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A 72-year-old female with recently diagnosed cholangiocarcinoma presented with sudden onset of retrosternal chest pain. Cholangiocarcinoma was diagnosed during workup for obstructive jaundice 4 months prior. Staging computerized tomography demonstrated no evidence of metastasis. However, laparoscopy showed local invasion making the malignancy unresectable. Chemotherapy was initiated via a left subclavian central venous port catheter (CVPC) also known as port-a-cath. She now comes in with chest pain. The chest pain is retrosternal, dull, and continuous. Vital signs were stable on admission. Cardiac enzymes were negative. No electrocardiogram changes noted concerning for acute coronary syndrome. On admission, a portable chest X-ray was performed [Figure 1].
Diagnosis: Fractured port-a-cath with embolized distal portion.
Figure 2 shows a fractured tunneled left-sided subclavian CVPC with its tip located near the insertion site of the left subclavian vein [Figure 2, blue arrow]. A portion of the fractured catheter was found within the right pulmonary artery [Figure 2, red arrow]. Interventional radiologist was able to retrieve the distal migrated fractured catheter from the segmental right pulmonary artery via the right common femoral vein approach under fluoroscopy guidance [Figure 3]. The left chest port-a-cath was removed and was subsequently replaced by a right chest port-a-cath.
Intravenous port-a-catheters are long-term tunneled central venous catheters, mainly used in cancer patients for chemotherapy infusions. The chemotherapy sessions are distributed over several weeks to months. Recent advances in cancer management have enabled infusion of these agents as an outpatient. With increasing use of these catheters, it is important to be aware of rare complications associated with it.
Catheter fracture with embolization is an uncommon, but life-threatening complication of these catheters, especially when inserted via subclavian vein approach. Pinch-off syndrome occurs when the catheter is intermittently compressed between the clavicle and the first rib and trapped between the subclavian muscle and costoclavicular ligament. This compression can cause transient or permanent obstruction of the catheter and may result in a tear or even complete transection with embolization of the catheter as described in this case. Pinch-off syndrome is experienced in only 1% of patients receiving a CVPC. However, 40% of these patients experience catheter embolization.[1,2] The fractured catheter can move to superior vena cava, right atrium/ventricle, and finally pulmonary artery. Most patients present with pain at the insertion site followed by nonfunctioning catheter. Moderate resistance to infusion is often experienced by nursing before catheter fracture. This complication can be avoided using jugular or cephalic vein approach. Early removal of the catheter along with retrieval of embolized portion is recommended either surgically or via percutaneous endovascular technique.
There are no conflicts of interest.