Peer Reviewed

Photoclinic

Central Venous Line Migration Into the Pulmonary Trunk in a 4-Year-Old

Volume 58 - Issue 10 - October 2018

Authors:
Ayobami D. Olanrewaju, MD, MTropPaed, MPH; Smita Bhaskaran, MD; and Zaid-Kaylani Samer, MD
Texas Tech University Health Sciences Center, Amarillo, Texas

Citation:
Olanrewaju AD, Bhaskaran S, Samer Z-K. Central venous line migration into the pulmonary trunk in a 4-year-old. Consultant. 2018;58(10):284-285.

 

A 4-year-old boy with T-cell acute lymphoblastic leukemia in remission presented with leukocytosis and a mediastinal mass. Chemotherapy was initiated using a peripherally inserted central catheter. Two months later, a right subclavian chest port (Port-A-Cath) was placed successfully under fluoroscopic guidance and was positioned appropriately in the superior vena cava.

Twenty-four months later, the boy presented to a pediatric oncology clinic for his ongoing chemotherapy. Upon attempting to flush his port, the patient developed pain and swelling at the port site. He was immediately sent to the hospital for a cathogram.

Fluoroscopy demonstrated port tubing located midline, at the expected location of the bifurcation of the pulmonary trunk (Figure). The patient was urgently transferred to the closest pediatric cardiothoracic service, where the tubing was removed from his pulmonary artery by an interventional radiologist along with a cardiothoracic surgeon.

central venous line
Figure. Fluoroscopy image showing the central venous catheter in the pulmonary trunk.

Discussion. Long-term implantable vascular access devices (Port-A-Caths) have become an integral part of care for pediatric patients with cancer.1,2 Port-A-Caths have lower rates of infection compared with other forms of central vascular access and ensure reliable access for count checks and chemotherapy administration.2 

Complications of Port-A-Caths include infection, thrombus formation, catheter occlusion, tube migration, and embolization.1,3 The rarest of these complications is central venous line (CVL) fracture and retention or migration of tubing.4,5 Retrospective chart reviews of retained CVL tubing in pediatric patients estimate a prevalence rate of 0.3% to 2%.3-5

It is unclear what causes CVL retention or migration. Forauer and Theoharis described the formation of a fibrin sheath on the catheter around its insertion site, which may play a role in the etiopathogenesis of port fractures.6 There is also histological evidence of vein wall thickening that occurs at the insertion site of long-term central venous catheters, possibly demonstrating a physiological progressive reaction of the vein to access devices.6,7 Kim and colleagues described a “pinch-off syndrome” that occurred specifically with subclavian Port-A-Cath insertions from direct compression of the catheter between the clavicle and first rib.8

Although Port-A-Caths are used for other clinical conditions that require long-term venous access, the vast majority of mechanical complications are seen among pediatric patients with cancer.1,4,5,7 Bautista and colleagues described how acute lymphoblastic leukemia and its therapy foster an ideal environment for thrombotic complications and their association with retained fixed-fragment catheter complications.3 Catheter fragment migration and retention has been reported in the innominate vein, subclavian vein, and saphenous vein. However, our literature search did not find any documented pediatric cases of catheter migration into the pulmonary trunk.8

Most experts recommend immediate catheter removal due to the risks of potentially fatal complications such as pulmonary embolus and obstruction of critical vasculature in the central venous system. Previous studies have suggested an association between prolonged CVL placement (especially for longer than 48 months) and an increased risk of mechanical complications of the catheter.3 Physicians who use long-term implantable catheter devices should always consider the possibility of catheter fracture and malfunction and should have a high index of suspicion after failed attempts at flushing the port. Experts recommend inclusion of this complication in the consent forms for caregivers and prophylactic removal of longstanding (>48 months) intravascular catheters whenever feasible.4

Chan and colleagues reported no difference in outcomes between conservatively managed cases of catheter retention and urgent removal.4 Theoretical risks associated with conservative management include catheter fragment-related infection, thrombus formation, catheter embolus, and occlusion of critical vasculature.1 Although such complications are infrequent, consensus exists among experts that immediate removal of the catheter fragment under fluoroscopic guidance is indicated.3-5,9

References:

  1. de Jonge RCJ, Polderman KH, Gemke RJBJ. Central venous catheter use in the pediatric patient: mechanical and infectious complications. Pediatr Crit Care Med. 2005;6(3):329-339.
  2. Hudman L, Bodenham A. Practical aspects of long-term venous access. Contin Educ Anaesth Crit Care Pain. 2013;13(1):6-11.
  3. Bautista F, Gómez-Chacón J, Costa E, et al. Retained intravascular fragments after removal of indwelling central venous catheters: a single institution experience. J Pediatr Surg. 2010;45(7):1491-1495.
  4. Chan BKY, Rupasinghe SN, Hennessey I, Peart I, Baillie CT. Retained central venous lines (CVLs) after attempted removal: an 11-year series and literature review. J Pediatr Surg. 2013;48(9):1887-1891.
  5. Milbrandt K, Beaudry P, Anderson R, Jones S, Giacomantonio M, Sigalet D. A multiinstitutional review of central venous line complications: retained intravascular fragments. J Pediatr Surg. 2009;44(5):972-976.
  6. Forauer AR, Theoharis C. Histologic changes in the human vein wall adjacent to indwelling central venous catheters. J Vasc Interv Radiol. 2003;14(9 pt 1):1163-1168.
  7. Jones SA, Giacomantonio M. A complication associated with central line removal in the pediatric population: retained fixed catheter fragments. J Pediatr Surg. 2003;38(4):594-596.
  8. Kim OK, Kim SH, Kim JB, et al. Transluminal removal of a fractured and embolized indwelling central venous catheter in the pulmonary artery. Korean J Intern Med. 2006;21(3):187-190.
  9. Sauro L, Sauro R, Manganelli F, Rotondi F. Time-delay to avoid: delayed recovery of a percutaneous central venous catheter fractured and embolized in the pulmonary artery [in Italian]. Recenti Prog Med. 2011;102(11):442-443.