Jurnal Kedokteran dan Kesehatan Indonesia

Indonesian Journal of Medicine and Health

Journal homepage: https://journal.uii.ac.id/JKKI

Percutaneous retrieval of intracardiac fragmented using a snare-loop catheter: A case report Adhitya Ginting*1, Ketut Putu Yasa2, Yan Efrata Sembiring1 1Department of Thoracic, Cardiac and , Faculty of Medicine, Universitas Airlangga/ dr.Soetomo General Hospital, Surabaya, Indonesia 2Division of Thoracic, Cardiac, and Vascular Surgery, Department of Surgery, Faculty of Medicine, Universitas Udayana/ Sanglah General Hospital, Denpasar, Bali, Indonesia Case Report ABSTRACT ARTICLE INFO We presented a 60-year-old woman with an history of end-stage renal Keywords: disease on regular hemodialysis, twice a week, came with a tunneled endovascular procedures, dialysis catheter (TDC) that was attached to the right internal jugular . intracardiac , TDC has been dysfunction since one week ago that was suspected as a equipment failure result of thrombosis in the lumen of TDC. TDC was trimmed at the insertion *Corresponding author: [email protected] of the jugular vein. And then a wire was inserted into TDC that has been DOI: 10.20885/JKKI.Vol11.Iss2.art14 trimmed. From Chest x-ray imaging, migration of fragmented TDC was History: found inside the heart chamber with wire inside the lumen. Fluoroscopy Received: December 31, 2019 showed a picture of a fragmented TDC in the heart chamber with a Accepted: August 13, 2020 wire inside the lumen. Retrieval of fragmented TDC used percutaneus Online: August 31, 2020 snare loop method with wire guiding that was inserted through the left Copyright @2020 Authors. This is an open access article femoral vein. Fragmented TDC was removed successfully. Retrieval of the distributed under the terms of the Creative Commons At- Simple snare loop method is quite effective and very cheap compared to tribution-NonCommercial 4.0 thefragmented commercial TDC snare,through open endovascular surgery or techniques laparoscopic is classified surgery thatas a simple.can be International Licence (http:// creativecommons.org/licences/ avoided. by-nc/4.0/). Kami melaporkan seorang wanita 60 tahun dengan riwayat penyakit saat ini adalah gagal ginjal kronik dengan hemodialisa reguler dua kali seminggu. TDC terpasang di vena jugularis interna kanan. TDC mengalami disfungsi sejak 1 minggu lalu, dicurigai akibat dari trombosis yang terbentuk di dalam lumen kateter hemodialisa. TDC kemudian digunting sebagian pada insersi vena jugular dan wire dimasukkan ke dalam kateter hemodialisa tersebut. Dari pencitraan X-ray didapatkan migrasi bagian kateter hemodialisa berada di dalam ruang jantung dengan wire di dalam lumen kateter hemodialisa. Fluoroskopi menunjukkan gambaran sebagian kateter hemodialisa berada di ruang jantung dengan wire terpasang di dalam potongan lumen kateter hemodialisa. Ekstraksi sebagian kateter hemodialisa dilakukan menggunakan metode loop snare dengan akses guiding wire yang dimasukkan melalui vena femoralis kiri. Fragmen kateter kemudian berhasil dikeluarkan. Pengambilan fragmen melalui endovaskular tergolong teknik yang sederhana. Loop snare yang sederhana sudah cukup efektif dan murah dibanding komersial snare, sehingga pembedahan terbuka ataupun laparaskopik dapat dihindari.

