Bi-Atrial Location of an Embolized Catheter Across a Patent Foramen Ovale: A Rare Paradoxical Embolism With Successful Percutaneous Retrieval

Abstract

Implantable port-catheter systems are being used increasingly for long-term intravenous therapy. Intracardiac catheter embolization is a serious complication and most reported cases have been right-sided embolizations. Left-sided embolization across a patent foramen ovale has been rarely described. We describe a case in which an embolized catheter was found to be present in the right as well as the left atrium across a patent foramen ovale. The catheter fragment was successfully retrieved by percutaneous intervention. It is important for contemporary cardiologists and interventionalists to be aware of this rare possibility in cases of intracardiac catheter fragment embolization. Key words: patent foramen ovale, embolus, catheter ————————————————————

Introduction

The implantable port-catheter system is commonly used for long-term intravenous administration of fluid, nutrition or chemotherapy. Intracardiac catheter embolization is a dangerous complication, and can result in arrhythmias, infection, and thromboembolic events, as well as myocardial perforation. Though right-sided embolization of port catheters have been reported previously, paradoxical embolism across a patent foramen ovale (PFO) into the left atrium is extremely rare.¹ We report a case of paradoxical embolism in which a 20 cm catheter fragment which was located in the left as well as right atrium across a PFO.

Case Report

A 58 year-old-man with a history of metastatic bladder cancer status post chemotherapy was referred to our center for embolization of a fractured catheter segment from a port-catheter system, found incidentally on a chest x-ray done for an unrelated reason. A chest x-ray revealed a 20-cm long, intra-cardiac catheter fragment. Based on the radiographic appearance, the proximal tip appeared to be in the right atrium and the distal tip in the inferior vena cava (Figure 1). The patient was taken to the cardiac catheterization laboratory for retrieval of the catheter. A 7 French (Fr) sheath was inserted percutaneously into the right femoral vein. A 7 Fr MPA 1 guide catheter was advanced over the J wire into the right atrium and an En-Snare 12-20 mm vascular snare (Angiotech Medical Device Technologies, Gainesville, Fla.) was then advanced through the guide catheter. The proximal tip of the embolized catheter appeared to be embedded in the tricuspid annulus and multiple attempts at retrieving the foreign body failed. The Angiotech snare was withdrawn and a guide catheter was then advanced to the distal tip of the foreign body. Contrast injection revealed that the guide catheter and the embolized catheter tip were in the left atrium at the junction of the left upper pulmonary vein and the left atrium. The tip of the catheter was against the wall of the pulmonary vein (Figure 2). The guide and snares were then withdrawn and replaced by a 6 Fr JR4 guiding catheter, which was manipulated in the right atrium against the embolized catheter. The catheter was freed and dislodged into the inferior vena cava and then into right iliac vein (Figure 3). Using the vascular snare, the catheter tip was retrieved and removed (Figure 4).

Discussion

Hitherto, there has been only one reported case of paradoxical embolism of a severed portacath fragment across a PFO into the left atrium.¹ This is a unique case in which the catheter fragment was present in the both the right as well as the left atrium across a PFO. We initially assumed that, as in most cases, the catheter was in the right atrium prior to catheterization. The inability to retrieve the proximal tip led to our decision to pursue extraction of the distal tip. The PFO as well as the left atrial location of the distal tip were rather serendipitous discoveries in this case. Transesophageal echocardiography prior to the procedure would have accurately localized the catheter as well as evaluated the interatrial septum for the presence of a PFO. This should be a consideration prior to such high-risk procedures before assuming a right-sided embolization. The first case of catheter embolization was reported in 1954² and its estimated incidence ranges from 0.2% to 4.2% in different series.^3-6 Various underlying mechanisms have been described, including the “pinch-off” syndrome (i.e. chronic compression of the catheter between the clavicle and the first rib), disconnection of the catheter from the port chamber, rupture of the proximal catheter, and rarely, trauma.⁷ Disconnection of the catheter from the port chamber is the likely mechanism in this case. Catheter embolization is mostly asymptomatic, and is discovered either as an incidental finding or due to a malfunctioning port-catheter system. However, serious complications have been described, such as pulmonary thromboembolism, right ventricular rupture, ventricular arrhythmias and sudden cardiac death.^8-10 Left-sided embolization can result in more serious complications than right-sided embolizations. Considering the relatively high prevalence of PFO11 and increasing use of portacaths, similar cases will likely be encountered in the future. Since our case did not have venous thrombosis or neurological symptoms, we did not consider PFO closure. However, in the light of catastrophic possibilities with left-sided embolizations, management of PFO with indwelling catheters needs to be further evaluated. In conclusion, this is a unique case of an embolized catheter across a PFO that was positioned in the right as well as the left atrium, and successfully retrieved by percutaneous intervention. Recognition of this possibility by contemporary interventionalists and further studies evaluating the appropriate management of PFO with indwelling catheters is required.

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———————————————————— Dr. Santhosh Reddy Mannem can be contacted at sm3386@columbia.edu Disclosure: The authors report no conflicts of interest regarding the content herein. This article received double-blind peer review from members of the Cath Lab Digest editorial board.