Retrieval of Embolized Intracardiac Peripherally Inserted Central Catheter Line: Novel Percutaneous Technique by Utilizing a Flexible Biopsy Forceps.

Peripheral catheter embolization to the heart is common but infrequently reported. In view of the hazardous complications of thrombosis, embolism, infection, arrhythmia and even death, percutaneous retrieval of such foreign bodies is usually attempted. Previously reported percutaneous technique of retrieval mainly involved the snaring technique. Herein, we report a novel nonsurgical retrieval technique for successful removal of a 46 cm long embolized intracardiac peripherally inserted central catheter by utilizing a flexible biopsy forceps. To the best of our knowledge, the use of flexible biopsy forceps for retrieval has hitherto been unreported and this case report therefore adds to the repertoire of percutaneous retrieval techniques for safe and easy removal of embolized catheters to the heart.

INTRODUCTION

The availability of newer and improved varieties of indwelling catheters has prompted their wide use, especially in patients on long duration chemotherapy. These catheters are prone for life-threatening complications like embolization.[1] Herein, we report a breast cancer patient on chemotherapy who presented with a missing inner portion of a peripherally inserted central catheter (PICC), which had embolized to the right side of the heart. We were successful in retrieving the embolized PICC with the help of a flexible biopsy forceps.

CASE REPORT

A 55-year-old female was on chemotherapy for breast cancer. She was put on a long PICC line through right brachial vein. After 4 weeks, she reported a burning sensation in right arm after each injection of the chemotherapeutic agent. On further evaluation, swelling and tenderness at the site of injection, was documented. On the removal of the PICC it was found that the whole internal portion of the line was missing. A central embolization of the internal portion of the PICC line was suspected, and the patient was referred to us for further management.

On examination, the patient's vitals were stable with no evidence of any arrhythmia. Echocardiography revealed a long foreign body within the right ventricle across the right ventricular outflow tract to the main pulmonary artery. We planned for an attempt at percutaneous catheter-based retrieval of the foreign body from heart.

On fluoroscopy, the embolized catheter was present in the form of a loop in the right atrium with a shorter radio-opaque free end attached to the right ventricular apex and the longer end was seen traversing the right ventricular outflow tract and pulmonary artery into the right inferior descending pulmonary artery [Figure 1].

Figure 1

Fluoroscopic image showing the embolized peripherally inserted central catheter with one end fixed in right ventricular apex and the other end lying in right inferior descending pulmonary artery with a loop in right atrium

PROCEDURE

Femoral venous access was created with a 9 F venous sheath. The free ends of the foreign body were not readily accessible, so snaring technique was not suitable in this case. We decided to use a 5 French (F) flexible biopsy forceps (Cook Medical, Bloomington, USA), which was introduced to the right atrium through a 7 F Judgkins right (JR) guiding catheter.

Multiple attempts to grab the portion of the long line in right atrium were in vain because it was highly mobile and the plane of jaws of the biopsy forceps were not getting into proper alignment with it [Figure 2]. Later it was possible to hook the right atrial loop of the PICC by the JR catheter and drag it into inferior vena cava [Figure 3a]. In the IVC, the long line was easily grabbed by the biopsy forceps [Figure 3b] and was subsequently removed in one piece through the femoral sheath [Figure 4a–c]. The total procedure time was around 35 min.

Figure 2

Fluoroscopic image showing attempts to grab the loop of the long line in right atrium but the plane of jaws of the biopsy forceps were not getting into proper alignment with it

Figure 3

(a) The right atrial loop of the peripherally inserted central catheter is being hooked by the JR catheter and being dragged into inferior vena cava, (b) In IVC the long line could be grabbed by the biopsy forceps and was subsequently removed in one piece through the femoral sheath

Figure 4

(a-c) Peripherally inserted central catheter after removal from the body along with the flexible biopsy forceps

DISCUSSION

Poor access of peripheral vasculature, administration of hyperosmolar, irritant solutions and solutions with low or high pH, and the need for uninterrupted intermediate-term therapy including antibiotics, hyperalimentation, chemotherapeutic agents, continuous inotropic therapy, long-term intravenous pain medication are the most common indications for using a PICC line.[2] The line is generally inserted into the brachial vein and is passed over a guidewire with the goal of having the distal end of the catheter reach the superior vena cava (SVC).

