Removal of Intravascular Foreign Bodies With a Simple Low-Cost Method: A Report of 5 Cases

Introduction

In the past decades, the implantation of intravenous devices for the most varied purposes has become increasingly frequent. ¹ The embolization of an intravascular catheter fragment was first described in 1954 by Turner et al. ² The incidence of venous catheters that progress to embolization can vary from 0% to 4.1% (with lower rates for hemodialysis catheters). Severe complications may occur in up to 50% of cases.^1,3 It is highly recommended to remove catheters with structural damage, embolization, or malposition as soon as possible. Intravascular foreign bodies were previously treated by conventional surgery with thoracotomies and extensive dissections. Presently, endovascular techniques for intravascular foreign bodies removal show great safety, improved efficacy, and low complication rates, with several devices already available for this purpose. ¹

Despite great technological advance, the varieties of endovascular materials are not readily available at many hospitals. The pigtail catheter, which is widely used in endovascular surgery, usually as a support for catheterizations or for performing arteriographies, is a common and easily accessible device. Its use for interlacing and traction of intravascular foreign bodies, especially large ones, such as hemodialysis catheters, is rarely described in the literature.^4,5

We report 5 cases of intravascular foreign body removal using a simple, low-cost, and easily reproducible technique with minimal cardiovascular risk for the patients.

Case Report

Case 2

A 55-year-old man, without comorbidities, was hospitalized with severe traumatic brain injury due to a fall from a height of 10 m (33 feet). He was under a prolonged intensive care unit (ICU) stay due to the neurological injury and a ventilator-associated pneumonia that evolved to septic shock and acute renal failure requiring dialysis. He underwent hemodialysis catheter implantation in the RIJV, however, due to low flow and malfunction, its removal was indicated. During an attempt to change the catheter, there was an accidental embolization of its distal portion. Ventricular tachycardia and worsening of the hemodynamic instability occurred. He was referred to the vascular surgery team for evaluation and an immediate surgical approach was indicated. Access was performed by right inguinotomy and great saphenous puncture under direct view (introducer 6-Fr). A hydrophilic guidewire and 5Fr pigtail catheter (Cook Medical) were positioned close to the FB (SVC and right atrium) and rotational movements were performed to interlace the catheter fragment (approximately 14 cm in length) followed by its traction to the surgical access site. The foreign body was removed through a small venotomy of the saphenofemoral junction followed by venorraphy (Figures 1 and 2). The procedure was successful and the patient remained under the care of the ICU team.

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Figure 1.

Radioscopic image showing: (A) Pigtail catheter being positioned at superior vena cava (black arrows); Foreign body (hemodialysis catheter) with proximal tip at superior vena cava and distal tip at right atrium (white arrows). (B) The foreign body (white arrows) intertwined with pigtail catheter (black arrows) as we call the “interlacing technique.” (C) Observe the foreign body (white arrows) moved to right external iliac vein after traction by pigtail catheter (black arrows).

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Figure 2.

Photograph of foreign body (hemodialysis catheter) after removal by the pigtail interlacing technique.

Case 3

Case 3 is a 76-year-old woman with a medical history of diabetes, metastatic breast cancer (bone and lung), and subdural hematoma due to a car accident. During her hospitalization in the ICU, a central venous catheter was implanted in the right subclavian vein and an accidental embolization of the guidewire occurred. A chest X-ray was performed and the FB was located from the superior (SVC) to the inferior vena cava (IVC). She was referred to a tertiary hospital to be evaluated by the vascular surgery team and an immediate surgical intervention was indicated. The procedure was performed under local anesthesia and sedation. A 6-Fr introducer sheath was placed percutaneously in the right common femoral vein. The interlacing technique with a 5Fr pigtail catheter (Cook Medical) and a hydrophilic guidewire was performed, and the FB was mobilized until the right common iliac vein (RCIV) (Figure 3). After the release of one end of the FB, the pigtail catheter was exchanged for a loop snare. The guidewire was then easily removed. The patient was discharged and referred to her hospital of origin during the immediate postoperative period. There were no complications during or after the procedure.

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Figure 3.

Chest X-ray and radioscopic images: (A) Foreign body (guidewire) with proximal tip at superior vena cava (white arrows). (B) Foreign body (guidewire) with distal tip at inferior vena cava and right common iliac vein (white arrows). (C) The start of the procedure to remove the foreign body (white arrows) with pigtail catheter (black arrows). (D) Observe the interlacing technique between the pigtail (black arrows) and the foreign body (white arrows) before traction.

Case 5

A 2-year-old boy with a medical history of metastatic sarcoma had a port-a-cath implanted in the in the left jugular vein (LJV) for chemotherapy. After 1 month, postinfusion thoracic swelling was observed. A chest X-ray was performed and diagnosed catheter disconnection from its reservoir. The proximal tip of the catheter was located in the left brachiocephalic venous trunk and the distal end in the right ventricle. He was referred to a tertiary hospital and the vascular team indicated immediate surgical intervention. Dissection and puncture of the right common femoral vein (RCFV) with a 5Fr introducer sheath was performed under general anesthesia. The FB was mobilized to the RCFV and successfully removed by using the interlacing technique with a 5Fr pigtail catheter (Cook Medical) and a hydrophilic guidewire (Figure 4). The procedure occurred without complications and the patient was discharged and referred to his hospital of origin during the immediate postoperative period.

