quiz difficult port removal case

[Admin]

First one with correct answer with justification win.

A nine-year old boy has completed treatment for acute lymphoblastic leukemia. An implanted resevoir for vascualr access was placed via a percutaneous left subclavian vein approach four years prior. A request was made for its removal by the Hematology-Oncology Service. At surgery, the port was mobilized without difficulty. However, the catheter could not be withdrawn despite a prolonged attempt at providing tension on the catheter. Dissection was undertaken to the infraclavicular area but the catheter could still not be withdrawn.

The next best step in management of this child with a difficult port removal is

A remove the port, ligate the catheter at its insertion and leave in place.

B leave the port and catheter in place.

C remove the port, ligate and suture the catheter to surrounding tissue at the insertion site.

D expose the subclavian vein for catheter removal.

E ligate the catheter and send the patient to interventional radiology for emergent removal.

[Admin]

A

correct

The clinical scenario is generally managed in one of two ways; either leaving the catheter in place after removal of the port, or having interventional radiology or cardiology snare the catheter from a groin approach. The inability to remove a central venous catheter due to its adherence at the insertion site or to the vein itself occurs in about two percent of catheter removal procedures. Possible explanations include calcification around the catheter at the insertion site or within the vein, or adherence of the catheter to the vein itself. Inability to withdraw a central venous catheter tends to occur when a catheter has been in place for an extended period of time; 61.4 ± 24.7 months in a report by Bautista and 37 ± 12 months in a report by Milbrandt. Moreover, the primary indication for placement of these catheters has been treatment for a malignancy.

The concerns raised by the presence of a retained catheter are for embolization, thrombosis and infection. The risks of these events are far less likely than the risks involved in trying to surgically expose great vessels where the catheters may be retained. In the two series noted above, most catheters were left in place with follow up radiographs to assess catheter position and Doppler ultrasound to monitor for thrombus. All patients have been asymptomatic. Some of these catheters had attempted, but unsuccessful, removal by interventional radiology.

The literature does indicate, however, that interventional radiology is a possible recourse for removal of a retained catheter fragment. This has primarily been successful for embolized catheter fragments. However, interventional radiology has also been used to successfully remove adherent catheter fragments.

In the scenario described, ligation of the catheter at the insertion site may be the best choice. The catheter is not likely to migrate, and suturing it to surrounding tissue might compromise removal attempts by interventional radiology if it was determined that catheter removal was desirable. Presence of the retained fragment has been tolerated well by patients in the few reports available. Removal by interventional radiology can be arranged and attempted as an elective procedure. There is no reason to leave the port itself in place and the risks of exposing the subclavian vein in this case is not justified. A chest film should be obtained to be sure the catheter has not embolized to the pulmonary artery postoperatively in which case removal by interventional radiology would be required.

[Dr Ammar]

E

[Admin]

think again my friend

[Hananmahdy]

A

[Admin]

your 1st answer, E (error)
your 2nd answer, A (correct answer), well done

[Manal Dhaiban]

E

[Admin]

think again my friend

[Admin]

A

correct

The clinical scenario is generally managed in one of two ways; either leaving the catheter in place after removal of the port, or having interventional radiology or cardiology snare the catheter from a groin approach. The inability to remove a central venous catheter due to its adherence at the insertion site or to the vein itself occurs in about two percent of catheter removal procedures. Possible explanations include calcification around the catheter at the insertion site or within the vein, or adherence of the catheter to the vein itself. Inability to withdraw a central venous catheter tends to occur when a catheter has been in place for an extended period of time; 61.4 ± 24.7 months in a report by Bautista and 37 ± 12 months in a report by Milbrandt. Moreover, the primary indication for placement of these catheters has been treatment for a malignancy.

The concerns raised by the presence of a retained catheter are for embolization, thrombosis and infection. The risks of these events are far less likely than the risks involved in trying to surgically expose great vessels where the catheters may be retained. In the two series noted above, most catheters were left in place with follow up radiographs to assess catheter position and Doppler ultrasound to monitor for thrombus. All patients have been asymptomatic. Some of these catheters had attempted, but unsuccessful, removal by interventional radiology.

The literature does indicate, however, that interventional radiology is a possible recourse for removal of a retained catheter fragment. This has primarily been successful for embolized catheter fragments. However, interventional radiology has also been used to successfully remove adherent catheter fragments.

In the scenario described, ligation of the catheter at the insertion site may be the best choice. The catheter is not likely to migrate, and suturing it to surrounding tissue might compromise removal attempts by interventional radiology if it was determined that catheter removal was desirable. Presence of the retained fragment has been tolerated well by patients in the few reports available. Removal by interventional radiology can be arranged and attempted as an elective procedure. There is no reason to leave the port itself in place and the risks of exposing the subclavian vein in this case is not justified. A chest film should be obtained to be sure the catheter has not embolized to the pulmonary artery postoperatively in which case removal by interventional radiology would be required.

[Manal Dhaiban]

thank you