Complication Complication Procedure Primary Diagnosis Subclavian vein injury Procedure Port a cath removal Primary Diagnosis ALL Give a synopsis of each case to start the presentation.

Clinical History 9 y old obese male with ALL underwent left subclavian Port a cath placement in June 2009. He completed his chemotherapy (Mtx, Adr, Vin) in Aug 2012. PMH: Obesity (BMI 35), ALL PSH: Port a cath 2009 MEDS :  Bactrim

Overview of Case He was taken to the operating room on November 19 for routine removal of his Port-A-Cath Intraop he had a firm calcification attached at the catheter entrance site and into the left subclavian vein During manipulation and attempted removal of the catheter, there was a tear in the subclavian vein necessitating intraoperative consultation with cardiothoracic surgeons removal of his proximal clavicle Once bleeding was controlled, patch repair of the tear in his vein after removal of the Port-A-Ca, which was densely adherent to the wall of the vein. The patient was eventually discharged home on November 22

Overview of Case Left subclavian plaque (specimen #2); excision: Fibrocalcific plaque

CVC Long-term CVC access plays a vital role In the pediatric oncology patients long-term bowel dysfunction Congenital metabolic diseases Other conditions in which a Reliable vein to access for Medications or blood draws is needed

CVC Complications Time of insertion While the line is in place Pneumothorax While the line is in place line infection Very little has been written or discussed about what to do should when a portion of the line becomes stuck within vein !

CVC The cause and optimal management of immovable central venous lines is unknown If a catheter appears fixed the options are to either leave the catheter fragment in situ to attempt intravascular removal open surgical removal

A multiinstitutional review of patients 2 pediatric tertiary hospitals Patients with retained intravascular fragments Retrospective patient chart review Prospective follow up of patients for evidence of complications related to the retained portions

A total of 299 central venous lines were removed with 6 patients identified as having fragments of lines left behind (2%) The lines had been in place for an average of 37 ± 12 months. The average follow-up period is 5.4 ± 3.9 years none of the patients have developed any symptoms, evidence of thrombus, infection, or catheter migration

Alberta Children's Hospital (ACH) 2003-07 2 of the patients had a very calcified tract, the line was stuck at the junction of the catheter and venous entrance point An attempt at endovascular removal failed The line was grasped through a transfemoral approach but line would not come away from the vein wall In one patient this maneuver resulted in a small embolus sent to the lungs

Alberta Children's Hospital (ACH) 2003-07 3rd patient the line tract was not calcified but adherent to subclavian vein wall A CXR done in the operating room demonstrated no calcification of the tract, no intravascular knot, and a normal position It was left insitu

Conclusion: Given the 2% incidence rate, the issue of managing a stuck long-term central venous line will face most individuals who place these lines. We have demonstrated that simply ligating the catheter and leaving the fragment in place appears to be a safe option with minimal risk to the patient.

Fibrin sheath was first described in 1971 The fibrin sheath found around these indwelling catheters was first described in 1971 In short-term lines, initially an area of endothelial injury with occasional associated thrombus can be seen

Fibrin sheath In long term catheters, vein wall thickening along the length of the catheter and bridging from the vein wall to catheter is later observed This tissue contains both cellular and acellular components including fibrin, collagen, and later endothelial cells Interestingly, an endothelial layer develops after 45 days that is indistinguishable from the vein wall and most of the catheter length becomes fixed to the vein wall by bridging between the vein wall proper and the neoendothelium of the fibrin sheath The cause of scarring causing catheter fixation in these unusual cases is not clear

Fibrin sheath

Analysis of Complication Was the complication potentially avoidable? Yes Would avoiding the complication change the outcome for the patient? Yes, Blood, ICU, pain, ROM What factors contributed to the complication? Calcification CVC Aggressive

Was the complication potentially avoidable? A. 31-7-130 et seq. and 31-7-140 et seq.