Sir,A rare but dreaded complication of central venous catheters (CVCs) is a retained fractured segment.[1] The embolised fragment can lead to catheter malfunction, arrhythmia, pulmonary symptoms, thrombosis, vessel stenosis, infections and sepsis, but most of the cases remain asymptomatic.[2]A 38-year-old lady with new-onset diabetes mellitus and a history of recurrent oligo-astrocytoma was scheduled for an awake craniotomy and excision of the residual lesion. After pre-operative workup and adequate glycaemic control, she was taken up for the procedure.Inside the operation theatre, after standard pre-induction monitors were attached, the left radial artery was cannulated and the right internal jugular vein was catheterised using a 7 French triple lumen CVC under ultrasound guidance and adequate local anaesthetic skin infiltration. After backflow of blood was confirmed in all three lumens, the catheter was secured to the skin with 3-0 non-absorbable monofilament nylon sutures. Throughout the surgery, the patient was haemodynamically stable with sinus rhythm.Examination of the routine chest radiogram taken in the immediate postoperative period confirmed that the tip of the CVC was in the right atrium.On the first post-operative day, the patient complained of irritation at the suture site of CVC. On removing the Tegaderm™ dressing for better inspection of the site, the catheter was found to be detached from the flanges but could not be located subcutaneously. During this time also, the patient was haemodynamically stable, albeit anxious. A cardiology consultation was done, and a decision to retrieve the catheter tip through the right femoral vein was made. After taking informed consent, the patient was shifted to the Cath lab and fluoroscopy showed that the distal part of the catheter from the flanges was cut and dislodged into the right heart [Figure 1].
Figure 1
Fluoroscopy showing the fragmented catheter in the right heart
Fluoroscopy showing the fragmented catheter in the right heartUnder image intensifier guidance, a 15-mm Amplatz Goose Neck® snare was inserted through the right femoral vein and the fragment was removed from the right ventricle [Figure 2]. Post procedure, the patient was haemodynamically stable. She was observed in the intensive care unit for a day and shifted to the ward in a stable condition.
Figure 2
The retrieved catheter tip (left) and the fractured flanges (right)
The retrieved catheter tip (left) and the fractured flanges (right)Central venous catheterisation, being an invasive procedure, is associated with several risks such as haematoma, pneumothorax, infections, arrhythmias, malposition, thrombosis and trauma to brachial plexus.[3] Nevertheless, the coronavirus disease (COVID)-19 pandemic saw an increase in the number of central venous cannulations, especially in those with post-COVID-19 mucormycosis.[4] Wearing personal protective equipment while doing central venous cannulation increases the chances of complications.[5]Fractured catheter is an infrequent but dangerous complication accounting for less than 0.1%. Fragmentation of the catheter may be caused either by mechanical shearing stress or the use of excessive force while inserting or removing the catheter. In this case, the fragmentation might have been due to a manufacturing defect. The fragmented catheter may migrate and lodge in the vena cavae, right atrium, right ventricle, pulmonary artery and the distal branches[6] and lead to complications such as catheter occlusion, cardiovascular or pulmonary compromise, cardiac arrest or sudden death.[1]A fragmented intravascular device can be retrieved either through conventional open thoracotomy or minimally invasive percutaneous endovascular approach, the latter leading to a faster recovery and an overall reduction in morbidity and mortality.[1] These techniques use various percutaneous equipment such as snares, tip deflecting wires and baskets for foreign body retrieval.[7] The most popular among these is the snare, which kinks less owing to its elastic manufacturing. Rarely, thoracotomy is required when both ends of the catheter are either fixed or entrapped, which makes it impossible to grasp. Endovascular retrieval, although requiring adequate facility and expertise, is a safe and feasible option.The manufacturer was informed about this complication, and all the remaining catheters were returned. They replied that they would analyse and rectify the defect.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Figure 1
Figure 2