complications of central venous port systems: a pictorial review

Central venous port devices are indicated for patients, who need long-term intravenous therapy. Oncologic patients may require intermittent administration of chemotherapy, parenteral nutrition, infusions, or blood transfusions. A venous port system is composed of a port chamber attached to a central catheter, which is implanted into the central venous system. The subcutaneous location of the catheter chamber improves the patients’ quality of life and the infection rate is lower than in non-totally implantable central venous devices. However, proper implantation, use, and care of a port system are important to prevent short- and long-term complications. Most common early complications (< 30 days) include venous malpositioning of catheter and perforation with arterial injury, pneumothorax, hemothorax, thoracic duct injury, or even cardiac tamponade. Delayed complications include infection, catheter thrombosis, vessel thrombosis and stenosis, catheter fracture with extravasation, or fracture with migration or embolization of catheter material. Radiologic imaging has become highly relevant in intra-procedural assessment and postoperative follow-up, for detection of possible complications and to plan intervention, e.g., in case of catheter migration. This pictorial review presents the normal imaging appearance of central venous port systems and demonstrates imaging features of short- and long-term complications.

Embolização para veia cava inferior de cateter totalmente implantável para quimioterapia

A fratura com embolização de cateter inserido perifericamente em pacientes que receberam quimioterapia representa uma complicação grave e rara, constituindo menos de 1% das complicações relacionadas a esse procedimento. Relatamos aqui um caso de embolização de cateter totalmente implantável em uma paciente de 57 anos submetida a laparotomia por lesão anexial complexa devido a um câncer de ovário com carcinomatose intraperitoneal disseminada diagnosticado no intraoperatório. A paciente foi submetida a histerectomia e salpingooforectomia bilateral, não sendo realizada cirurgia oncológica radical. A análise histopatológica revelou adenocarcinoma de ovário G3. Em outubro de 2013, exame radiológico de rotina diagnosticou fratura e embolização de segmento distal do cateter para veia cava inferior retro e supra-hepática. A paciente não apresentou nenhuma sintomatologia. Procedeu-se à retirada do cateter através da veia femoral pela técnica do laço, sem complicações. Paciente está sem evidência de doença 24 meses após a realização do procedimento.

Totally implantable catheter migration and its percutaneous retrieval: case report and review of the literature

Totally subcutaneous intravascular portals have been increasingly used to administer long-term chemotherapy and parental nutrition. The reported complications are rare. Accidental endovascular rupture of a fragment of catheter is one of the most formidable complications of the central vein catheterization. The Authors report a case of deployment of a Port-a-Cath catheter and its percutaneous retrieval. The catheter accidentally detached and migrated from the reservoir of the port-a-cath placed in the left subclavian vein to the right heart cavities through the blood stream. A review of the Literature is also given, focusing on the possible factors responsible for this unusual complication.

Fracture at catheter of totally implantable venous access port with migration into the right pulmonary artery: A serious complication

Totally implantable venous access port has become an essential prerequisite for many chemotherapy protocols in solid tumors and hematological malignancies. However, we should be aware of its complications such as: venous thrombosis, extravasations, dislocation, obstruction, catheter leakage, and local or systemic infections. Among those complications, a dislodged broken catheter is rare and dangerous. We report a new case with review of literature to make oncologists aware about this entity and the necessity of monitoring by chest radiography. Percutaneous endovascular retrieval of a dislodged Port-A catheter (portacath) is both safe and effective. However, there are potential risks of valve damage and fatal tachycardia during retrieval of a fractured Port-A catheter. Physicians should be aware of these complications.

Ventricular Tachycardia from a Central Line Fracture Fragment Embolus: A Rare Complication of a Commonly Used Procedure-A Case Report and Review of the Relevant Literature

A 22-year-old male admitted with multiple gunshot wounds (GSW) had central line placed initially for hemodynamic monitoring and later for long term antibiotics and total parenteral nutrition (TPN). On postoperative day 4 he presented with bouts of nonsustained ventricular tachycardia; the cause was unknown initially and later attributed to a catheter fragment accidentally severed and lodged in the right heart. Percutaneous retrieval technique was used to successfully extract the catheter fragment and complete recovery was achieved.

Fracture and migration of implantable venous access port catheters: Cause analysis and management of 4 cases

This study aimed to investigate the causes and managements of the fractures and migrations of the implantable venous access port catheter (IVAPC). The fracture or migration of IVAPC occurred in 4 patients who were treated between May 2012 and January 2014 in Union Hospital, Wuhan, China. The port catheter leakage was found in 2 cases during drug infusion. Catheters that dislodged to the superior vena cava and right atrium were confirmed by port angiogram. The two dislodged catheters were successfully retrieved by interventional procedures. Catheter fracture occurred in two cases during port removal. One catheter was eventually removed from the subclavian vein through right clavicle osteotomy and subclavian venotomy, and the other removed by external jugular venotomy. Flushing the port in high pressure and injury of the totally implantable venous access port (TIVP) during implantation are usually responsible for catheter displacement. Interventional retrieval procedure can be used if the catheter dislodges to the vena cava and right atrium. Catheter fracture may occur during removal if clipping syndrome occurs or the catheter is sutured very tight during implantation.

