1. 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.

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

3. 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

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

6. 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

7. 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 !

8. 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

9. 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

10. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. Fibrin sheath

18. 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

19. Was the complication potentially avoidable?
A et seq. and et seq.