Peripherally inserted central catheters line are being increasingly used for reliable intravascular access in low birth weight neonates, which can be used effectively for a prolonged time of period like, long duration of antibiotic therapy, total parenteral nutrition, chemotherapy regimen or for administration of medications that should not be done peripherally (e.g. inotropes) as well as repeated blood samplings. Reference Chopra, Flanders and Saint1–Reference Westergaard, Classen and Walther-Larsen3 It is a catheter that is introduced percutaneously at a peripheral site which extends into the superior or inferior vena cava and remains there for days or weeks. Although these lines are generally safe and effective, complications do occur which include thrombus formation, catheter occlusion, infection, and fractured catheter fragment embolisation. Reference Westergaard, Classen and Walther-Larsen3 Few case reports have documented successful retrieval of embolised umbilical venous catheter in low birth weight infants by transcatheter approach. Reference Hsu, Wang, Yeoh and Lin4–Reference Patel, Ramarao, Desai, Savich and Patel8 Here, we describe a case of transcatheter retrieval of an embolised peripherally inserted central catheter line in the right ventricle extending to the left pulmonary artery in a 1100 g baby. To the best of our knowledge, this is the first case where transcatheter retrieval of peripherally inserted central catheter line has been performed from the left pulmonary artery in such a very low birth weight pre-term neonate.
Case report
A very low birth weight (1100 g) male neonate born out of non-consanguineous marriage at 32 weeks of gestation was referred to our centre on day 4 of life for retained fractured segement of peripherally inserted central catheter line which embolised to the heart. On admission, the baby was haemodynamically stable with oxygen saturation of 96% at room air, heart rate of 130 beats per minute, respiratory rate of 50 per minute, and capillary refilling time of 2 s. On clinical examination, there was no evidence of cyanosis or murmurs and femoral pulses were palpable. The baby had features of clinical sepsis as evidenced by deranged blood counts, thrombocytopenia, elevated inflammatory markers, and coagulopathy. Blood culture was sent and IV antibiotics were started empirically based on the existing ICU protocol. Chest radiograph showed normal bronchovascular markings with no evidence of cardiomegaly; however, it confirmed the presence of peripherally inserted central catheter line inside the cardiac silhouette. Electrocardiogram was suggestive of normal sinus rhythm with no pre-mature beats and no cardiac chamber enlargement. Bedside echocardiography showed the presence of patent foramen ovale in an otherwise structurally and functionally normal heart with presence of hyperechoic central line (peripherally inserted central catheter line) extending from right ventricular cavity to the left pulmonary artery.
After initial stabilisation and obtaining written informed consent, neonate was taken for transcatheter retrieval of the peripherally inserted central catheter line under strict aseptic measures inside the cardiac catheterisation lab (Philips Azurion). Meticulous steps were taken to avoid hypothermia like, use of pre-warmed linen and bedsheets, adjustment of catheterisation room temperature, use of pre-warmed betadine for painting of local body parts, rectal temperature monitoring, and use of warm saline during procedure. Heparin was judiciously used since neonate had coagulopathy and thrombocytopenia. The procedure was performed under conscious sedation without using general anaesthesia.
Right femoral venous access was taken using 24-gauge cannula and a 0.014” coronary guide wire and 4 Fr radial Sheath (Terumo Glide sheath) was introduced. Cinefluroscopy showed peripherally inserted central catheter line extending from right ventricular to left pulmonary artery. (Fig. 1a,1b) A 0.014” BMW (Balanced Middleweight Universal, Abott) wire was introduced across right ventricular and parked inside the left pulmonary artery. 4Fr JR (JUDKINS RIGHT) catheter was negotiated over the wire up to the main pulmonary artery. Due to difficult angulation of left pulmonary artery, it was very difficult to advance the catheter inside left pulmonary artery. Hence, another 0.014” Balance Middle Weight wire was advanced through the catheter inside the left pulmonary artery. The peripherally inserted central catheter line was entangled between the two Balance Middle Weight wires by rotating both the wires over each other Wire Entanglement technique. (Fig 2a) After peripherally inserted central catheter line was entangled between two Balance Middle Weight wires, it was pulled out slowly under fluoroscopic guidance. Since entanglement assembly got released, peripherally inserted central catheter line was pulled out until main pulmonary artery only. (Fig 2b) Afterwards, a 4Fr Amplatz gooseneck snare with 10 mm diameter was introduced into the main pulmonary artery through the catheter, peripherally inserted central catheter line was snared and removed en-masse through the femoral venous access under fluoroscopic guidance. (Fig. 3a,3b).
Fig. 1. ( a ) AP view and ( b ) Lateral view showing Peripherally Inserted Central Catheter extending from right ventricle to the left pulmonary artery.