INTRODUCTION done through surgery or special procedures Hemodialysis requires access to the patient's that can be performed by specialists. There vessels. Access to these vessels can be are three common types of vascular access,

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Arterio-venous graft (AV graft), and central complication are high costs of management.2,3 venousthey are catheter Arterio-venous (also known fistula as hemodialysis(AV fistula), comparedThe most to AV fistulacommon or AF non-infectious graft, and these catheter). In this study, we will discuss about complication of TDC is hemodialysis catheter hemodialysis catheters and their complications. dysfunction. According to The National Kidney Foundation (NKF/DOQI) guidelines, tube that is usually inserted into a large vein in theHemodialysis chest. Hemodialysis catheter cathetersis a man-made can be insertedflexible into a vein in the neck or in the groin. Every min,hemodialysis with arterial catheter pressure dysfunction before ispumping defined isif hemodialysis catheter has two holes called ports. lessextracorporeal than negative blood 250 flow mmHg. cannot The reachmost common 300 ml/ One of the ports drain blood from the body that cause is thrombosis either inside or outside of be cleaned through a dialysis machine and then the hemodialysis catheter lumen. Complication the clean blood is returned to the body through from the removal of hemodialysis catheters can the other ports. The place where the catheter also occur because the adhesion process in the enters the skin is also called the exit site.1 cuff is not adequately formed.2 Hemodialysis catheter is a temporary The rarest complication is migration of fragmented hemodialysis catheter into the heart. or AV graft surgery. Hemodialysis catheter is also This can be caused by a fragile hemodialysis hemodialysis access while waiting for AV fistula catheter tip or because a fragmented catheter is be done. Hemodialysis catheter is inserted by the released into the heart during the replacement surgeonused as an with option ultrasound if AV fistula guiding or or AV X-ray graft imaging cannot process from hemodialysis catheter.2 in the operating room. Hemodialysis catheter can be used immediately after being inserted into a CASE DESCRIPTION vein. The risk of infection increases in the area Our patient was a 60-year-old woman where hemodialysis catheter is attached both at complaining about her TDC disfuncionality since the entrance to the body and in the bloodstream. one week ago. She has history of end-stage renal In addition, there can be damage to the vein disease on regular hemodialysis, twice a week, where the hemodialysis catheter is inserted. came with TDC that was attached to the right Hemodialysis catheter is inserted with the help of internal jugular vein about six months. Consent ultrasound so that they can be installed properly. was taken from her legal guardian. The anesthetic use local anesthetic techniques.1 The patient came by herself to our hospital In general, the most preferred blood vessel because of TDC dysfunction during hemodialysis. The patient was asymptomatic. Physical examination showed a body temperature of riskaccess of isinfection AV fistula, problems because and of the thrombosis. high average In 37.5°C, TDC has been dysfunctional since 1 week addition,blood flow AV that graft can is thebe achieved,preferred bloodand the vessel low ago because at that time, the extracorporeal

min. Laboratory tests showed ureum 45 mg/dl, catheteraccess, because is blood the vesselaverage access blood flowlast thatchoice can for be creatinineblood flow 14 hemodialysis mg/dl, and potassiumwas less than 5 meq/liter. 300 ml/ hemodialysisachieved is similar because to the it can AV causefistula. non-infectious Hemodialysis The patient was planned for a replacing of the complications which will be discussed later and TDC with a temporary hemodialysis catheter compile infection, except for the initiation of in the operating room under local anesthesia. hemodialysis while awaiting surgery. Tunneled Dialysis Catheter (TDC) is associated with higher rates of complications, morbidity and mortality

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Figure 1. Tunneled Dyalisis Catheter (TDC) inserted into central vein.2

