13 September 2023: Articles
A 47-Year-Old Woman with a Retained Central Venous Catheter Line Guidewire Presenting with a Right Atrial Thrombus Requiring Removal During Open Heart Surgery: A Case Report
Challenging differential diagnosis, Unusual or unexpected effect of treatment, Diagnostic / therapeutic accidents, Rare coexistence of disease or pathologyAhmad Alsaka Amini1ABEF*, Abeer Alzuabi1ABCE, Mohannad Baniyaseen2BCD, Maro Gharbi1EFG, Mohamed Abdel Aziz3D, Mohamed Magdy Abbas4F
Am J Case Rep 2023; 24:e939908
BACKGROUND: A central venous catheter (CVC) is an indwelling catheter that is inserted into a large central vein for different purposes, including hemodynamic monitoring and administration of fluids and medications. This report is of a 47-year-old woman with a retained CVC line guidewire presenting with a large right atrial thrombus requiring removal during open heart surgery. CVC insertion is one of the most frequently attempted procedures in intensive care units, emergency departments, and operation rooms, especially for critically ill patients. Possible complications range from failure to place the catheter to cardiac arrest. One of the rarest complications is missing the guidewire after insertion, which is usually discovered early after inserting it.
CASE REPORT: We report the case of a 47-year-old woman who had a CVC line inserted following complicated open cholecystectomy. A few years later, she developed shortness of breath, with an incidental finding of a huge right atrial thrombus and a wire shown on transthoracic echocardiography. The right atrial thrombus required open heart surgery to excise the thrombus and the wire, which was done successfully. The thrombus was histopathologically and clinically proven to be an organized right atrial thrombus formed around the CVC guidewire.
CONCLUSIONS: This case report presents a rare complication of CVC insertion. Because this procedure is increasingly used, clinicians should be aware of the potential complications of retained CVC lines. Moreover, this report outlines different techniques to prevent such fatal complications and emphasizes the significance of radiography after insertion.
Keywords: central venous catheters, Heart Atria, Thoracic Surgery, Foreign Bodies, Radiography
Central venous catheter (CVC) insertion is widely used in intensive care units (ICUs), emergency departments (EDs), and operating rooms, mainly for critically ill patients [1,2]. A CVC is an indwelling catheter introduced into a large central vein, frequently in the internal jugular vein, subclavian vein, or femoral vein, and advanced until it reaches the superior vena cava, inferior vena cava (IVC), or right atrium . It is mainly used to either monitor and maintain patient hemodynamics or to administer medications and fluids; other uses include total parenteral nutrition administration, dialysis, plasmapheresis, and facilitation of further complex interventions, such as transvenous pacemaker placement.
The Seldinger technique is the most common method of inserting a CVC. It requires a metallic guidewire to be introduced into the lumen of a venipuncture needle, which provides a track for sliding the CVC . There are many potential complications associated with CVC insertion, such as failure to place the catheter (22%), arterial puncture (5%), catheter malposition (4%), pneumothorax (1%), subcutaneous hematoma (1%), hemothorax (less than 1%), and cardiac arrest (less than 1%) . Intravascular loss of a guidewire is an exceedingly rare complication that is usually discovered either immediately after the procedure or incidentally by routine radiograph or computerized tomography weeks or months later . We report an unusual presentation of a retained guide-wire that led to a massive right atrial thrombus 4 years after the placement of a right internal jugular CVC.
The aim of this case report is to familiarize healthcare professionals and increase their awareness of a rare and a preventable complication that can end tragically. Moreover, this case emphasizes the importance of imaging modalities after insertion of a CVC line.
A 47-year-old female patient was referred to the ED with 1 week of new-onset shortness of breath on exertion, which had worsened in the 3 days before presenting to the hospital. The shortness of breath was also associated with chest pain radiating to the left shoulder and pedal edema. The referral was from a private hospital, where an echocardiography revealed a right atrial thrombus (Figure 1) and a foreign body that was thought to be a wire extending from the right atrium IVC and ending at the femoral vein on abdominal X-ray (Figures 2, 3). On presentation, her vital signs were stable, and laboratory test results were within normal limits, and her chest X-ray showed mild cardiomegaly.
Upon further detailed history, it was found that the patient had an open cholecystectomy 4 years prior, in 2018, which was complicated with an intra-abdominal abscess that required postoperative ICU admission and CVC insertion.