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Figure 4.

Radioscopic images showing: (A) Pigtail catheter being positioned at superior vena cava (black arrows); Foreign body (port-catheter) with proximal tip at left brachiocephalic vein and distal tip at right ventricle (white arrows). (B) The interlacing technique between the pigtail (black arrows) and the foreign body (white arrows) before traction. (C) Observe the foreign body (white arrows) movement to inferior vena cava after traction by pigtail catheter (black arrows). (D) The foreign body (white arrows) intertwined with pigtail catheter (black arrow) at right external and common iliac vein.

Table 1 summarizes the 5 reports.

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Table 1.

Clinical Characteristics of the Reported Cases.

Case	Sex	Age, y	Foreign Body	Implantation site	Location Site (Proximal to Distal Part)	Embolization Mechanism	Removal Access	Device Used for Retrieval
1	Female	57	Hemodialysis catheter	Right jugular vein	SVC/RA	Fracture and accidental embolization	Inguinotomy + GSV puncture	Pigtail
2	Male	55	Hemodialysis catheter	Right jugular vein	SVC/RA	Fracture and accidental embolization	Inguinotomy + GSV puncture	Pigtail
3	Female	76	Guide-wire	Right subclavian vein	SVC/IVC	Accidental embolization	RFV puncture	Pigtail + loop snare
4	Female	71	Port-a-cath	Right jugular vein	SVC/RA	Catheter disconnection and embolization	RFV puncture	Pigtail + loop snare
5	Male	2	Port-a-cath	Left jugular vein	Left BCV/RV	Catheter disconnection and embolization	Inguinotomy + RFV puncture	Pigtail

Abbreviations: BCV, brachiocephalic vein; GSV, great saphenous vein; IVC, inferior vena cava; RA, right atrium; RFV, = right femoral vein; RV, right ventricle; SVC, superior vena cava.

Discussion

The high number of central venous accesses and fully implantable catheters makes them the most common intravascular FB. ³ The embolization incidence of intravenous catheters is estimated at 1%. However, considering that the complications associated with those embolizations can reach up to 71%, with mortality between 24% and 60%, the extraction of FB is strongly recommended even in asymptomatic patients. ⁴

In a systematic review, Surov et al ⁶ identified that of all the embolization cases described, 66.5% (143/215) were of totally implantable catheters (port-a-cath) and only 4.6% (10/215) associated with hemodialysis catheters. Fracture and embolization of hemodialysis catheters is a rare event, with only a few reports and case series.^5,7–9 This lower frequency can be associated to its larger caliber and greater material stiffness. Of the 5 cases reported here, 2 were related to hemodialysis catheters, both related to improper handling and accidental embolization.

The right common femoral vein is the recommended venous access site for removal of endovascular FB. This access has the advantage of comfort for the patient and medical professional, puncture facility, the greater caliber of the vessel and its proximity to the skin, and the presence of a posterior bony shield that allows security for compression.^1,3 In 2 of 5 cases reported here, we opted for saphenofemoral junction dissection and puncture under direct view. Considering the high FB caliber (8Fr), access by dissection was performed in order to provide safe direct manual extraction through a small venotomy of the great saphenous vein arch. As for cases 3 and 4, however, the FB was removed through the introducer sheath due its small diameter. In case 5, considering the patient’s age, the choice was also of inguinotomy for safe removal of the FB through RCFV.

The positioning of the embolized fragment depends on factors such as length, degree of stiffness, venous flow pattern, the patient’s position at the time of the event, and the force of gravity. The FB location varies according to the literature: pulmonary artery, ¹⁰ right ventricle, and hepatic vein, ⁴ right atrium, and IVC. ¹¹ In an extensive systematic review (215 cases) of intravascular FB by Surov et al, ⁶ the sites with most occurrences were the pulmonary arteries (35%) followed by the right atrium (27.6%) and right ventricle (22%). In both cases of hemodialysis catheter embolization of this study (cases 1 and 2), as soon as the 1 case of port-a-cath embolization (case 4), the distal tips of the catheters were located in the right atrium and the proximal tips in the SVC. In case 3 (guidewire), the proximal tip of the FB was located in the SVC and the distal tip in the IVC. In case 5, probably because the patient was a child (with shorter body length), the distal tip of the catheter was found inside right ventricle and proximal tip in the left brachiocephalic vein (Table 1).

