A refinement of Hong’s technique for the removal of stuck dialysis catheters: an easy solution to a complex problem

INTRODUCTION

Although a tunneled central venous catheter (CVC) is normally placed as a temporary measure to allow the maturation of an arteriovenous fistula (AVF) or graft (AVG), it can end up being used for many years in cases of failure of peripheral vascular access or where veins have been exhausted and the CVC remains the only option for vascular access (1). Long-term use is associated with several complications which necessitate removal or substitution of the catheter: damage to the vessel wall around the catheter resulting in thrombosis or fibrosis, vessel perforation or breaking of the catheter and infections (2-3-4-5). The complications encountered when positioning CVCs are well documented in the literature, but there are far fewer reports on the complications of catheter removal. CVC extraction is normally uneventful once the cuff has been removed from the tunneled subcutaneous portion. Sometimes a fibrocellular sleeve that glues the intravenous part of the catheter to the venous wall in one or more points prevents it from being simply pulled out (6). This creates a risk of possible detachment of fragments of the catheter as it is being pulled out (4, 7). When the whole catheter cannot be removed, it is cut near the vein entry point and left in situ. Only the tunneled segment is removed while the stump of the intravascular catheter is buried subcutaneously. An incarcerated catheter left in situ, however, can be a focus for thrombosis and consequent occlusion as well as infection (3, 4, 7). The true incidence of these problems in adults with hemodialysis catheters is unknown: a rate of 16% of stuck catheters has been reported in children undergoing chemotherapy (8).

Hong pioneered the breakthrough technique to free a bilumen stuck catheter by endoluminal dilation technique simply using a balloon PTA (Percutaneous Transluminal Angioplasty) catheter over a glide wire during general anesthesia (9). The technique has independently been applied by others (10, 11). We report the largest series of stuck twin catheters removed by means of endoluminal dilation in four consecutive patients. We review the technical details reported by Hong and others (9-10-11-11) in using this maneuver and compare them with the refinements we made.

TECHNIQUE

All the procedures reported were carried out in an angiographic room under local anesthesia and conscious sedation.

The twin catheter branches were isolated at their site of entry into the jugular vein and cut between two clamps. Following extraction of the cuff, the tunneled part of the CVC was removed. A 10 cm long 5F valved introducer (Terumo, Tokyo, Japan) was positioned with its dilator assembled into the stump of the catheter in the jugular vein and the clamp removed. A guide wire was advanced under fluoroscopy through the dilator of the introducer into the lumen of the stuck catheter. The dilator was then removed from the introducer, the lock solution aspirated from the side port and heparinized saline solution injected. A 5F Glidecath hydrophilic catheter (Terumo) was used to coaxially maneuver the hydrophilic guide wire to the inferior vena cava (IVC) where it was replaced with an Amplatz stiff guide wire (Boston Scientific, USA). A 5-6 mm×40 mm balloon catheter (Fox Cath, Abbot, USA) was advanced over the stiff wire and inflated with diluted contrast medium several times through the same introducer along the entire length of the dialysis catheter to its maximum diameter at a pressure of 20 atm (except patient 3, see case report) using a syringe manometer (Indeflator, Abbott, USA) (Fig. 1). Incarcerated sections of the hemodialysis catheter, where resistance to inflation was encountered, showed up as constrictions in the balloon catheter during inflation. The pliant CVC catheter was inflated to dilate the vessel wall, then the balloon catheter was deflated and reinflated to a lower pressure until it adhered to the inner wall of the CVC, facilitating the maneuver of pulling out the CVC by providing better internal grip.

Fig. 1 -

CLINICAL CASES

From March 2012 to March 2013 we applied a modification of Hong’s technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Patients 2 and 4 had been referred from outer center specifically for the removal of their stuck catheters. All the catheters were smoothly and easily withdrawn from central veins. None of the patients reported severe chest pain. No complications arose from the procedure.

Case 1

A 65-year-old man affected by autosomal dominant polycystic kidney disease began peritoneal dialysis in 2007. Then he started hemodialysis in 2010 via a tunneled twin catheter (GEMINI, Bellco, Italy) positioned in his right jugular vein. Following a successful kidney transplant, an attempt was made in September 2012 to remove the catheter (dwell time 2 years). One line was removed easily, while the other remained stuck. The patient was admitted to the angiographic room to complete removal of the device in October 2012. The stuck catheter was uneventfully removed using the technique described above.

