Ann Thorac Surg 1998;66:938-939
© 1998 The Society of Thoracic Surgeons
Case Reports
Surgical retrieval of an embolized central venous catheter in a premature baby
Pietro A. Abbruzzese, MDa,
Enrico Chiappa, MDb,
Pierclaudio Murru, MDc,
Lino Stefanini, MDb,
Stefano Longo, MDa,
Roberto Balagna, MDd
a Division of Cardiac Surgery, Infantile Regina Margherita Hospital and University of Torino, Torino, Italy
b Division of Cardiology,, Infantile Regina Margherita Hospital and University of Torino, Torino, Italy
c Department of Neonataology, Infantile Regina Margherita Hospital and University of Torino, Torino, Italy
d Anesthesiology and Reanimation Service, Infantile Regina Margherita Hospital and University of Torino, Torino, Italy
Accepted for publication March 24, 1998.
Address reprint requests to Dr Abbruzzese, Divisione di Cardiochirurgia, Ospedale Infantile Regina Margherita, Piazza Polonia 94, 10126 Torino, Italy
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Abstract
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Embolization of central venous catheter fragments is usually treated with percutaneous interventional techniques, which are difficult to apply in infants with very low birth weight. We surgically removed a catheter fragment in a preterm neonate, to avoid the impending thrombosis of the right pulmonary artery. The operation was performed with a nerve hook introduced through a tiny incision in the vessel’s wall. The procedure was well tolerated, and no stricture remains at the site of incision.
Accidental embolization of fragments of central venous catheters occasionally occurs. Although in children and adults retrieval is usually performed with catheter techniques, in infants with very low birth weight (<1,500 g) this can be difficult or even impossible because of the dimensions of the vessels and the cardiac structures. We describe the successful retrieval of a retained fragment of a silicone catheter through a median sternotomy approach in an infant with very low birth weight.
A 27-week preterm 5-day-old male baby, weighing 1060 g, was referred to our unit for treatment of an embolized central venous catheter fragment. He had been intubated and mechanically ventilated since birth because of a severe respiratory distress syndrome. A patent ductus arteriosus had not been medically treated because of coagulation problems. A 0.6-mm silicone catheter had been centrally inserted through the left antecubital vein for intravenous feeding and administration of drugs on his fourth day of life.
At admission, transthoracic echocardiography confirmed the presence of the retained thread-like foreign body, extending from the right atrium to the distal right pulmonary artery (Fig 1). At that time no mechanical obstruction to the pulmonary flow was present, and we therefore elected to avoid any intervention. However, echocardiograms were repeated during the following days and showed evidence of progressive right pulmonary flow obstruction.
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Fig 1. Subcostal paracoronal view depicting the course of the embolized catheter with the distal end (arrows) reaching the proximal right pulmonary artery. (Ao = aorta; PA = pulmonary artery; RA = right atrium; RV = right ventricle.)
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The baby underwent an operation for removal of the foreign body and closure of the patent ductus arteriosus at 13 days of age. The operation was performed intrapericardially through a median sternotomy approach. The patent ductus arteriosus was isolated and ligated. The right pulmonary artery was dissected free and clamped proximally and distally. A 10-cm catheter fragment was retrieved from the right pulmonary artery by means of a blunt nerve hook introduced through a less than 1 mm longitudinal incision on the vessel’s wall, which was thereafter closed with a 7/0 polypropylene stitch. The postoperative course was uneventful, and the surgical incision healed very well. A postoperative echocardiogram showed optimal reconstruction of the right pulmonary artery with no obstruction at the site of incision.
Placement of silicone central venous catheters is increasingly popular in neonatal intensive care units [1]. Even though embolization of fragments of these catheters is rare, having been reported in neonates only three times [2–4], it is likely to occur more frequently in the near future, in view of its widespread use. Percutaneous retrieval of these fragments with endovascular retrieval snares is a well-established procedure in older children and adults. In contrast, in the literature only one report exists [2] of such a treatment for an embolized catheter in a 27-week preterm infant, weighing 1,084 g. In a second, much bigger baby [3], removal of the line by cardiac catheterization was attempted unsuccessfully and a sternotomy was required. In the third case [4], a thoracotomy and a pulmonary arteriotomy were employed for retrieval of the fragment. In our case the small body size discouraged us from attempting a percutaneous approach. Because the silicone catheter was barely recognizable at fluoroscopy, we felt that maneuvering a catheter snare within the tiny cardiac structures would be unsafe.
We therefore elected to use a surgical approach by a median sternotomy, which proved to be a very simple and safe one. We were worried that an incision on the right pulmonary artery, which was only 2.5 mm in diameter, could cause a stricture in it, but the use of a blunt neurosurgical hook allowed us to "fish" the catheter through a tiny incision. The same procedure could have been performed through a right thoracotomy. However, the simultaneous presence of a hemodynamically significant patent ductus arteriosus led us to use a median sternotomy. Moreover, this incision would have allowed us to open the main pulmonary trunk or even the right atrium if the right pulmonary approach was impossible.
In conclusion, a median sternotomy approach can be considered a safe alternative to the percutaneous methods for removing embolized fragments of venous catheters, if tiny dimensions of the babies prevent their use or additional procedures are to be performed.
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References
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- Chathas M.K., Paton J.B., Fisher D.E. Percutaneous central venous catheterization: three years’ experience in a neonatal intensive care unit. Am J Dis Child 1990;144:1246-1250.[Abstract/Free Full Text]
- Ochicubo C.G., O’Brien L.A., Kanakriyeh M., Waffarn F. Silicone-rubber catheter fracture and embolization in a very low birth weight infant. J Perinatol 1996;16:50-52.[Medline]
- Watkin S.L., Stephenson T.J. Embolization of a percutaneous central venous catheter. Clin Pediatr 1994;33:126-127.
- Khilnani P., Toce S., Reddy R. Mechanical complications from very small percutaneous central venous Silastic catheters. Crit Care Med 1990;18:1477-1478.[Medline]
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