The case was referred to the cardiology and cardiothoracic teams for further evaluation, and an immediate decision was made for admission on May 31, 2022. Surgical intervention after confirmation of a foreign body location was considered. Transthoracic echocardiography (TTE) done on the same day of admission showed ejection fraction of 53% and the presence of a mobile lobular thrombus seen in the right atrium, measuring 4×3.2 cm, hitting the tricuspid valve during diastole but not prolapsing and attached to the wall of the right atrium near the IVC. Another shadow was seen in the intrahepatic portion of the IVC, suspicious for propagating thrombus and a detached line. Also, a hyperechoic shadow was seen in the right ventricle, which was possibly a coiled line. Furthermore, a coronary angiography was done on the same day of admission and revealed normal coronaries.
As the case was discussed with the cardiothoracic surgery team, it was agreed to proceed for open heart surgery. The patient was assessed by the anesthesia team for preoperative evaluation and was classified as ASA III E (American Society of Anesthesiology Class III Emergency). She was prepared for platelets, fresh frozen plasma, and packed red blood cells, as the hemoglobin dropped to 8 g/dL, from 10 g/dL.
Intraoperatively, the ascending aorta, the left femoral vein, and the superior vena cava were cannulated for cardiopulmonary bypass. The IVC was not cannulated centrally because the thrombus was encroaching on the IVC and right atrium junctions in the echocardiogram. Cardiopulmonary bypass was initiated and maintained at 2.2 L/min/m2 body surface area. The systemic temperature was maintained at 34°C. The aorta was not cross-clamped.
On cardiopulmonary bypass, the right atrium was opened after snaring both the superior vena cava and IVC. A huge thrombus was found, measuring approximately 6.5×4×2.5 cm (Figures 4, 5). It was attached to the free wall of the right atrium, which was excised with the attached atrial wall. There were no guidewires inside the right atrium or right ventricle. The snare on the IVC was then removed to allow for manual palpation of the inside of the IVC, which revealed the remaining wire. The hard part of the wire was removed, while the coil covering the wire was removed as much as possible, and the terminal end was cut off flush with the opening of the IVC. The right atrium was closed using a running suture of Proline 4-0. The patient was weaned off cardiopulmonary bypass. Protamine sulphate was given, decannulation was done, and the chest wall was closed in layers, per usual protocol. The case was done under general anesthesia, with total intravenous anesthesia, insertion of a central venous line in the left internal jugular vein and arterial line, and transfusion of 1 unit of packed red blood cells. Later, the patient was moved to the ICU intubated (Figure 6) and was in a stable condition. In the ICU, the patient was extubated a few hours after the surgery. During her 3-day ICU stay, she was given cefuroxime and was vitally stable, awake, and conscious.
After monitoring in the ICU, she was in a good condition and was moved to the ward on day 3 after surgery. In addition, another TTE was done on postoperative day 5, revealing left ventricular ejection fraction of 60%, disappearance of the right atrial thrombus, in situ IVC lead, and a possible small right ventricular foreign body. As the thrombus was excised, it was sent for histopathology. The report of June 8, 2022, concluded right atrial mass biopsy, consistent with degenerated thrombus, showing diffuse degenerated fibrinoid material, with trapped red blood cells and very few inflammatory cells, with hemosiderin-laden-macrophages (Figures 7, 8).
Before the patient’s discharge, a consultation was done by the interventional radiology team for further assessment and possible removal of the other part of the wire that was left in place due to inability to remove it surgically. After the team studied the case and found it very challenging, with very limited chances of removal, we advised the patient in an outpatient clinic appointment to keep the wire in place. In any event, the patient was asymptomatic for long time and was recommended against any intervention. Six months later, the patient came for a follow-up and was asymptomatic. A TTE follow-up was done, which showed the same postoperative TTE findings.
In this case report, we present a unique finding resulting from a complicated CVC insertion procedure, which could be have been avoided if all preventive measures were taken. In this report, we show how this complication could be fatal to the patient, as such complications indeed increase the morbidity and mortality rates. Nevertheless, it is crucial to identify the complications immediately after insertion to avoid them.
The CVC insertion procedure is one of the most common procedures, done on an almost daily basis in ICUs, EDs, and operating rooms [1,2]. As previously reported, CVC insertion is associated with a wide range of complications .
Moreover, guidewires have been used broadly in different intravascular procedures for either arterial or venous catheterizations, including CVC insertion. The high prevalence of performing such procedures increases the possibility of missing guidewires, which is an avoidable complication . Even though losing the guidewire entirely in the vascular system can cause cardiac arrythmias, vascular wall damage, and thrombosis, loss of a guidewire is habitually asymptomatic, and symptoms might start to arise months or years later, as in our patient .