Case 2

A 68-year-old woman with chronic renal insufficiency was hemodialyzed via a TESIO catheter positioned in her right internal jugular vein for about 12 years. Removal was necessary because of repeated CVC-related Acinetobacter infections. One catheter line had been removed with difficulty but the other had remained stuck and was left buried. The buried line was removed by means of endoluminal ballooning without complications. A computed tomography scan carried out 2 months later showed a residual calcified sheath in the vein lumen.

Case 3

A 54-year-old man, positive for lupus anticoagulant, had several failed AVFs and AVGs. He was in hemodialysis since April 2008 via a tunneled twin catheter (GEMINI, Bellco, Italy) with one line in the left internal jugular vein and the other in the right internal jugular vein. Following the successful formation of a right AVF, removal of the CVC was carried out in 2012 (dwell time 4 years). The right line was pulled out without resistance but the left line was stuck. To locate the site of incarceration rapidly and reduce the number of inflations along the stuck catheter, a 15 cm long PTA balloon was chosen. Since the length of the balloon catheter was likely to increase the friction inside the dialysis catheter during insertion, a low-profile material was considered more suitable. In this case a 0.018” guide wire (V18; Boston Scientific, USA) was placed into the IVC through the 5F valved introducer and a small number of dilations carried out with 3-6 mm×10 cm low-profile balloon catheters (Bantam; Bard, USA). An inflation pressure of 6-8 atm was sufficient to eliminate the waist of the balloon in correspondence with the left brachiocephalic vein (Fig. 2). The stuck catheter was then removed without effort.

Fig. 2 -

Case 4

A 51-year-old woman with renal insufficiency secondary to unspecified glomerulonephritis had a TESIO catheter (Medcomp, USA) placed in the right internal jugular vein following closure of an AVF and unfeasibility of other vascular access. This catheter was removed and a new TESIO catheter placed in the left internal jugular vein in September 2003 due to recurrent infections. An attempt was made to remove the left catheter in February 2013 (dwell time 9 years and 6 months) because of a micotic infection, but as it was stuck it was left in place and buried. A new TESIO catheter was inserted in the right internal jugular vein. In the 3 days that followed the patient reported headaches for a temporary venous congestion. The patient was placed in anticoagulant therapy. Both lines of the left catheter were successfully removed following endoluminal dilation as described for the other cases.

DISCUSSION

The problem of incarcerated long-term indwelling catheters is on the increase as more patients with chronic renal insufficiency are given hemodialysis via central vein access. The main reasons for the use of long-term catheters are urgent start hemodialysis, the failure or the non-development of an AVF, the exhaustion of sites for vascular access and the increase in the number of elderly patients (1).

Although a life-saving tool, long-term indwelling catheters are dogged by a number of complications, both during insertion and as a consequence of their permanence. The latter include the mechanical problems of thrombosis and venous stenosis, and infections (2-3-4-5).

The pathogenesis of fibrin sheath formation is inherent to the permanence in situ of tunneled catheters. This process begins with damage to the endothelial lining of the vessel as a result of contact with the catheter, followed by thrombosis and the proliferation of smooth muscle cells and fibroblasts with adhesion of the catheter to the vessel wall, catheter malfunction and venous stenosis (6). Catheter adhesion due to fissuring of the material or penetration of the catheter has also been reported (4).

Among the factors favoring the development of adhesions, the most significant is the length of time the catheter remains in situ. Hassan and Liu first signaled the danger of incarceration of long-term catheters (12, 13). Ryan reported a rate of incarceration of up to 22% (5 of 23) for catheters that had been in position for over 2 years (10). To a lesser extent, female gender and left side may also influence the rate of CVC incarceration, presumably due to smaller vessels and larger areas of friction between vessel walls and catheter, respectively (14-15-16). Periodic substitution of the catheter every 15-18 months has been proposed as a way of preventing catheters becoming stuck, but the dangers involved in the maneuver to replace a functioning catheter outweigh the risk of late complications from the original catheter. Applying excessive traction to pull out a stuck catheter can have very serious consequences, for example, potentially fatal vascular lesions, catheter fragment detachment and embolization in the right atrium or in the pulmonary artery (7, 17, 18).

Attempts to detach the adhesions between vessel wall and catheter by means of multiple jugular and femoral accesses with an improvised snare have been reported, but the procedure is complicated and has never been described for more than one patient at a time (15, 19). In addition, results have not always been satisfactory, with only part of the catheter being freed of adhesions (19).