Fig. 2. ( a ) Lateral view showing peripherally inserted central catheter line entangled between the two Balance Middle Weight coronary wires [Wire Entanglement technique]. ( b ) Lateral view showing peripherally inserted central catheter line pulled out in main pulmonary artery by entanglement technique.
Fig. 3. ( a ) 4 Fr Amplatz gooseneck snare with 10 mm diameter in main pulmonary artery. ( b ) Embolised fragment of peripherally inserted central catheter line being snared out.
Post-retrieval cinefluoroscopy showed the absence of any residual segment of the line anywhere in the body. (Fig 4) Bedside echocardiography also confirmed the absence of residual fragments inside the heart. Post procedure, the sheath was removed and haemostasis was achieved by local compression.
Fig. 4. Post retrieval cinefluoroscopy shows absence of any residual segment of the Peripherally inserted central catheters line.
The baby was haemodynamically stable during the procedure and was shifted back to paediatric cardiac ICU for observation. He was discharged and referred back to the referring hospital for further neonatal care.
Discussion
Peripherally inserted central catheter lines are widely used in neonatal ICU for rapid and dependable central venous access in pre-term babies for long term vascular access. Several complications involving peripherally inserted central catheter line have been described including local complications, catheter migration, malposition, thromboembolism, infection, and fracture of the catheter causing embolisation.
The first transcatheter retrieval of an intravascular foreign body can be attributed to Porstmann in connection with his catheter technique for ductal closure. Porstmann’s foreign body was a guide spring deliberately passed across the ductus and not an accidentally embolised fragment of guidewire or tubing. Reference Porstmann, Wierny and Warulce9
Removal of a centrally embolised foreign body is indicated in almost all cases because of the high incidence of complications. Mortality is highest with the embolised fragment located in the right side of the heart and slightly lower in the vena cava. Among the causes of death, perforation of the cardiac chamber is the most common followed by septic endocarditis, arrhythmia with heart failure, thrombus involving the vena cava with subsequent pulmonary embolism, and necrosis of the cardiac wall. Reference Grabenwoeger, Bardoch, Pock and Pinterihis10
Although foreign body retrieval is very common in adults and older children, very few case reports have mentioned successful retrieval of the embolised central venous catheter in very low birth weight neonates using interventional techniques. Reference Hsu, Wang, Yeoh and Lin4–Reference Patel, Ramarao, Desai, Savich and Patel8 However, most of these cases dealt with an indwelling umbilical venous catheter rather than a peripherally inserted central catheter line as in our case. Also, none of these cases had the embolised fragment retrieved from the left pulmonary artery.
Percutaneous retrieval is ideal being less invasive. This approach was technically very challenging in our case as we were dealing with a 5 days old pre-term neonate born at 32 weeks of gestation having very low birth weight of 1100 g, with features of clinical sepsis, coagulopathy and embolised catheter fragment extending from right ventricular to left pulmonary artery. Due to the small calibre of blood vessels, it was challenging to obtain the appropriate sized sheath and interventional catheters for the needed access. Few cases were described in the literature where 4 or 5 Fr sheaths were used successfully. Reference Hsu, Wang, Yeoh and Lin4–Reference Patel, Ramarao, Desai, Savich and Patel8 Though the catheter could be snared, it was often found to be difficult to retrieve it back into a 4Fr sheath as the catheter fragment was looped, thus limiting the success of its retrieval using this technique.
In our case, we retrieved the peripherally inserted central catheter line successfully from the left pulmonary artery by using wire entanglement technique followed by use of 4Fr Amplatz gooseneck snare (10 mm) in such a very low birth weight neonate under conscious sedation (without GA) with high risk of bleeding due to coagulopathy and thrombocytopenia. Other techniques for retrieval of a foreign body such as retrieval baskets, biopsy forceps, and small balloon techniques have been well documented. Reference Paulus and Fischell11
Several complications which are possible while attempting retrieval of a catheter from left pulmonary artery includes risk of haemorrhage, infection, dysrhythmias, cardiac perforation, pericardial effusion, cardiac tamponade, thromboembolism, sudden cardiac arrest, and limb ischaemia. However, our procedure was uneventful without any complication and the catheter was retrieved successfully.
Conclusion
Although it is very challenging to retrieve embolised central catheters from heart, with meticulous planning retrieval can be performed safely in very low birth weight newborns.
Acknowledgements
We are thankful to the team of Anesthetist, Intensivists, Pediatricians, Nursing staff and all clinical staff of the institute for taking good care of all the children.
Financial support
This work was supported by U. N. Mehta Institute of Cardiology and Research Centre itself and received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflict of interest
None.
