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Online Articles: Letters to the Editor

Pleural Catheter Fracture During IPC Removal

An Under-reported Complication

Matus, Ismael MD, FCCP*; Colt, Henri MD, FCCP, FAWM

Author Information
Journal of Bronchology & Interventional Pulmonology: January 2021 - Volume 28 - Issue 1 - p e1-e3
doi: 10.1097/LBR.0000000000000684
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To the Editor:

Indwelling pleural catheters (IPCs) provide effective drainage, pleurodesis, long-term palliation, decreased in-hospital time, and improved quality of life in patients with symptomatic recurrent malignant pleural effusions.1,2

Complications include catheter-related infections (4.8%), insertion tract metastases (<5%), symptomatic pleural fluid loculations (5% to 14%) and chest pain prompting catheter removal (0.6%).3–8 In one report using Rocket Medical IPCs, removal was complicated by fracture or intentional severing (9.8%), leaving a portion of the catheter in the pleural space. PleurX catheters may also fracture (personal communications) and, although rarely described in the literature (Van Meter and colleagues’ systematic review includes only 1 case of almost 2000 IPCs), reports are found in the Food and Drug Administration’s Maude publication.9,10

Our early experience with the new Rocket IPC pleural catheter (Rocket Medical plc) suggests that complications during catheter removal are more frequent than currently reported. In a series of 17 consecutive patients, we note 4 complicated removal cases (23.5%) where adhesions extended beyond the catheter’s cuff or a well-circumscribed membrane along the path of the tunneled portion of the IPC required surgical dissection (Fig. 1). In 1 case, adhesions extended beyond the tunneled portion and into the pleural insertion site (n=3 cases), removal was further complicated by fracturing the subdermal portion of the catheter when it was tugged on postdissection as per customary removal instructions.

F1
FIGURE 1:
Circumscribed membranous adhesion along tunneled portion of indwelling pleural catheter (IPC) (A); adhesion extends into IPC insertion site requiring cut-down at insertion site (B); fractured IPC (C).

IPCs (particularly the polyester cuffs) are made to incite a foreign body reaction that promotes adhesions to the cuff, thereby creating an anchor that prevents migration or infection of the pleural space. Although both IPCs appear structurally similar (Fig. 2), it is unclear whether design differences between the Rocket IPC and PleurX IPC catheters contribute to our increased complication rate with Rocket IPC (Table 1), or if variations in design might serve as synergistic determinants leading to catheter fracture during removal.

F2
FIGURE 2:
Indwelling pleural catheters comparisons: (A) Rocket (left)/PleurX (right) (B). PleurX (top)/Rocket (bottom).
TABLE 1 - Comparison of Product Specifications
Characteristic Rocket IPC PleurX
Overall length 67.5 cm 66.0 cm
Outer diameter connector side (averages of 5) 4.99 mm 5.06 mm
Inner diameter connector side (averages of 5) 2.7 mm 2.68 mm
No. fenestrations 30 30
Distance between fenestrations 1.7 cm 1.8 cm
Fenestration section length 24.15 cm 25.5 cm
Fenestration diameter 2.0 mm 1.9 mm
Fenestration pattern Pairs alternate at 90 degrees
Barium stripe 1.7 mm 1.8 mm
Distance between cuff and first fenestration 15.0 cm 12.5 cm
Distance between cuff and valve 29 cm 28.5 cm
Cuff length 12 mm 10 mm
Cuff material Polyester Polyester
Catheter material Silicone Silicone
Data provided by Rocket Medical (R&D Department), published with permission.
IPC indicates indwelling pleural catheters.

Data graciously provided by Rocket Medical shows that despite similar dimensional properties, less Newton force is needed to fracture the Rocket IPC as compared with the PleurX catheter. Rocket IPC’s decreased tensile strength might increase fracture risk when the catheter is displaced by 14 cm as opposed to 24 cm for PleurX (Table 2). Furthermore, IPCs’ polyester cuff material was intentionally designed to induce tissue ingrowth to secure the catheter. This may be why fractures occur in front of the cuff proximal to the exit site during tensile strength testing. Why adhesions and well-circumscribed membranes extend beyond the cuffs remains unclear.

TABLE 2 - Rocket Indwelling Pleural Catheters Tensile Catheter Testing (N=10)
Average Newton Force Applied Before Fracture Average Displacement MM Notes
Rocket 85.408 141.2
Pleurx 98.82 244.33 2 Catheters did not snap
Data provided by Rocket Medical (R&D Department), published with permission.

Until recently, our 21 year collective experience with pleural catheters was, for the most part limited to PleurX IPC. Techniques related to insertion, such as maintaining cuff location ~1 cm from the skin incision/exit site and keeping the length of the subcutaneous tract at 5 cm, and removal, such as applying blunt forceps and tweezers parallel to the subdermal portion of the IPC and completely freeing the cuff before applying force during extraction, were implemented during the initial transition to Rocket IPC and remained unaltered. Perhaps maintaining similar removal techniques for both catheters contributed to our fracture rate. Known differences in design and tensile strength of these IPCs suggests that catheter-specific removal techniques may be warranted.

CONCLUSIONS

Our early experience suggests that complications related to Rocket Medical IPC-removal are more frequent than previously described. To further study this question, we propose that future reports of catheter-related complications during removal be divided into cases with and without catheter fracture, and into cases with either significant tract-related adhesions, and/or insertion site/pleural space adhesions. Reports should also specify whether portions of the catheter are left in situ, or whether further dissection or even thoracoscopy is needed for removal of catheter fragments.

Ismael Matus, MD, FCCP*

Henri Colt, MD, FCCP, FAWM†
*Thoracic Surgery and Interventional Pulmonology Service, Helen F. Graham Cancer Center and Research Institute, Christiana Care, Newark, DE
†University of California, Irvine, CA

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