Central venous catheters (CVCs) have a wide variety of applications, from administering total parental nutrition or vasoactive drugs to monitoring intracardiac pressures.1 One type of CVC, the coronary sinus (CS) catheter (Fig. 1), has 3 major components: an infusion lumen for delivering retrograde cardioplegia, an occlusion balloon for occluding the CS, and an additional port through which coronary perfusion pressure can be continuously monitored.2,3 The infusion of a cardioplegic solution via the antegrade route alone or in combination with retrograde delivery, as well as the use of a hypothermic protocol, enhances myocardial preservation.4 At Tufts Medical Center, the use of a CS catheter (EndoPlege Sinus Catheter by Edwards Lifesciences, Irvine, CA) was jointly selected by our cardiac surgery team and cardiac anesthesia services for minimally invasive aortic valve replacement. It is the responsibility of the anesthesiologist, using ultrasonographic guidance, transesophageal echocardiography (TEE), and fluoroscopy, to place the introducer sheath and CS catheter, maintain placement and function throughout the procedure, and ensure safe catheter removal at the conclusion.
The CS catheter is no longer in use in many minimally invasive cardiac surgery programs because of challenges associated with its placement and positioning, including individual anatomical differences, the risk of complications such as perforation, and an unacceptably high rate of displacement during surgery. We experienced a complication involving the CS catheter that did not occur during placement but instead during removal at the conclusion of surgery.
The institutional policy of Tufts Medical Center and Tufts University Health Sciences is that a case report is not research that must be approved by the IRB. The patient and family were not contacted, and the IRB determined that approval was not required.
An 83-year-old woman was scheduled for minimally invasive aortic valve replacement. Her medical history was significant for worsening shortness of breath, severe aortic stenosis, hypertension, type 2 diabetes, hyperlipidemia, pulmonary hypertension, and stage 2 chronic kidney disease. Physical examination revealed a systolic ejection murmur. Transthoracic echocardiography revealed an ejection fraction of 65%, aortic valve area of 1 cm2, a maximum gradient of 40 mm Hg, a mean gradient of 22 mm Hg, mild mitral regurgitation, and trace tricuspid regurgitation. Cardiac catheterization revealed no significant coronary artery disease.
A right radial arterial catheter and a left antecubital fossa 18 g angiocatheter were placed preoperatively. General anesthesia was induced and maintained with IV morphine, propofol, fentanyl, vecuronium, and 100% oxygen. The trachea was intubated with a #7 endotracheal tube, and isoflurane was delivered at a concentration of 0.7% to 1.0% after proper tube placement was confirmed. Ultrasonography was used to identify the right internal jugular vein. The right neck was then prepped and draped in a sterile fashion, and an 11F introducer sheath was placed in addition to a 9F pulmonary artery vent catheter, under direct ultrasonographic guidance. Both TEE and fluoroscopy were used to accurately place the CS catheter at the proximal CS, and surgery proceeded uneventfully.
At the conclusion of surgery, the CS catheter and 11F sheath were to be removed before the patient was transported from the operating room to the intensive care unit (ICU). Balloon deflation was confirmed, through ease of deflation as well as complete return of instilled contrast, and the CS catheter was carefully withdrawn. Minor resistance during catheter removal was met at the start. Removal continued, albeit slowly, then became almost effortless, providing no indication of any catheter malfunction. As the CS catheter exited the introducer, it was immediately noted that the tip had fractured (Fig. 2). The surgeon was immediately notified and the decision made to remove the 11F introducer and obtain a chest radiogram. Before catheter removal, TEE did not show any foreign body in the right atrium or ventricle, and the 11F introducer appeared intact. After the introducer was removed, inspection revealed the fractured CS catheter tip lodged in the distal end of the sheath (Fig. 3). A chest radiogram was then obtained that confirmed the absence of any additional catheter fragments. The patient remained hemodynamically stable throughout the removal of the CS catheter, introducer, and CS catheter tip and was then transported to the ICU in critical but stable condition.
Using TEE and fluoroscopy to guide proper catheter placement and maintenance, in combination with monitoring CS oxyhemoglobin saturation, CS flow, and distal tip pressure, has improved both patient safety and the clinical value of the data obtained through catheter use.4,5 Even with ultrasonographic, TEE, and fluoroscopic guidance, complications still may occur occasionally during catheter insertion. The most well documented of these include direct injury to the CS, placement in a false lumen, unintentional arterial puncture, and perforation of the upper lung, right atrium, or ventricle.4
To date, no reports describe the rate or type of complications due to the removal of CS catheters specifically as a subtype of CVCs. Some of the more frequently reported complications of CVC removal include air embolism, catheter fracture, hub separation, and catheter knotting.6 It is estimated that in 0.5% to 3% of patients with indwelling CVCs, a fracture of the catheter and embolization of the fragment have occurred, most commonly from using a disproportionate amount of traction during removal of the catheter.6 A possible cause of device failure in this case could include an inability to deflate the balloon fully and therefore it may have caught on the introducer and contributed to catheter shearing. The introducer has a slight groove embedded in it toward the proximal end (Fig. 4) and may have made this scenario more likely.
We have presented a rare CS catheter extraction complication that, to our knowledge, has not been previously reported. Several different approaches to managing fractured CVC catheters have been used, including cutaneous cut-down with a distal venotomy; the use of radiological loops, snares, or coils; and, in some cases, surgical exploration to retrieve the catheter fragment(s).7
When possible, percutaneous endovascular techniques are preferred because of their high rate of success and minimal rate of complications.8 We recommend that if fracture of a catheter is suspected, manipulation of the catheter should immediately cease and notification should be made to the surgical team to discuss a plan for intervention. Further radiologic studies should be conducted to determine a course of action appropriate to the circumstances. In our case, after TEE confirmed the absence of catheter fragments in the heart, the decision was made to remove the introducer sheath with the expectation that the fractured tip would be lodged within it. A representative from Edwards Lifesciences was contacted and notified about the details of the device failure. Based upon Food and Drug Administration regulations for a device malfunction that resulted in no patient harm or death, voluntary reporting was completed through the Web-based reporting tool available on the Food and Drug Administration website.
I would like to acknowledge my colleague Dr. David R. Moss, who contributed to editorial work with revision requests.
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© 2014 International Anesthesia Research Society
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