Fracture and embolization of an implantable venous access de
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A 61-year-old male patient was diagnosed with inoperable stomach cancer. A TIVAD of the type Braun Celsite ST301® was inserted in the right subclavian vein for administration of chemotherapy. Location was confirmed by chest X-ray and the TIVAD was reported functioning with good backflow. During the initiation of the chemotherapy treatment, the TIVAD was reported malfunctioning. Contrast X-ray showed fibrin sheaths at the distal end of the catheter. An endovascular procedure was performed by an interventional radiologist and fibrin sheaths were mechanically removed with a snare.

Intraoperative X-ray with contrast showed normal contrast accumulation distal to the catheter tip and the patient received the first dose of chemotherapy. One month later the patient was hospitalized with bilateral pulmonary thromboembolism. The patient was treated with low-molecular-weight-heparin and discharged. The chemotherapy treatment continued as scheduled, with one pause due to a fracture of the right humerus after a fall. Occasionally, the TIVAD was malfunctioning and medication was administered using a peripheral venous catheter. During a planned pause in treatment, the patient sought hospital care due to the worsening of his general condition. CT showed the progress of malignancy and another round of chemotherapy was initiated and administrated using the TIVAD without any problems. Less than a week after, the patient reported feeling a tender swelling underneath his left foot.

Ultrasound showed no DVT. The swelling and tenderness disappeared spontaneously, but the patient reported brief incidents of pain under his left foot. A CT scan was performed the next time the TIVAD did not function, showing that the distal 8 cm of the catheter was missing. The patient had no symptoms and reported no discomfort of any kind. The TIVAD was removed, confirming a fracture. A chest CT showed no foreign bodies. A full-body CT scan without contrast was performed, revealing the missing catheter part located at the level of the left knee. Vascular surgeons performed an endovascular procedure through the femoral vein assuming the catheter had embolized to the popliteal vein. Contrast examination revealed no catheter in the vein and another approach through the femoral artery was made, where contrast imaging shows that the catheter was, in fact, located in the popliteal artery.

The catheter, measuring 7.5 cm, was successfully removed with the use of a snare without any complications. The patient was discharged from the hospital and referred for a diagnostic echocardiogram. A bubble echocardiogram was performed to detect an atrial septal defect but was unsuccessful in doing so. For a final diagnosis, the patient was recommended a transesophageal echocardiogram, but as the diagnosis would not alter the course of treatment, the patient declined further examinations. Except for the reported episodes of pain and swelling of the left foot, the patient suffered no injury and finished his chemotherapy treatment.

Source:https://academic.oup.com/jscr/article/2020/12/rjaa548/6056322
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