Multiple factors can lead to the loss of a guidewire, such as disturbing the physician while inserting the CVC, physicians’ hand skills and expertise, work overburden, and absence of supervisor’s guidance and care for trainees, which is the most reported risk factor in the literature . In the present case, we do not have an idea of how the guidewire had gone unnoticed for 4 years, as the procedure was done overseas.
As we mentioned earlier, our patient presented 4 years after insertion of a CVC in an ICU. This is considered a long time, and removal of the wire was practically difficult to remove and manage, as missed guidewires can usually be detected immediately after insertion by routine radiography ; indeed, most patients with missed guidewire presented much earlier than did our patient. There are few cases documented in the literature with a similar timeline [2,7].
The lack of documented cases such as ours made it more difficult for us to compare it with others in the management plan; nevertheless, our case made a distinctive presentation, emphasizing the seriousness of a patient’s presentation from a simple CVC insertion that could have ended the patient’s life.
Comparing the cases in the literature with our case, we concluded that most patients who had symptoms years after CVC insertion presented a challenging decision for the anesthesiologist, intensivist, and surgeon on whether to remove the guidewire either surgically or by using the snaring catheter under interventional radiology or to proceed with conservative management. Although the loop snare technique, which is done by interventional radiology, is the method of choice for removal of a retained guidewire, our patient had a massive atrial thrombus that led to the development of shortness of breath, and an immediate surgical intervention was best for her condition; additionally, removal of the neo-intimalized guidewire causes severe damage to the vessel wall, as in the case with our patient, in which the remaining part of the wire in the IVC could not be removed .
On the other hand, a documented case presented a female patient during the COVID-19 pandemic who needed a CVC insertion for dialysis, which was complicated with migration of the guidewire to the pulmonary artery and subsequently to the left breast tissue. This event occurred 3 weeks later, which is considered an early complication needing immediate intervention, unlike our case, in which the complication took years to develop. Nevertheless, the guidewire was removed by laparotomy after a failed trial of snaring technique, similar to our case, which also required surgical intervention for removal .
Concerning the intracardiac degenerated thrombus, a similar documented patient presented with shortness of breath, hemoptysis, and ischemic changes in the right foot. TTE showed a missed guidewire in the right atrium and looped inside the right ventricle, forming multiple mobile intracardiac thrombi. One of the thrombi passed from the right atrium to the left atrium through the foramen ovale, causing the right foot ischemic changes. The pulmonary computed tomography angiography showed emboli in the segmental artery of the right lower lobe and a subsegmental artery of the left lower lobe, which required emergency cardiac surgery to prevent further emboli .
Overall, missing a guidewire can be prevented by following a simple checklist of steps, starting with avoiding any kind of distractions, checking that the guidewire is longer than the catheter, always holding the proximal end of the guidewire during dilation and insertion of the catheter, looking over the guidewire on the tray after finishing the procedure, and, finally, conducting a routine chest X-ray to scan for any missing guidewires or CVC complications to ensure that the line is in place to start your infusions . All these measures together will reduce or even prevent iatrogenic complications.
In this report, we have presented a rare complication of CVC insertion. Because this procedure is increasingly used, clinicians should be aware of the potential complications of retained CVC lines. It has been noted in the literature that an increasing numbers of CVC procedures led to the higher incidence of complications. The rate of such complications can be reduced by following the checklist steps noted above while conducting the procedure. The importance of radiography after insertion is crucial in ruling out a missed guidewire and preventing long-term complications.
FiguresFigure 1.. Transthoracic echocardiography showing a right atrial thrombus attached to the right atrial wall (red arrow). Figure 2.. Abdominal X-ray showing the guidewire (red arrow) passing through the inferior vena cava. Figure 3.. Abdominopelvic X-ray showing the guidewire (red arrow) ending with the hook of the guidewire (yellow arrow) reaching the femoral vein. Figure 4.. Excised right intra-atrial tumor measuring 6.5×4×2.5 cm. Figure 5.. Intraoperative photo showing part of the guidewire within the excised right atrial mass. Figure 6.. Postoperative chest X-ray showing endotracheal tube, sternotomy sutures, and newly inserted left internal jugular central venous catheter. A curvilinear radio-opaque shadow is seen at the left-upper quadrant, which is the remnant of the guide wire (red arrow). Figure 7.. (A, B) A photomicrograph of the right atrial thrombus in a 47-year-old woman removed during open heart surgery. The histopathology shows degenerated fibrin, red blood cells suggestive of degenerated thrombus. Hematoxylin and eosin stain, ×400. Figure 8.. Immunohistochemical stain (DAKO) CD68: Positive for macrophages in granular tissue, ×400.
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