Percutaneous Retrieval of a Dislodged and Migrated Port Catheter Using Ablation Catheter and Balloon Trapping Technique

Totally implantable venous access devices (TIVADs), also known as port-a-cath or ‘ports’, have been used since the 1970s with readily available central venous access via large veins including subclavian, internal jugular, and axillary, but catheter fracture and migration can occur as a late complication, with an estimated frequency of 0.1% to 6.0%.^1,2 Mostly these are asymptomatic, but may present with non-specific symptoms including infections.^3–5 Nevertheless, percutaneous retrieval of a migrated port catheter via femoral access route is the preferred approach and has high success rate.⁵ Presented here is a case of a 62-year-old patient with a history of rectosigmoid carcinoma (Dukes C) and a dislodged port catheter in the right atrial appendage extending into the hepatic vein. We successfully displaced the catheter which was deeply lodged in the hepatic vein with a deflectable ablation catheter and were able to retrieve the port catheter using balloon trapping technique via a 10 Fr femoral sheath.

Case Report

A 62-year-old woman with history of rectosigmoid carcinoma (Dukes C) was referred by the surgical team for a dislodged central venous port catheter. She was diagnosed with rectosigmoid carcinoma in 2019 and had completed chemotherapy regimen and exploratory laparotomy with Hartmann’s procedure. A port catheter was implanted prior to commencement of chemotherapy and planned for removal after the patient had been recently diagnosed as free from cancer. Otherwise, she was asymptomatic with good functional status. Unfortunately, it was noted that the port catheter had dislodged during removal and chest radiography confirmed the presence of the dislodged port catheter (Figure 1A) while CT scan showed the catheter lodged in the right atrium extending into the inferior vena cava and right hepatic vein (Figure 1B and C).

The decision to proceed with percutaneous retrieval was made after evaluating several factors. First, the fractured catheter was lodged deeply in the right atrium but could be accessed percutaneously. Second, surgical retrieval might not be advisable since the patient had recently completed chemotherapy and recovery from a surgical incision could be prolonged.

Attempted Retrieval of Port Catheter via Conventional Method

The patient was subjected to retrieval of the port catheter via 10 Fr right femoral vein approach and location of the dislodged port catheter was confirmed under fluoroscopy guidance. The larger femoral sheath was ideal; however, regrettably, such an option was unavailable in our inventory. Our strategies were tailored to displace the distal portion of the port catheter from the hepatic vein into the inferior vena cava and then proceed with conventional snaring technique. A pigtail catheter (Figure 2A) was used to displace the distal tip of the port catheter but was unsuccessful due to the port catheter being lodged too deeply within the hepatic vein and lack of stiffness from the pigtail catheter. We also attempted both a ‘home-made’ snare (using a coronary wire and a semi-compliant balloon through a guiding catheter) and the EN Snare system (Merit Medical; Figure 2B) to capture the tip in the right atrial appendage, but were unsuccessful.

Manipulation of Deflectable Ablation Catheter

Failing these strategies, we opted for a stiffer deflectable ablation catheter (Biosense Webster). We opted for the ablation catheter for several reasons. First, its 8 Fr size makes it easy to manipulate, thanks to its deflective properties. Second, considering the cost implications, we used a recycled catheter after thorough sterilisation. Additionally, the introduction of a new Agilis catheter (Abbot Cardiovascular) or another snaring device incurred another cost to the patient. Hence, the ablation catheter was deflected while hooking the port catheter (Figure 3A), and due to its stiffness, we were able to release the port catheter into the inferior vena cava. Unfortunately, both the home-made snare from right femoral vein and the EN Snare (Figure 3B) from the left femoral vein were unable to retrieve the port catheter from the femoral sheath on either side due to malalignment (Figure 3C) of the catheter to the sheath.

In addition, while attempting to snare the port catheter with the EN Snare, we noticed that the proximal tip of the port catheter was lodged inside a small branch of the left external iliac vein, which we were unable to retrieve using bilateral femoral approach. Again, deflectable ablation catheter was used and successfully displaced the proximal tip back into the main vessel (Figure 3D).