Sinus arrest and asystole caused by a peripherally inserted central catheter

BACKGROUND

Transient bradycardia in the critical care setting is frequently caused by hypoxemia or oropharyngeal manipulation. Central lines have been associated with a variety of cardiac arrhythmias, but sinus arrest and asystole have not been previously reported.

METHODS

A 38-year-old woman with multisystem organ failure had several episodes of prolonged sinus arrest, slow junctional escape rhythm, and periods of asystole lasting over 6 seconds. The cause of the repetitive bradyarrhythmia was evaluated by clinical observation including the response to parasympatholytic agents, by detailed analysis of rhythm strips, and review of cardiac imaging studies.

RESULTS

The episodes of bradycardia did not coincide with orotracheal manipulation, were not prevented by escalating doses of glycopyrrolate, and were not accompanied by AV conduction disturbance as is frequently seen during a transient increase in vagal tone. Review of the patient's chest X-ray and chest CT revealed that the tip of a peripherally inserted central catheter migrated to the vicinity of the sinoatrial node. Removal of the catheter resulted in prompt resolution of the episodes of sinus arrest.

CONCLUSIONS

This case demonstrates that migration of a peripherally inserted central catheter to the sinoatrial node can provoke prolonged sinus bradycardia, sinus arrest and asystole.

Radio-opacity and incidental identified mechanical complications of totally implantable venous access devices placed in the chest

BACKGROUND

Totally implantable venous access devices (TIVAD) may be associated with different complications. Certain mechanical port disorders can easily be diagnosed on chest radiographs if the implanted systems are radiopaque and well visible. There are no reports regarding the visibility of TIVAD on chest X-rays.

PURPOSE

To assess the radio opacity of TIVAD implanted in the chest as well as type and frequency of mechanical complications of ports on chest X-ray images.

MATERIAL AND METHODS

Chest X-rays of 985 patients from the time period 2007-2009 were analyzed retrospectively. In these patients 1190 TIVAD were inserted. All parts of the TIVAD, i.e. port chamber, connection, and port catheter, were checked for their visibility on chest radiographs. An opacity score was used here as follows: ++ well visible; + visible; - partly or completely invisible. Mechanical complications of TIVAD incidentally detected on chest X-ray were also analyzed retrospectively.

RESULTS

Nineteen TIVAD models with diverse configuration and visibility of port chambers, connections, and catheters were identified in our study. Eighty-eight percent of the analyzed port systems were well visible or visible on chest radiographs. Twelve percent of the port chambers and catheters were partly visible or completely invisible. In 9% of the TIVAD, different mechanical complications were diagnosed on chest X-ray images.

CONCLUSION

TIVADs should be evaluated carefully on every chest X-ray. Ideally, they should be radio-opaque and well visible on thoracic X-ray images. Unfortunately, this is not always the case. Therefore, manufacturers of TIVAD should take into consideration to use exclusively radio-opaque materials that allow sufficient visibility of each port component on chest radiographs.

Percutaneous retrieval of an embolized central venous chemoport in a patient with colon cancer

The central access device is commonly used as a route of chemotherapuetic agents in patients with malignant diseases for its convenient and safety for insertion. This report describes a case of 66-year-old man with colon cancer who suffered a rare complication in which a chemoport embolized into the inferior vena cava and it was successfully retrieved by a percutaneous approach using a goose neck snare.

Frequent AV node reentrant tachycardia induced by oversized port catheter

PURPOSE

Here, we describe the efficiency of interventional electrophysiology therapy in a critically ill patient with heart failure because of incessant AV node reentrant tachycardia after surgical port implantation.

METHODS

Electrophysiology diagnostic and radio frequency ablation were utilized in the study.

RESULT

We presented a 78-year-old patient with colorectal cancer, surgical port implantation, and progressive heart failure due to an incessant AV node reentrant tachycardia (AVNRT). This rhythm disturbance was refractory to any conventional pharmaceutical treatment. The electrophysiology diagnostic obtained an AVNRT. During fluoroscopy, an oversized port catheter with a loop touching the tricuspid valve annulus was discovered. This port catheter was responsible for premature beats, which induced incessant AVNRT. A manual reposition of the port edge and additional AV node slow pathway modification terminated further tachycardia.

CONCLUSION

Electrophysiology diagnostic and radiofrequency ablation procedures are promising techniques also in critically ill patients with hemodynamic compromising supraventricular tachycardia.

Dislocation of Intravenous Port Systems - Three Case Reports

Background

Many patients with intravenous chemotherapy have an intravenous port system because of high tissue toxicity of most chemotherapeutic agents in the case of paravasation. With more port systems implanted, the rate of complications is increasing. Apart from catheter thrombosis, we primarily know of fracture of the port catheter.