Among the causes related to embolization of venous devices are catheter damage due to incorrect handling; the use of small syringes with high pressure; the compression of the device between the clavicle and the first rib (pinch-off syndrome), poor connection between the portal and the catheter, and material fatigue. ¹¹

The mechanism related to spontaneous embolization of hemodialysis catheters is mainly related to its fracture at the bending point and can be caused by local trauma, ¹² material weakness or excessive handling, and relocation. ¹³ However, fracture and spontaneous migration of this type of device is a rare event and the data published on this subject do not provide evidence to clarify which characteristics are most associated with these complications (period of use, type of material, location of the catheter insertion, angulation of its curvature in cervical region^6,8). Accidental embolization during the manipulation of venous catheters, as occurred in the cases depicted here, is a rare but already described event in the literature. ¹⁴

The removal of venous FB should be done as soon as possible. Its permanence over 6 to 8 weeks is associated with an endothelial reaction and fibrosis, impairing its removal.^1,7 In the past, extraction of these FB required conventional surgery (open thoracotomy) with high operative morbidity and mortality. Currently, endovascular techniques have brought safety and practicality, as long as they are performed prematurely.^7,11 In all cases reported here, surgical intervention was performed within 24 hours of the patient’s transfer to our service, minimizing any risks.

The main concerns regarding an embolized catheter fragment are related to the local thrombogenic factors, the risk of the vascular wall perforation, the risk of severe arrhythmias, and sudden death. ⁷ The patient from case 2, reported in this study, had tachyarrhythmia at the time of embolization and presented with hemodynamic instability. However, the rapid diagnosis and intervention by the vascular team made the outcome favorable. In addition, embolization can trigger other serious complications such as pulmonary embolism, bacterial endocarditis, sepsis, myocardial lesions, and hemoptysis.^1,5,8,11

In our reported cases, the intravascular removal of the foreign bodies was a complete success with a short surgical time and absence of cardiac complications or to the access site. It is believed that the longer the cardiac chambers are manipulated, the greater the chance of arrhythmias and cardiac complications in general. ³ Hence, the FB with a tip located inside cardiac chambers represents an unfavorable and challenging situation for vascular surgeons. In these situations, it is necessary to use simple and easily executable techniques. Therefore, the removal by interlacing and traction with a 5Fr pigtail catheter must be considered, given its simplicity and execution speed, avoiding the intracardiac manipulation of complex and arrhythmogenic devices.

The approach to intravenous FB can vary between open surgical technique, endovascular techniques, or even expectant management with anticoagulation and clinical observation. ⁴ Currently, there is an arsenal of devices available for FB removal, including basket, loop snare, grasping forceps, and gooseneck snares, the latter being the most widely used due to its easy handling and good angulation for capture. Still, the costs involved with the use of these materials can be an impediment to their use, depending on hospital facilities.

The technique of interlacing and traction with a pigtail catheter is poorly described in the literature. The use of the pigtail for maneuvering FB without accessible free ends toward the puncture site was initially described for reduced caliber catheters by Auge et al. ¹⁵ Afterward, the use of the pigtail was described in the literature by other authors as an auxiliary instrument in the movement of the intravascular FB, in order to free one of its extremities and facilitate the use of a capture loop.^3,4,11 Our initial experience with the 5Fr pigtail catheter (Cook Medical) for interlacing and traction of embolized FBs in the venous territory shows that it is possible to not use a capture loop even for larger caliber catheters and it is a safe, effective, and low-cost technique.

This study has some limitations. Considering the small number of cases, we cannot specify the general applicability of this technique for foreign bodies of any shape, size, caliber, and positioning in the venous territory. In addition, the use of other pigtail catheter types has not been tested.

The need for inguinotomy and venotomy for larger FB is a disadvantage of the technique due to the impossibility of pulling the FB inside the introducer until outside. Failure to foresee this difficulty and attempting to extract the FB by percutaneous puncture may lead to major bleeding through the femoral access with poor outcomes. As an advantage, compared with other techniques, the FB does not need a free tip in order to be captured, avoiding cardiac chamber manipulation. The interlacing is possible as long as the FB and pigtail catheter are side by side in the vessel. In order to provide a stronger grip and assist the removal of the foreign body a standard or stiff guidewire can be placed inside the pigtail catheter.

Regarding the length of the FB, perhaps FB such as guidewire and catheters fragments larger than 10 cm are capable of traction by pigtail rotational movements. We do not have information on foreign bodies shorter than this. The vessel caliber does not seem to be of great importance to the technique, since it has been effective in patients ranging from 2 to 76 years of age.

The endovascular technique is considered the gold standard method for intravascular FB removal, avoiding surgeries with extremely high morbidity and mortality rates and adding efficiency with reduced global costs. Despite technological developments, the access to materials and their high costs remain an obstacle. The vascular surgeon needs to use ingenuity and creativity in the face of challenging cases.

Conclusion

Despite the fact that there is an arsenal of endovascular possibilities for removing foreign bodies, our experience with the interlacing and traction pigtail technique shows that it is an alternative approach due to its low cost, great practicality and low risk. This technique should be considered whenever there are few devices available and its benefits should be widespread.