DEMOGRAPHICS: 28-year-old Caucasian female.
HISTORY: The patient has bilateral lung transplants that have been complicated by antibody-mediated rejection requiring chronic photopheresis. She had a left-sided subclavian (SV) double lumen 10Fr Vortex port (CVC) placed in 2014 for access, which had been functioning well until about 9 years later when the port would no longer draw back. Unsuccessful attempts were made to remove the catheter in standard fashion. In the interim, a similar dual-lumen femoral venous port was placed for continued photopheresis. Unfortunately, a short period thereafter, she developed persistent bacteremia despite courses of antibiotics necessitating removal of all intravascular foreign bodies. PLAN: After a multidisciplinary discussion with Cardiac Electrophysiology and Cardiac Surgery teams, the decision was made to proceed with removing the embedded CVC with the assistance of a pacemaker lead-locking-device (LLD) and a laser sheath. This technique has rarely been described previously, and we wanted to share a safe approach to successfully removing the catheter. First, access was obtained in bilateral common-femoral-veins and a Bridge(R) Rescue balloon was advanced to the superior-vena-cava (SVC), where it was tested and parked in the inferior vena cava. Cardiac surgery team was available for a sternotomy in case of inability to control a major venous injury endovascularly. On the contralateral side, a snare was advanced to the distal tip of the catheter forming a rail for the extraction tools. The catheter was then dissected down to the level of the vessel and three LLDs were advanced through the catheter and locked in place. A 16Fr Spectranetics Laser Sheath was then advanced under fluoroscopic guidance and laser energy was used to dissect the catheter away from the incorporated wall of the occluded SV as the sheath and device were advanced. Tension was then applied, and the catheter was removed in whole. Hemostasis was achieved through pressure and purse-string prolene suture.
DISCUSSION: While incorporated chronic catheters pose little risk if left indwelling, they require removal in setting of recurrent or persistent bacteremia. We demonstrate the technique and safety of using an LLD platform for removal of such a CVC in adults with a multidisciplinary approach in rare cases of incorporation resistant to standard approaches of removal.
