23 de noviembre del 2014
Kyung J. Chung, MD, Harvey L. Chernoff, MD, Lucian L. Leape, MD, and Marshall B. Kreidberg, MD
Frequent use of central venous catheters for total parented nutrition (TPN) in small infants has resulted in various complications such as infection, arrhythmia, and perforation, among others [1,2]. Embolic catheter fragments from these lines are also a recognized complication 13-91.
We report two small infants in whom the TPN line became severed and the distal fragment lodged in the right atrium. Using snare retrieval equipment introduced through the femoral vein, the catheter fragments were successfully removed without complications.
A 25-day-old infant weighing 4,050 gm received parented nutrition because of intractable diarrhea. A number 20 polyethelyne catheter was inserted percutaneously into the left subclavian vein. On the eleventh day the catheter was noted to be leaking at the site of entry into the skin. Examination revealed that the catheter had broken at this point, and the distal segment was not visible. Chest X-ray demonstrated that the catheter fragment had migrated to the right atrium (Fig. 1). The patient was taken to the cardiac catheterization laboratory. A 5F end-hole Cook catheter containing a 125 cm, 0.018-inch Curry snaring wire* was introduced into the right femoral vein percutaneously through a sheath introducer and advanced to the right atrium. Under biplane fluoroscopic visualization the catheter fragment was snared and removed (Fig. 2). The patient tolerated the procedure well.
A 40-day-old infant weighing 2,100 gm underwent operative introduction of a Silastic central venous catheter into the jugular vein for administration of TPN because of intractable diarrhea. At the time of line removal 45 days later, it was noted that the end of the catheter was irregular, and breakage was suspected. Chest X-ray confirmed the presence of the distal catheter fragment in the original location. Exploration of the neck incision failed to locate the catheter. Repeat chest X-ray showed that the catheter had migrated to the right atrium (Fig. 3). The patient was taken to the cardiac catheterization laboratory and the fragment was retrieved with a technique similar to that used in Case 1.
Chest X-ray showing the proximal part ot tho bmkon cathotor in tho Idt rubdarlan vein and the distal tip in the right atrium.
Serious complications of intracardiac foreign bodies include infection, perforation, arrhythmia, and thromboembolism [6-93. Richardson et al[71 reported a 45% complication rate when foreign bodies were not removed from the heart either surgically or nonsurgically. Therefore, early removal of such foreign bodies is advised in most patients.
With the advent of percutaneous cardiac catheterization technique in small infants, removal of a foreign body can be accomplished nonsurgically. The procedure is similar to the routine cardiac catheterization technique. A looped snaring wire is positioned in the tip of an end-hole catheter before the catheter is introduced into the vein. The catheter-snare assembly is then inserted through a sheath introducer and manipulated into the right atrium; the snare is opened by advancing it beyond the tip of the catheter. Attempts are then made to snare the broken fragment with the aid of biplane fluoroscopy. Successful snaring of the foreign body is indicated by movement of the fragment when the snare is moved. The snaring wire is then gently tightened by withdrawing the external ends until the fragment is securely held against the catheter. With the snare tension maintained, the entire assembly is slowly withdrawn from the right atrium and out of the femoral vein, along with the sheath.
A (antero-posterior view), B (lateral view) The embolized catheter is snared in the right atrium with a Curry snaring wire.
The snare technique has the advantage of a high degree of flexibility and mobility to maneuver within the small vascular compartments of infants. Very small snaring wires are available that will pass through a 5F catheter. Bronchoscopic forceps and ureteric stone catchers have been used for the same purpose, but these instruments are less suitable in small infants because of their size, lack of maneuverability, and the danger of perforation due to rigidity of the instrument.
Once a central venous line has broken intravascularly, it progressively moves centrally. Eventually, it will lodge in the pulmonary artery, where retrieval is much more difficult. Therefore, it is advisable to attempt removal of these foreign bodies as soon as the problem is recognized. Early removal will also minimize the risk of the associated complications of embolized catheters.
From our experience with snare retrieval of intracardiac catheter fragments in two small infants, this attempt should be made as soon as the problem is recognized to avoid further complications. We prefer end-hole catheters with snaring wire with flexible mid-segment (Curry Retrieval Set) because of its maneuverability and size.
Chesl X-ray film showing a piece of fractumd catheter In the rigM atrium.
Autor: Kyung J. Chung, MD, Harvey L. Chernoff, MD, Lucian L. Leape, MD, and Marshall B. Kreidberg, MD
Fuente: Catheterization and Cardiovascular Diagnosis 6:331-335 (1980)
Ultima actualizacion: 13 DE DICIEMBRE DE 2007