IMAGE OF THE WEEK 2013

WEEK 5

 

MANAGEMENT OF DISLODGED PORT-A-CATHETER

 

 

 

Figure 1: Dislodged port-a-catheter as indicated by the catheter (white arrows) which is found in the right ventricle and left pulmonary artery. It is no longer connected to the port which is found in the right anterior chest wall.

(Click on image to enlarge)

 

 

 

Dislodgement of port-a-catheter is an uncommon event, with a reported incidence of about 4.1% to 5.1%. (1,2)  In a reported series, 42% of the dislodged catheter ended up in the right ventricle, 33% in the right atrium and 25% in the pulmonary artery. Figure 1 showed a dislodged port-a-catheter, completely disconnected from the main port in the right anterior chest wall with the proximal end of the catheter resting in the right ventricle and the distal end looping in the left pulmonary artery. 

In 80% of the cases, the patients presented with port-a-catheter dysfunction and dislodgement confirmed on chest x-rays. In the remaining 20%, the dislodgement were diagnosed at surgical removal.

 

Possible mechanism by which dislodgement occurs may be due to degradation of the catheter material over time, which results in most cases to fracture of the catheter rather than dislodgement. Over zealous flushing of port-a-catheter, particularly if the catheter is occluded may result in stretching and ballooning of the catheter over the snout of the connector of the port and thus dislodgement. In the case depicted in Figure 1, the patient reported several months back, feeling a sharp pain with swelling around the port when the nurse forcefully flushed her port-a-catheter during a follow-up visit. The dislodgement occurred a while back as instillation of contrast into the port, showed extravasation of contrast into the surround subcutaneous tissue and not into the vein (Figure 2). The tract between the right internal jugular vein and the port would have sealed off by then.

 

 

Figure 2:  Instillation of contrast into the port resulted in extravasation of the contrast into the surrounding subcutaneous tissue (white arrow head). The tract between the right internal jugular vein and the port has completely sealed over.

(Click on image to enlarge)

 

To date, there are very little or no reports of complications arising from a dislodged catheter, mainly because most of the dislodged or fracture catheters are removed immediately once they are diagnosed. However, complications that can arise are related to infection of the catheter, thrombosis and embolisation or it can migrate further down the pulmonary artery causing pulmonary embolism of the distal segment of the lung supplied by the occluded pulmonary artery.

 

Management of dislodged port-a-cath is usually non-surgical via transcatheter techniques using a gooseneck snare guidewire under fluoroscopic guidance in 98%-100% of cases. The catheter is easily removed without significant complications. Open surgical removal is reserved for failed percutaneous transcatheter removal and depending on the site at which the catheter comes to rest, cardiopulmonary bypass may be required. The port is removed surgically under local anaesthetic.

 

 

REFERENCES

 1.       Coccaro M, Bochicchio AM, Capobianco AM, Di Leo P, Mancino G, Cammarota A. Long-term infusional systems: complications in cancer patients. Tumori. 2001 Oct;87(5):30811.

2.       Ho C-L, Chou C-M, Chang T-K, Jan S-L, Lin M-C, Fu Y-C. Dislodgment of port-a-cath catheters in children. Pediatr Neonatol. 2008 Oct;49(5):17982.

 

Images and text contributed and prepared by

Mr William Chong, Thoracic Unit, Department of Surgery, RIPAS Hospital.

All images are copyrighted and property of RIPAS Hospital.

 

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