Patient was taken to the operating theater into the blood vessels. Wire was retained, and with stable blood pressure was 150/90 mmHg, then the patient was carried out on imaging heart rate was 98 times per minute, respiratory using X-ray with a mobile C-Arm system. X-ray rate was 22 times per minute, oxygen saturation imaging revealed migration of the fragmented was 99% without O2 support. ECG monitoring TDC inside the cardiac chamber with a wire was installed on patient. Disinfection of the in the lumen of the fragmented TDC (Figure operating area used povidone iodine and alcohol. 2 and 3). The procedure was stopped and the Then, draping of the patient used sterile ducts. patient was planned for an extraction of the TDC could not be aspirated using a 10cc syringe. fragmented TDC in the hybrid operating theater. This was suspected as a result of thrombosis that The condition of patient was stable with blood forms in the TDC lumen. TDC was trimmed at pressure was 140/90 mmHg, heart rate was the insertion area (in the jugular vein). Wire was 92 times per minute, respiratory rate was 20 inserted into the fragmented TDC which has been times per minute, and oxygen saturation was trimmed, because the fragmented TDC was not 99% saturation without hemodynamic support. good, then the fragmented TDC was aspirated

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Figure 2. Fragmented TDC showed in Mobile C-arm X-ray

Figure 3. Fluoroscopy imaging showed fragmented TDC in heart chamber using the Mobile C-arm X-ray

The patient was prepared entering the hybrid extraction of the fragmented TDC using the operating theater for extraction of fragmented snare loop method (Figure 4) with wire guiding TDC. Once ready, the patient was brought into through the left femoral vein. After 11 Fr sheath the hybrid operating theater with stable blood was inserted to the left femoral vein, the guiding pressure was 140/90 mmHg, heart rate was 90 wire was inserted into the femoral vein until they times per minute, respiratory rate was 20 times reached the fragmented TDC. Then a snare loop per minute, and the oxygen saturation was 99% was inserted until it bound to the fragmented without hemodynamic support. ECG monitoring TDC and then the snare loop was locked. The were installed on the patient. Disinfection of snare loop was pulled slowly until it approached the operating area used povidone iodine and the left femoral vein. Fragmented TDC were alcohol and then draping used sterile ducts. extracted through an incision in the left femoral Fluoroscopy showed a picture of a fragmented vein and then the incision area was covered TDC in the heart chamber with a wire attached layer by layer, the skin was covered by simple to the lumen of the fragented TDC (Figure 3). continuous suture.

From fluoroscopy, the patient needed

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Figure 4. Four type of snare loops. From above, (A) a simple snare loop is made with a 5-F, 0.038-inch Cobra 2 catheter endhole and an 18- inch, 180-cm-long guidwire. (B) Snare loop originates from the endoscopic set.

loop(C) Cook is made Medical kinking (Bloomington, using forceps. IN)4 IVC retrieval filter set. (D) The last snare is the same snare loop as the first snare loop, only the apex of the guidewire

After the procedure, we evaluated the of either thrombosis or stenosis of the vein. fragmented TDC, that entered the patient's Mechanical complications consist of bleeding heart, was completely removed. There was no due to previous puncture of blood vessels, remaining fragmented TDC from the evaluation pneumothorax, and very rarely is the migration of the catheter into the heart chamber.6 operation. the patient was monitored in the Using hemodialysis catheters in proper is very ICU.via fluoroscopy The electrocardiogram during the operation. and the Afterphysical the important because it can reduce the likelihood examination were normal. There were not any of complications. Repair of catheter dysfunction major or minor complications such as arrhythmia, is preferred rather than try to replace the bleeding, vascular or cardiac perforation, or hemodialysis catheter and re-inserting in a local hematoma. Two weeks after the patient different place. The causes of hemodialysis discharged, the patient came to the outpatient and had no complaints. lumen of the hemodialysis catheter, a curved catheter dysfunctionor malposition are fibrincatheter, formation and acute in the or DISCUSSION chronic thrombosis. Central venous stenosis The main complications of TDC are infection, resulting from an endothelial injury associated occlusion, and mechanical.5 The infection consists with placement. It can of bacteremia and sepsis. The occlusion consists