Once the catheter is in its correct position, the guidewire is removed, and the catheter is secured in place at the level of skin. Care must be taken to prevent the line entering the jugular vein via the subclavian vein and thus avoid drug delivery into a smaller caliber vein. Verification of the correct position of the catheter tip is done by a postprocedural X-ray. The SVC is considered the best tip location. PICC lines are very pliable and allow more freedom of arm movement than traditional peripheral access devices. These lines can be used for an extended period that can range from 3 to 512 days.[3]

Peripherally inserted central catheter line placement, although a very safe technique, can be complicated by catheter dysfunction (thrombotic and nonthrombotic), catheter leakage, catheter site infection and bloodstream infection.[4] Occlusion of the catheter is the most frequently reported complication.[5] PICC fragment embolization is the most dreaded complication and therefore demands high clinical suspicion and immediate attention.[1] The intravascular fragment usually becomes lodged within the right heart where it could produce complications such as arrhythmia, hypotension, increased central venous pressure, tachycardia, loss of consciousness and compromised valvular function. Less frequently, the fragment can lodge more distally within a pulmonary artery (as in our case) with the risk of causing thrombosis and pulmonary infarction. A pediatric study of 1650 PICC placements identified 11 children with a fractured line requiring an invasive retrieval.[6] In a series of 220 documented cases of the catheter embolism, the morbidity was 71% and the mortality was 38% if the centrally embolized catheter fragment was not removed.[7]

Mostly nonsurgical methods are employed for catheter retrieval using interventional radiological techniques (loop snares, hooked guide wires, and Fogarthy balloon catheters). Surgical intervention is rarely undertaken. In the early 1980s, retrieval of catheter fragments was mostly attempted with a Dormia basket,[8] flexible endoscopy forceps[9] or with a self-made wire snare while today the nitinol gooseneck snare loop enjoys almost exclusive application.[210] Recently there was a report of percutaneous removal of intravascular fractured port-A catheter using 8 F hydrophilic glide-sheath, exchanged utilizing the existing peripheral intravenous line in the right cephalic vein using a snaring technique. Nitroglycerin was used as a venodilator.[11]

A flexible biopsy forceps, commonly known as bioptome is a small pincer-shaped cutting/grasping instrument used in medicine for taking biopsy specimens. It can either be built into or threaded through a vascular catheter or endotracheal tube that delivers the biopsy forceps directly to the desired site of tissue. There are two basic types of flexible biopsy forceps-one is stiff device, maneuvered independently through the vasculature and the other type is more flexible, can be positioned only with the aid of a long sheath or introducing catheter. Smaller sized biopsy forceps (e.g., 4 F, 5 F) can be used to retrieve foreign bodies. Potential advantages of these devices are that they can grab the side as well as ends of the object. When no free end is available, they can grab the center of a piece of catheter. The limitations of the device include that the jaws should open perpendicular to the object to be grabbed, three-dimensional alignment is crucial and that it may not open widely enough to grab larger FBs.

In the index case, it appears that the catheter was accidentally detached from its connector and then it migrated and embolized in one piece through the long veins with one end in right ventricle and the other in right descending pulmonary artery. Fortunately, the patient had no cardio-pulmonary complications. The catheter was successfully retrieved using a novel nonsurgical technique utilizing flexible biopsy forceps because none of the ends were available for snaring. To the best of our knowledge, the use of flexible biopsy forceps for retrieval has hitherto been unreported. The patient was discharged subsequently without any further complications.

CONCLUSION

Peripherally inserted central catheter is widely used in clinical practice due to several clinical advantages, chiefly being its ease of use and low complication rates. PICC embolization is a rare but a dreaded complication. High degree of clinical suspicion is required, and immediate action warranted in cases of probable embolization. Embolization to heart is a life-threatening complication, so early retrieval is mandatory. Nonsurgical percutaneous retrieval techniques carry less complication and better success rate. A nitinol gooseneck snare loop technique is commonly used for retrieval. The use of a flexible biopsy forceps as reported in our case is a novel and a hitherto unreported technique of safe and easy retrieval of embolized intra-cardiac catheters.