Coronary Wire and Balloon Trapping Technique

With the use of an ASAHI SION blue coronary wire via a Judkins Right (JR) 3.5 catheter (Medtronic) from the left femoral vein, we managed to manoeuvre the guidewire through the port catheter, which was made possible by using multiple orthogonal fluoroscopic projections. We were then able to advance a non-compliant (NC) balloon via the ASAHI SION blue guidewire into the port catheter and inflate inside the catheter which trapped and aligned the port catheter to the JR 3.5 (Figure 4A). With the absence of malalignment, the port catheter (Figure 4B) was retrieved safely via the 10 Fr left femoral sheath. Final angiography of the iliac and femoral veins showed no perforation or dissection.

Discussion

Endovascular therapies are emerging and gaining favour among practitioners compared to conventional methods due to minimally invasive procedure with fewer complications.³ However, with steep learning curves, the incidence of serious complications, such as embolised intravascular foreign body (IFB), is expected to increase and pose significant morbidity and mortality, with Woodhouse and Uberoi, and Schechter et al. recording mortality rate of 38%.^4,5

The first retrieval case of dislodged IFB was published in 1954 with open surgery but unfortunately was a fatal encounter.⁵ Subsequently, revision was invented for minimally invasive surgical procedures, and, finally, introduction of the first percutaneous snaring case in 1967.^5,6 Edelstein et al. reported on the successful retrieval of fragmented polyethylene catheter with ureteric stone catcher catheter without any complications and was essential in demonstrating the safety of percutaneous snaring of IFB.⁷

However, identification of dislodged IFB is complicated because clinical presentations may vary from asymptomatic to major organ embolisation.^5,8 Previous literature has demonstrated that only 32% of patients presented with serious symptoms, but higher incidences were detected incidentally.⁵ Some risk factors may contribute, such as manufacture defect and loose fixation of the safety lock.⁹ Moreover, repetitive movement of fixed port catheters, especially against solid anatomical structures, such as bones, may create sequential mechanical stress and lead to fracture.⁶

Over decades, the concept of snaring IFB remained consistent but the techniques and tools had evolved in numerous ways. Old-fashioned hooked-end thinner guides with Teflon catheter were among the fundamental ways of snaring but have been replaced by the latest nitinol gooseneck snare (Covidien) or even multi-looped snare (Angiotech).^5,10 Offered in multiple sizes, both snaring devices facilitate the hastening of retrieval with enhanced torquability and remain first liner workhorse tools for snaring.^3,10,11 However, on certain occasions, grasper-type devices, such as retrieval forceps (Cook Medical), are required, especially for larger vessel or oddly angle fragmented IFB.^10,11 Conventional methods offer simplicity with direct capturing of the foreign body but are occasionally limited by reachability. In addition, risk of distal embolisation or further fracturing of the foreign material may occur in cases of adhesion. Hence, after exhausting various techniques and devices, we decided to employ a balloon trapping technique for our patient.

Gupta et al. first described the technique in 2005 with a case series of three patients in whom they encountered difficulties in retrieving the dislodged port catheters with conventional methods.¹² Using a coronary guidewire in the fragmented port catheter, an inflated balloon adhered to the port catheter, and with constant traction, the retrieval of the port catheter was successful.¹² Few principles are required for this technique. First, the fragmented port catheter consisted of a cylindrical internal lumen and second, the external port catheter diameter was smaller than the femoral sheath.^11,13

An additional valuable concept from Gupta et al. is the importance of coaxial alignment between port catheter and the femoral sheath as illustrated with our case. Coaxial alignment was achieved first by the stiffness of the coronary guidewire especially the shaft component and, second, by adherence of the inflated balloon to the port catheter.¹² These factors were essential and ensured a successful retrieval of the dislodged port catheter with minimal risk of trauma to the vessels as demonstrated in our case.

Nevertheless, the primary drawback of this technique lies in its cost. However, considering the procedural success attributed to the coaxial alignment of the retrieved port catheter, we believe it offers a precise therapeutic solution, particularly in the context of our patients. Furthermore, it is noteworthy that the cost of a coronary wire and a balloon is comparable to that of another snaring device.

Conclusion

Retrieval of a dislodged port catheter was challenging, but the right tools and techniques were fundamental in ensuring a successful procedure. Our case illustrates the balloon trapping technique, and we may be the first to describe use of a deflectable ablation catheter during snaring of a port catheter together with the balloon trapping technique.