C

●

bvh©

I

Cine

htgrsl

b

Rvrai

fiaettc

vispttd

A

ASE REPORT

Pulmonary Embolism Due to Catheter Fracture From a TunneledDialysis Catheter

Vishal Sagar, MD, and Eleanor Lederer, MD

The patient presented to the emergency room with hemoptysis and pleuritic chest pain. A chest x-ray revealed aroken dialysis catheter tip lodged in the pulmonary artery. The fractured catheter tip was removed via the femoralein using a loop snare. As has been described for central lines and venous ports, a fractured catheter tip from aemodialysis catheter may also lead to pulmonary embolism. Am J Kidney Dis 43:E5.2004 by the National Kidney Foundation, Inc.

NDEX WORDS: Pulmonary embolism; dialysis catheter; fractured catheter tip.

cdpbwchtediiiflddp

lfltiobdmo

v

b

wv

ATHETER FRACTURE leading to pulmo-nary embolism is a rare complication of

mplantable catheters. We report a case of pulmo-ary embolism due to a tunneled dialysis cath-ter.

CASE REPORT

A 36-year-old woman with a long-standing history ofypertension was started on hemodialysis via a left-sidedunneled catheter 6 months ago. She presented to the emer-ency room with cough, hemoptysis, and right-sided pleu-itic chest pain for the last 7 days. She had no otherymptoms and was receiving dialysis 3 times per week. Herast dialysis was 1 day prior to presentation.

A chest x-ray performed in the emergency room showed aroken catheter tip lodged in the pulmonary artery (Fig 1).The patient was taken immediately to the Interventional

adiology Suite, where the broken catheter tip was removedia a femoral vein approach. A loop snare was used toemove the catheter tip. She did well after the procedure andnother tunneled dialysis catheter was placed via the rightnternal jugular vein.

DISCUSSION

Rare cases of pulmonary embolism due to aractured catheter tip have been reported withmplantable venous ports used for chemotherapys well as with peripherally inserted central cath-ters.1,2 Only 1 case of embolization of a frac-ured dialysis catheter tip has been reported inhe literature.3 Ours is the second report of such aomplication in a patient with a dialysis catheter.

Known complications of implanatable centralenous catheters include infection, thrombosis,njury to the surrounding structures, and extru-ion.4 However, one needs to be aware of theossibility of catheter separation and emboliza-ion of the distal fragment. The true incidence ofhe rate of catheter embolization is not known

ue to underreporting of such cases. Radiologi-

merican Journal of Kidney Diseases, Vol 43, No 2 (February), 20

al evidence of narrowing of the catheter lumenue to mechanical compression as the catheterasses between the clavicle and the first rib haseen reported in approximately 1% of the casesith central venous catheters.5-7 This has been

alled the “pinch off” sign, and certain reportsave indicated that this might predispose to fu-ure catheter breaks and embolization.8 How-ver, the pinch-off sign has not been reported forialysis catheters. There have been no studiesndicating a relationship between the duration ofmplantable catheters or the flow rates with thencidence of catheter fractures. Indeed, bloodow rates of 300 to 350 mL/min are used withialysis catheters, and yet cases of fracturedialysis catheters have not been reported in theast.The fractured component of the catheter can

odge anywhere distally along the bloodow—the vena cava, right atrium, right ven-

ricle, the pulmonary trunk, pulmonary artery, orts branches. This depends on the size and weightf the broken segment.9 Possible complicationsesides pulmonary embolism include myocar-ial rupture, valvular perforation, rupture of pul-onary artery, infective endocarditis, infection

f the thrombus, and pulmonary abscess.Removal of the foreign body by a nonsurgical

From the Department of Nephrology, University of Louis-ille, Louisville, KY.

Received June 23, 2003; accepted in revised form Octo-er 28, 2003.Address reprint requests to Vishal Sagar, MD, 2400 Mell-

ood Ave #1209, Louisville, KY 40206. E-mail:ishalsagar@yahoo.com

© 2004 by the National Kidney Foundation, Inc.0272-6386/04/4302-0027$30.00/0

doi:10.1053/j.ajkd.2003.10.038

04: E5 e13

pTgbcef

pa

ap

aa

si2

tJ

at

ie

cnc

Pv

i(d

nf

bnst

SAGAR AND LEDERERe14

ercutaneous approach is possible in most cases.his can be done using loop snares, hookeduide wires, Fogarty balloon catheters. or Dormiaaskets.10 Retrieval should be attempted in allases to prevent possible complications.10 How-ver, there are 2 cases reported in the literature

Fig 1. X-ray performed on admission showing theroken hemodialysis catheter tip lodged in the pulmo-ary artery. The larger arrow shows the broken tip. Themall arrow is pointing at the jagged edge where theip broke off from the catheter.

or whom broken catheter pieces remained in the b

ulmonary artery for more than 10 years withoutny complications.2,11

REFERENCES

1. Vadlamani P, Dawn B, Perry MC: Catheter fracturend embolization from totally implanted venous accessorts: Case reports. Angiology 49:1013-1016, 19982. Thanigaraj S, Panneerselvam A, Yanos J: Retrieval of

n IV catheter fragment from the pulmonary artery 11 yearsfter embolization. Chest 117:1209-1211, 2000

3. Chawla LS, Chegini S, Thomas JW, et al: Hemodialy-is central venous catheter tip fracture with embolizationnto the pulmonary artery. Am J Kidney Dis 38:1311-1315,0014. Lokich JJ, Bothe A Jr, Benotti P, Moore C: Complica-

ions and management of implanted venous access catheters.Clin Oncol 3:710-717, 19855. Nace CS, Ingle RJ: Central venous catheter “pinch off”

nd fracture: A review of two under-recognized complica-ions. Oncol Nurs Forum 20:1227-1236, 1993

6. Aitken DR, Minton JP: The “pinch-off sign”: A warn-ng of impending problems with permanent subclavian cath-ters. Am J Surg 148:633-636, 1984

7. Prager D, Hertzberg RW: Spontaneous intravenousatheter fracture and embolization from an implanted ve-ous access port and analysis by scanning electron micros-opy. Cancer 60:270-273, 1987

8. Hinke DH, Zandt-Stanstny DA, Goodman LR, et al:inch-off syndrome: A complication of implantable subcla-ian venous access devices. Radiology 177:353-356, 19909. Kadir S, Athanasoulis CA: Percutaneous retrieval of

ntravascular foreign bodies, in Athanasoulis CA, Pfister RCeds): Interventional Radiology. Philadelphia, PA, W.B. Saun-ers, 1982, pp 379-39710. Fisher RG, Ferreyro R: Evaluation of current tech-

iques for nonsurgical removal of intravascular iatrogenicoreign bodies. AJR Am J Roentgenol 130:541-548, 1978

11. Reynen K: 14-year follow-up of central embolization

y a guidewire. N Engl J Med 329:970-971, 1993 (letter)