be decreased AV fistula flow or AV graft flow in

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the extremities. It is usually asymptomatic, but thrombectomy can be considered.9,10 clinical symptoms can occur when it becomes hemodialysis patients increase, the prevalence of tunneledAlthough hemodialysisthe effort to make catheters AV fistulas remains in durationgetting more when flow inserting than it should, the catheter. especially6 from high (National Vascular Access Initiative, Fistula AV Fibrinfistula orin AVthe graft. lumen The of risk the factor hemodialysis is a long First). In the United States, the use of TDC was catheter can be removed when the guiding 62.3% in hemodialysis patients in 2006. Infection wire was inserted during the replacement associated with catheter placement and central procedure or using balloon angioplasty. In the venous stenosis is a common complication of case of acute thrombosis, thrombolytic agent TDC that makes them unfavorable compared or thrombectomy can be used to retaining the patency, even with slight risk of bleeding during used while waiting for vascular access surgery the procedure. Endovascular interventions such orto AVkidney fistula transplantation. and AV graft. Therefore However, TDC there is only are as percutaneous angioplasty are the best choice groups of patients who use TDC as long-term in the management of chronic central venous hemodialysis access because these patients stenosis.6 have not a vascular access site remaining, poor TDC is associated with infectious and non- vascular access for hemodialysis, or refusing infectious complications. It would increased to make vascular access. In these patients, morbidity and mortality of patient.7 These unusual complications associated with the use complications can occur right after inserting or of TDC may occur, for example, migration of TDC can occur slowly during TDC usage.8 Thrombus fragment into the heart.11 can form in the lumen of hemodialysis catheters, Chawla reviewed and proved that the which can lead to tissue complications such as interruption of TDC causing migration to the pulmonary embolism, septic embolism, central heart was very rare unless deliberately cut venous stenosis, and cardiac arrhythmias. during the procedure to replace the TDC. A Optimal management of thrombus in the severed catheter tip can settle in the right heart hemodialysis catheter lumen is still being chamber, vena cava or migrate to the pulmonary debated. When a thrombus in a hemodialysis artery and its branches depending on its size and catheter is detected, patients are usually given weight.12 Potential complications that can occur anticoagulant therapy, using INR with the same are perforation of the heart, valves, and blood target as patients with deep vein thrombosis vessels including the formation of thrombus and for three months. Mostly, TDC is not removed the phenomenon of embolism due to fragments (unless it is no longer needed). The duration that are cut off. Catheter fragments can be seen of anticoagulation can vary depending on the using X-ray. An echocardiogram or CT scan may severity of thrombosis, the risk of bleeding, and be needed if fragments are not visible between the need for using a hemodialysis catheter.9 the shadows of the heart.11,13 Thrombus in the right atrium associated Taking a fragmented TDC that migrates with a hemodialysis catheter is a serious depends on how long the fragment in the heart complication, related to an average mortality (the longer the likelihood of adhesions), there rate of around 18%. In a systematic review, are risk factors for complications, and the site about 71 reported cases has thrombus in the of the cut is located. Cutting is required if the right atrium associated with a hemodialysis fragment is in the right heart space and the catheter, the authors recommend for removal of a proximal branches of the pulmonary artery due hemodialysis catheter and using anticoagulation to complications that can occur there (infection, if the thrombus is less than 6 cm. If patients have perforation, thrombosis, and arrhythmias). contraindications to anticoagulants (thrombus These complications can occur within a year, greater than 6 cm or abnormalities of the heart), mostly within a month, and rarely within 2 years.