Coaxial systems with advancement external to the stuck catheter have also been proposed, but they are complex and risky, especially where the catheter has a tortuous path (20). The use of laser, also involving a coaxial system external to the catheter, implies a limit to the diameter of the catheter that can be treated (21). Other restrictions to wider feasibility are the high cost and general anesthesia being required, necessitating admission to specialized centers. Finally, stuck catheters can be removed by major surgery through a thoracotomy or a sternotomy, but this is unlikely to be feasible in patients with serious comorbidities (22). In the real world, the stuck catheter is often buried with the consequent risk of infection and/or thrombosis. Placing a second catheter contralaterally, as in our patient 4, creates a risk of superior vena cava thrombosis.

In our series regarding only twin CVCs we used Hong’s technique, which consists of endoluminal balloon dilation of the catheter to break the adhesions between the device and the vein wall.

Any device left within the vascular system is subject to englobement by endothelial reaction, but the specific characteristics of hemodialysis catheters favor this method: the accessible route to the outside of the body and large-bore diameters of hemodialysis catheters enable the insertion of balloon catheters on guide wires. The elasticity of the polyurethane, carbothane or silicone the catheters are made of permits local distension along the tube without cracking. Two major advantages of the endoluminal ballooning procedure are that hemodialysis catheters can be replaced using routine materials and avoiding further expensive devices and that the same site of access is used for placement and removal.

So far this is the only technique for removing stuck catheters to have a 100% success rate on an intention-to-treat basis, counting Hong’s first patient, Ryan’s five cases, Farooq’s one and the four we report (9-10-11). Like Ryan and Farooq we did not utilize general anesthesia. We isolated the catheter at the same point near the venous entry site as Farooq did, in order to have a straight line of traction with the lowest possible level of friction.

Our original contribution to the procedure is that once the catheter had been cut, we placed a valved sheath directly into the catheter stump to prevent air embolism or endoluminal thrombosis, facilitating guide wire and PTA catheter manipulations (Farooq used a 10F sheath for diagnostic purposes only after CVC removal).

Another adjustment we made was to place a non-glide stiff safety wire in the IVC rather than from a femoral approach as Farooq did to allow inflations of the balloon catheters without inadvertently pushing the guide wire into the right atrium and to avoid the risk of drying of the hydrophilic guide wire which can prevent any further maneuvers. The use of a 0.018” guide wire (as in case 3) and routine PTA catheters (not ultra-compliant as Hong and Ryan reported) enables the use of lower profile PTA catheters with superior diameter and length if necessary. Finally, leaving the balloon catheter slightly inflated once the CVC is detached gives extra grip on the CVC for pulling out and helps avoid cracking of the catheter at points of maximum friction.

The main technical details reported by the authors using Hong’s technique are reported in Table I.

TABLE I -

Coaxial system on the bench. Focal overexpansion (arrow) of the stuck catheter due to inflation of PTA catheter (black arrowhead) at 20 atm inside the 5F valved sheath (white arrowhead) inserted into the stuck dialysis catheter.

Endoluminal dilation showing the point of adhesion (arrow) between the catheter and the venous wall at correspondence of the left brachiocephalic vein. Guide wire on the right side after regular removal of the right Tesio line (arrowhead).

BALLOON ENDODILATION FOR STUCK CATHETER REMOVAL: TECHNICAL FEATURES IN REPORTED SERIES

	Number of patients	Catheter Type	General Anesthesia	Isolation Vein entry site	Valved Introducer	Stiff wire in IVC	High-pressure PTA Catheter
IVC, inferior vena cava.
† Only after catheter removal for diagnostic purpose.
*Glide wire was placed in the IVC.
Hong (2011)	1	Bilumen	+	−	−	−	+
Ryan (2012)	5	Bilumen	−−−−−	−−−−−	−−−−−	−−−−−*	+++++
Farooq (2012)	1	Twin	−	+	−†	+	−
Our series	4	Twin	−−−−	++++	++++	++++	−−−−

Hong’s technique was confirmed to be a simple, safe and highly effective method in the removal of incarcerated long-term twin CVCs also in the presence of a calcified sleeve (Patient 2, Fig. 3) previously not considered compatible with endovascular removal (19). Like Columbus’ egg, it is a simple but powerful solution which relies on ordinary readily available tools and promises to be a real innovation in the hazardous removal of stuck long-term hemodialysis catheters. If the reliability of this technique is confirmed in a larger number of cases, the removal of stuck hemodialysis catheters should be routinely referred to the interventional radiologist.

Fig. 3 -

Coronal computed tomography without contrast enhancement: residual calcified sleeve (arrow) 2 months after the removal.

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