Complication

ComplicationComplication Subclavian vein injury Subclavian vein injury

ProcedureProcedure Port a cath removal Port a cath removal

Primary DiagnosisPrimary Diagnosis ALL ALL

Clinical History

9 y old obese male with ALL 9 y old obese male with ALL underwent left subclavian Port a underwent left subclavian Port a cath placement in June 2009. He cath placement in June 2009. He completed his chemotherapy completed his chemotherapy (Mtx, Adr, Vin) in Aug 2012.(Mtx, Adr, Vin) in Aug 2012.

PMH: PMH: Obesity (BMI 35), ALL Obesity (BMI 35), ALL PSH: PSH: Port a cath 2009 Port a cath 2009 MEDS : MEDS :   Bactrim Bactrim

Overview of Case

He was taken to the operating room on November 19 for routine removal of his Port-A-Cath

Intraop he had a firm calcification attached at the catheter entrance site and into the left subclavian vein

During manipulation and attempted removal of the catheter, there was a tear in the subclavian vein necessitating intraoperative consultation with cardiothoracic surgeons removal of his proximal clavicle

Once bleeding was controlled, patch repair of the tear in his vein after removal of the Port-A-Ca, which was densely adherent to the wall of the vein.

The patient was eventually discharged home on November 22

Overview of Case

Left subclavian plaque (specimen #2); excision:

Fibrocalcific plaque

CVCCVC

Long-term CVC access plays a vital Long-term CVC access plays a vital role role In the pediatric oncology patientsIn the pediatric oncology patients long-term bowel dysfunction long-term bowel dysfunction Congenital metabolic diseasesCongenital metabolic diseases

Other conditions in which a Other conditions in which a Reliable vein to access for Reliable vein to access for Medications or blood draws is Medications or blood draws is neededneeded

CVC Complications CVC Complications

Time of insertion Time of insertion PneumothoraxPneumothorax

While the line is in placeWhile the line is in place line infection line infection

Very little has been written or Very little has been written or discussed about what to do should discussed about what to do should when a portion of the line becomes when a portion of the line becomes stuck within vein !stuck within vein !

CVCCVC

The cause and optimal management of The cause and optimal management of immovable central venous lines is immovable central venous lines is unknownunknown

If a catheter appears fixed the options If a catheter appears fixed the options are are

to either leave the catheter fragment in situ to either leave the catheter fragment in situ

to attempt intravascular removal to attempt intravascular removal open surgical removalopen surgical removal

A multiinstitutional review of patients A multiinstitutional review of patients

2 pediatric tertiary hospitals2 pediatric tertiary hospitals Patients with retained intravascular fragmentsPatients with retained intravascular fragments

Retrospective patient chart review Retrospective patient chart review

Prospective follow up of patients for evidence of Prospective follow up of patients for evidence of complications related to the retained portionscomplications related to the retained portions

• A total of 299 central venous lines were A total of 299 central venous lines were removed with 6 patients identified as removed with 6 patients identified as having fragments of lines left behind having fragments of lines left behind (2%)(2%)

• The lines had been in place for an The lines had been in place for an

average of 37 ± 12 months. The average average of 37 ± 12 months. The average follow-up period is 5.4 ± 3.9 yearsfollow-up period is 5.4 ± 3.9 years

• none of the patients have developed any none of the patients have developed any symptoms, evidence of thrombus, symptoms, evidence of thrombus, infection, or catheter migrationinfection, or catheter migration

Alberta Children's Hospital (ACH) 2003-07

2 of the patients had a very calcified 2 of the patients had a very calcified tract, tract,

the line was stuck at the junction of the the line was stuck at the junction of the catheter and venous entrance pointcatheter and venous entrance point

An attempt at endovascular removal An attempt at endovascular removal failedfailed The line was grasped through a The line was grasped through a

transfemoral approach but line would transfemoral approach but line would not come away from the vein wall not come away from the vein wall

In one patient this maneuver resulted in a In one patient this maneuver resulted in a small embolus sent to the lungssmall embolus sent to the lungs

Alberta Children's Alberta Children's Hospital (ACH) 2003-07Hospital (ACH) 2003-07 33rdrd patient the line tract was not patient the line tract was not

calcified but adherent to subclavian calcified but adherent to subclavian vein wall vein wall

A CXR done in the operating room A CXR done in the operating room demonstrated no calcification of the demonstrated no calcification of the tract, no intravascular knot, and a tract, no intravascular knot, and a normal position normal position

It was left insituIt was left insitu

• Conclusion: Conclusion: • Given the 2% incidence rate, the issue of

managing a stuck long-term central venous line will face most individuals who place these lines.

• We have demonstrated that simply ligating the catheter and leaving the fragment in place appears to be a safe option with minimal risk to the patient.

Fibrin sheath Fibrin sheath

The fibrin sheath found around these The fibrin sheath found around these indwelling catheters indwelling catheters was first described in 1971 was first described in 1971

In short-term lines,In short-term lines, initially an area of endothelial initially an area of endothelial

injury injury with occasional associated with occasional associated

thrombus can be seen thrombus can be seen

Fibrin sheath Fibrin sheath

In long term catheters, In long term catheters, vein wall thickening along the length of the catheter vein wall thickening along the length of the catheter

and bridging from the vein wall to catheter is later and bridging from the vein wall to catheter is later observed observed

This tissue contains both cellular and acellular This tissue contains both cellular and acellular components including fibrin, collagen, and later components including fibrin, collagen, and later endothelial cells endothelial cells

Interestingly, an endothelial layer develops after 45 Interestingly, an endothelial layer develops after 45 days that is indistinguishable from the vein wall and days that is indistinguishable from the vein wall and most of the catheter length becomes fixed to the vein most of the catheter length becomes fixed to the vein wall by bridging between the vein wall proper and the wall by bridging between the vein wall proper and the neoendothelium of the fibrin sheathneoendothelium of the fibrin sheath

The cause of scarring causing catheter fixation in The cause of scarring causing catheter fixation in these unusual cases is not clearthese unusual cases is not clear

Fibrin sheath Fibrin sheath

Analysis of Complication

• Was the complication potentially avoidable?– Yes

• Would avoiding the complication change the outcome for the patient?– Yes, Yes,

– Blood, ICU, pain, ROMBlood, ICU, pain, ROM

• What factors contributed to the complication?– Calcification CVC– Aggressive

A. 31-7-130 et seq. and 31-7-140 et seq.

Was the complication potentially avoidable?