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Nellore and Trerotola described an unusual in the patient's body which can be a source of case of migrating fragments from the left to the complications in the patient. Deciding which pulmonary artery after 2 years of release. In steps to take depends on what fragments will his review of catheter embolism, Richardson be taken, the position of the instrument system noted that the highest mortality occurred in used, the approach to the fragment, and the emboli in the right heart. Extracting fragments is process of bringing the fragment out through needed either through percutaneous or through the safest and most easily accessible exit points. surgery. However, not all fragment embolization needs to be removed. If the fragment cannot be (Figure 5). In this case, the operator uses the percutaneously removed because it is localized in endovascularThe loop snare loop used snare is a techniquemodified loop(Figures snare 6 a very distal place or has been present for a long and 7). time without symptoms and the patient decides Retrieval of intravascular or intracardiac of not to operate (or surgery is contraindicated tunneled double lumen catheter fragment has because of too high a risk of morbidity and various techniques. In the 2019, the retrieval mortality at that location), then the patient of the fragment of the catheter procedure was must be monitored closely strict. Prophylaxis performed by Semadi. The procedure was of endocarditis and low-dose warfarin (1 mg/ performed under general anaesthesia and C-Arm day) for at least 2 years (or low-dose aspirin) guidance. About 7 cm Golf stick incision was made are highly recommended in such cases. High at the right Sedillot’s triangle. The incision was vigilance is needed in these patients because done until the internal jugular vein was exposed. fragments that have long been able to migrate Purse string was made around prior incision and cause complications.11,13 Every endovascular specialist will be Under C-arm guidance, a mixter right angle confronted with a problem of a malfunctioning, clampwith 4-0 was non-absorbable inserted to retrieve monofilament the distal suture. tip of interrupted, or migrating device that requires dislodging double lumen catheter. The fragment retrieval. The cause of migration from the catheter of the catheter can be retrieved smoothly.15 is very numerous, in this case, a fragmented TDC No techniques have been recommended for migrates into the cardiac chamber. The method retrieval procedure up until now in this case. for retrieval of fragments is various, in this case, The technique that will be used depends on the we used the loop snare method.4,14 type and location of the hemodialysis catheter, it Snare and graspers for extracting fragments also depends on the experience of the operator. are widely sold in the market. However, it is easy In our case, the patient comorbid was end- to make a snare loop with standard 5-F and 180- stage renal disease, so the patient needed a cm, 0.018-inch guide wire angiographic catheters hemodialysis catheter for regular hemodialysis. (Figure 4). Mallmann has reported success using But there are no any comorbid directly related this snare loop up to 100%. The advantage of to the procedure. Based on the location of this type of snare loop are many size choices the fragment of the catheter, the most likely for this loop and the cost is not expensive. If the complication is cardiac arrhythmia. Meanwhile, end of this loop is made kinking using forceps, the complication for retrieval of intravascular or this snare can be directed to the desired side.4,14 intracardiac of tunneled double lumen catheter In almost all cases, it is possible to extract fragment is the injury to the blood vessels so that fragments without the need for surgery. In some thrombosis and bleeding can occur. cases, a large or stiff fragment can be taken and Our study has limitations. It is a single study, observational, and non-comparative surgery with local anesthesia can be performed. study. This case is still rare. If there is another Thetaken best to atime more to extractsuperficial fragments site where is just simple after study found, it is better to use a case series or the incident. A fragment becomes an alien corpus comparative study. The management of this case

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remains a challenge, endovascular specialists is a dangerous situation, but it could be managed who experience a similar case can apply this early by knowing the exact site of the foreign procedure and it must be done by a competent body using a chest radiograph. doctor. Intracardiac or intravascular foreign body

(3b)Figure second 5. The plane, modified (4) goldloop marker.snare parts.16 (1) variable diameter loop, (2) radioopaque loop, (3a) first plane,

16

Figure 6. Endovascular loop snare technique uses first plane.