Case Report

We describe 3 patients of our chemotherapeutic clinic who experienced complications of the intravenous port system implanted in the vena brachialis. All of them showed fracture and loss of the port catheter, followed in some cases by symptoms such as cardiac problems.

Conclusion

We have to discuss the use of intravenous port systems. Besides their comfortable use, intravenous port systems have to be handled with care and it has to be considered in every case if there really is the need for an implantation.

Intravenous Port Catheter Embolization: Mechanisms, Clinical Features, and Management

Venous catheters are important therapeutic devices for the administration of fluid and chemotherapeutic agents; however, their use may be associated with serious complications, such as catheter rupture and embolism. Most data on port catheter embolization consist of isolated case reports; only a few studies have examined a large number of patients with port catheter embolism. The purpose of this study was to identify the incidence of clinical symptoms in patients with catheter dislocation and to determine the role of catheter fragment localization in combination with the presenting symptoms. We conducted a retrospective analysis of patients admitted to Martin-Luther University Hospital Center from January 1994 to September 2005. In total, 41 patients with centrally dislocated catheter fragments were analyzed. Most catheter fragments were located in the pulmonary artery, superior vena cava, and right atrium. Of the patients in whom the catheter fragments were located in the right atrium, right ventricle, and the pulmonary artery, 7.3% presented cardiac symptoms. Catheter malfunction occurred in 39%. In 53.7%, catheter embolism was found incidentally. The embolized catheter fragments were retrieved by a goose-neck snare under fluoroscopy within 24 hours after the diagnosis without any complications. The mean length of these fragments was 11.6 cm. Catheter embolism may go undiagnosed for a prolonged period and be found incidentally. In these patients, predominantly local symptoms occur; however, severe systemic clinical signs may develop. The risk of serious complications in asymptomatic catheter embolism is unknown. Catheter fragments should be removed to prevent further complications.

Transluminal removal of a fractured and embolized indwelling central venous catheter in the pulmonary artery

Vascular catheters are associated with complications such as infection, thrombosis and stenosis. The embolization of a venous catheter fragment is a rare complication. A 39-year-old woman underwent placement of a totally implantable venous access device for chemotherapy to treat a recurrent liposarcoma of the left thigh. The "pinch-off sign" was noted on a routine chest X-ray but that was ignored. Three-months after implantation of the intravenous access device, the indwelling central catheter was fractured and embolized to the pulmonary trunk. The catheter in the pulmonary trunk was successfully removed through a percutaneous femoral vein approach using a pigtail catheter and goose neck snare.

ASDIN Clinical Case Focus: Cause for Inadequate Clearance: Hemodialysis Catheter Migration into the Coronary Sinus

Complications associated with central dialysis catheters prove to be an important source of morbidity that challenge patients and clinicians alike. While thrombosis, stenosis, and infection remain the most common threats to functioning central dialysis catheters, malposition of such devices may similarly result in serious consequences. Despite advanced techniques used to confirm initial catheter placement, the very nature of these catheters entails frequent manipulation for vascular access and therefore they may migrate after repeated use. When compared with the loss of patency and infection, complications involving malposition or migration may present in a more insidious fashion, such as a gradual decline in achievable blood flow rate or observed clearance over time. We describe a patient who acutely developed both clinical and biochemical evidence of inadequate clearance after several months of suboptimal catheter function. When the central dialysis catheter was examined fluoroscopically, it was found to have migrated into the coronary sinus.

Atypical pulmonary embolism of port catheter fragments in oncology patients

GOALS OF WORK

Embolization of venous catheter fragments to the pulmonary vasculature is a very rare form of pulmonary embolism which is only sporadically reported in the literature. The incidence and clinical picture of this complication are unknown.

PATIENT AND METHODS

In this retrospective analysis between 1999 and 2004, in our clinic, 1,014 port catheters were implanted. In this 5-year period, the patients' files were screened for the incidence of pulmonary embolism of catheter fragments and the accompanying complication rate.

MAIN RESULTS

In 11 patients, port catheter dislodgment and embolism into the pulmonary artery occurred. In all the patients' port examination by fluoroscopy, catheter dislocation and embolization were shown. In these 11 patients, no obvious clinical signs indicating dislocation of catheter fragments into the pulmonary circulation were found. None of these patients demonstrated respiratory symptoms. Heart rate, blood pressure, respiration frequency, and even oxygen saturation were normal. In 7 of the 11 patients, malfunction of port catheter was the first indicator of catheter dislocation. In four patients, embolized catheter fragments were an incidental finding. The main cause of catheter embolization was the pinch off syndrome. All embolized catheter fragments were retrieved by a 'goose-neck' snare without complication.

CONCLUSION

These results suggest that the migration of fractured catheter into the pulmonary artery occurs in 1% of the central port catheter implantation. It is often asymptomatic, and malfunction of the catheter may be the first sign of this complication. The pinch off syndrome might be prevented by using the internal jugular vein or by implantation of the port catheter more laterally in the subclavian vein.