INTRODUCTION

It is estimated that the prevalence of chronic kidney disease is rising, leading recently to an increase in the number of patients requiring dialysis. The most common form of dialysis is hemodialysis (HD), with a worldwide prevalence of 89%, followed by peritoneal dialysis that is the preferred method of dialysis of the remaining 11%1.

Hemodialysis (HD) requires access to the vascular system, and the form of vascular access is a shared patient-doctor decision. The preferred method is usually arteriovenous fistulas (AVFs) because of the lower complications rates and superior long-term durability2. Alternative means of vascular access for HD, which include arteriovenous grafts (AVGs) and central venous catheters (CVCs), are chosen mainly for cases with many comorbidities and shorter life expectancy. There are two types of CVCs, nontunneled CVCs that are used in critically ill patients and are designed for short-term dialysis, and tunneled CVCs that can be used for long-term HD.

We present a case of successful retrieval of a floating piece of a tunneled HD catheter that was trapped accidentally in the venous system of our patient at the time of catheter insertion.

CASE REPORT / TECHNIQUE

Our patient, a 77-year-old female with history of diabetes mellitus, hypertension and obesity, started HD on 9/1/23 with the use of a non-tunneled jugular catheter. The dialysis team decided to exchange over the wire the non-tunneled with a tunneled catheter, and on 23/1/23, while advancing the catheter through the sheath, a segment of the introducer sheath approximately 10 cm long was detached and remained floating in the venous system. Over the same wire that was used for the exchange, the dialysis team inserted again a non-tunneled catheter to regain access to the vascular system of the patient. As a result of that action, the tip of the non-tunneled catheter was embedded in the proximal end of the floating introducer sheath (Figure 1). Urgent transfer to the Vascular Surgery department of our hospital followed for further treatment.

At admission, the patient was transferred to the radiology department and a computed tomography scan of the region was performed to establish the exact position of the floating piece. The floating piece was visualized trapped partly in the superior vena cava and, to a greater extent, within the right atrium (Figure 2). The patient was transferred to the angiographic suite, and under fluoroscopy an attempt was made to remove the floating piece of the introducer sheath. From the intravascular solutions available, including loop-snare, helical basket and grasping forceps, our interventional radiologist was more familiar with the use of the loop-snare technique. With access through the non-tunneled catheter that had been inserted in the right jugular vein after the accidental loss, a 20mm ONE Snare® Endovascular Snare System (Merit Medical Systems, Inc.) was used. The proximal end of the floating introducer sheath that was fixed around the tip of the non-tunneled catheter was liberated after pulling the catheter back, and that free end was firmly grasped with the snare system (Figure 3). Retraction and temporary parking of the floating piece at the level of its insertion in the right jugular vein followed (Figure 4). Transfer of the patient to the operating room and open removal of the lost introducer sheath was finally achieved (Figure 5). The remaining course of treatment of our patient was uneventful, and she was discharged from our hospital the next day.

DISCUSSION

Catheter fracture and dislocation is an uncommon but life-threatening complication with an estimated rate of 0.1%3. Catheter fractures can occur owing to excessive pressure within the catheter, pinch-off syndrome, catheter malpositioning, catheter fatigue, and incorrect use of the catheter4. The site to which the fractured fragments migrate varies, with the most prevalent being the right heart chambers. According to Cheng et al., broken catheters embolize frequently to superior vena cava (23.9%), right atrium-inferior vena cava (20.6%), right atrium-hepatic vein (11.9%), and right atrium-right ventricle (10.8%)5. A catheter fragment in the heart can be the cause of serious complications, including mortality, arrhythmia, clotting, perforation, and infections6.

The standard surgical method for the retrieval of a dislodged catheter is thoracotomy; however, morbidity and mortality may significantly increase with this procedure. The endovascular approach is the safest method for retrieving a dislodged catheter. There are 3 devices available for extraction of foreign body percutaneously: loop-snare, helical baskets, and grasping forceps. High success rates have been reported for the loop snare method, a standard method of endovascular treatment for the retrieval of a dislodged catheter7. For cases with no free end of the dislodged catheter available to grasp with the snare, modifications have been described with good results8,9. Some risks associated with this procedure include penetrating the wall of the heart or the tricuspid valve, leading to cardiac perforation or tamponade. Another possible complication of this procedure is cardiac arrhythmia, and a transient ventricular arrhythmia has been described to develop when the guidewire or the catheter crosses the sinus node or the atrioventricular node10.

CONCLUSION

The collaboration of a vascular surgery team and an interventional radiology team in this case, helped our patient to avoid a cardiac surgery that could lead to serious complications. This is an example of the results that can be achieved when we push boundaries and collaborate with different specialties for the benefit of the patient.