Figure 7. Endovascular loop snare technique uses the second plane.16

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CONCLUSION dialysis catheters for hemodialysis: A Sys- In conclusion, if there is a fragmented TDC, tematic approach and clinical practice algo- it is necessary to identify the location of the rithm. Journal of Clinical Imaging Science. 2015;5(1):1–12. After informing the patient, the fragments can be 7. Hong JH. An easy technique for the re- takenfragment using using snare X-ray, especially fluoroscopy, in high-risk or CT patients scan. moval of a hemodialysis catheter stuck in (patients at risk of endocarditis and fragments central . Journal of Vascular Access. that are in the right heart and proximal to the 2010;11(1):59–62. pulmonary artery). 8. Forneris G, Savio D, Quaretti P, Fiorina I, Ce- Retrieving fragments through endovascular cere P, Pozzato M, et al. Dealing with stuck hemodialysis catheter: State of the art and techniques is simple, and there are many tips for the nephrologist. Journal of Ne- kinds of instruments for this purpose. Almost phrology. 2014;27(6):619–25. in all situations, a simple snare loop is quite 9. Miller LM, MacRae JM, Kiaii M, Clark E, Dip- effective and the cost is very cheap compared to chand C, Kappel J, et al. Hemodialysis tun- commercial snare. Open surgery can be avoided neled catheter noninfectious complications. but it depend on the cases. Canadian Journal of Kidney Health and Dis- ease. 2016;3(1). CONFLICT OF INTEREST 10. Wang L, Wei F, Jiang A, Chen H, Sun G, Bi The Authors have none to declare. X. Longer duration of catheter patency, but similar infection rates with internal jugular ACKNOWLEDGEMENTS vein versus iliac vein tunneled cuffed he- The Authors have none to declare. modialysis catheters: A single-center ret- rospective analysis. International Urology REFERENCES and Nephrology. 2015;47(10):1727–34. 1. Barret B. Some facts about central venous 11. Sequeira A, Sachdeva B, Abreo K. Uncom- catheters (hemodialysis catheters). Yhe mon complications of long-term hemodi- Kidney Fund Canada. 2010;(February alysis catheters: Adhesion, migration, and 2010):1–3. perforation by the catheter tip. Seminars in 2. Banerjee S. Dialysis catheters and their Dialysis. 2010;23(1):100–4. common complications: An update. Scien- 12. Hong JH. A breakthrough technique for the removal of a hemodialysis catheter stuck 3. Zhu LN, Mou LJ, Ying-Hu LJ, Wei GN, Sun JF. in the central vein: Endoluminal balloon FailuretificWorldJournal. to place a 2010;9:1294–9. tunneled hemodialysis dilatation of the stuck catheter. Journal of catheter due to malformation of right inter- Vascular Access. 2011;12(4):381–4. nal jugular vein draining to subclavian vein. 13. Zhou L, Yu S, Gou S, Shi M, Cui T, Fu P. Journal of International Medical Research. Removing the incarcerated tunneled 2018;46(6):2481–5. cuffed venous catheters: An experience 4. Thompson K. Non-surgical retrieval of de- vices and foreign bodies. Endovascular To- 2018;46(3):246–7. day. 2010;(July):29–32. 14. Amorettifrom a single N, Hauger center. O, BloodMarcy Purification.PY, Hovorka 5. Adeel Ebad C, Davitt S, Gnanasekaran R, I, Lesbats-Jacquot V, Fonquerne ME, et al. Khan A, Moran AM. Application of Hong’s Foreign body extraction from soft tissue technique for removal of stuck hemodialy- sis tunneled catheter to pacemaker leads. A new technique. European Radiology. Radiology Case Reports. 2017;12(1):97– 2010;20(1):190–2.by using CT and fluoroscopic guidance: 101. 15. Semadi IN, Koerniawan HS, Irawan H. 6. Pereira K, Osiason A, Salsamendi J. Vas- Retrieval of intravascular fractured frag- cular access for placement of tunneled ment of tunnelled double lumen cathe-

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ter in hemodialysis patient. Open Access Macedonian Journal of Medical Sciences. 2019;7(1):124–6. 16. Micro M. objects from any angle . Three different types in various sizes make our snare the ideal interventional solu - tion for use in middle-sized to large vessels (Multi- Snare ®), in distal smaller vessels (Multi- Snare ® Micro) and for supporting the implan. Multi-Snare®. 2015. http://www. pfmmedical.com

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