Removal of central venous port-catheter by the combination of interventional radiological procedures.

We encountered a patient with an infection related to an implanted central venous port-catheter that necessitated removal of the system. As the catheter had tightly adhered to the venous wall, removal was impossible with standard methods. After trial and error, we used a guiding catheter that was advanced over the implanted catheter to detach the fibrin sheath on the implanted catheter that had adhered to the vessel wall. At that time, a pull-through technique was used. After we succeeded in detaching the adhesion with the guiding catheter, we were able to withdraw the implanted catheter.

[Catheter Replacement Methods in Hemodialysis Patients With Dysfunctional Tunneled-Cuffed Catheters With Fibrin Sheaths]. / 对形成纤维蛋白鞘的带涤纶套和隧道透析导管的更换方式探索.

Objective: Tunneled-cuffed catheters (TCCs) are frequently used for establishing hemodialysis access for maintenance hemodialysis in older patients with exhausted resources of peripheral vessels. Fibrin sheath formation around the catheter is one of the most common complications of long-term use of indwelling catheter, which may cause the malfunction of the catheter. In this study, we intend to compare the prognosis of two catheter replacement methods, in situ replacement and replacement through a fibrin sheath crevice, with both being assisted by balloon dilation, and to explore the optimal catheter replacement process. Methods: A retrospective study was conducted with 52 patients who underwent a replacement of their TCCs. Among them, 27 cases had their TCC replaced by the modified method of replacement through a fibrin sheath crevice and were referred to as the sheath crevice group, while 25 cases underwent in situ catheter replacement and were referred to as the in situ group. The primary outcome indicators included maximum blood flow in hemodialysis catheter and the urea clearance rate calculated by Kt/V values at the 1, 3, and 6-month follow-ups. The secondary outcomes included dialyzer alarms being set off and catheter-related infections during follow-up. Results: There was no significant difference between the general data of the two groups. There was no massive blood loss during the replacement procedure. Neither were there cardiac tamponade, catheter-associated infections, or other complications. Follow-ups were made 1, 3, and 6 months after the replacement procedure. The sheath crevice group had higher catheter blood flow and Kt/V values at the 6-month follow-up than the in situ group did ([241.85±9.62] mL/min vs. [234.40±11.21] mL/min, P=0.014 and 1.31±0.55 vs. 1.27±0.49, P=0.005, respectively). During the follow-up process, access alarms were reported in 5 patients (three in the in situ group and two in the sheath crevice group) during dialysis. No catheter-associated infection occurred in either group. Conclusion: The catheter replacement method of balloon dilation-assisted catheter insertion through a fibrin sheath crevice is safe and effective, resulting in better long-term catheter blood flow compared with that of in situ catheter replacement.

Ectopic Calcification of Fibrin Sheath on the Catheter.

We describe a case of hemodialysis catheter that appeared to be encased in a sleeve-shaped fibrous sheath with calcification. Ectopic calcification is a serious complication in hemodialysis patients with calcium-phosphorus metabolism disorder. Clinical awareness and understanding of this condition is imperative to the prevention and management of ectopic calcification.

A novel technique for removing a fibrin sheath from a mediport catheter in the pediatric population.

Mediport (also known as port, portacath or Infusaport) is a commonly placed central venous access in pediatric patients. Fibrin sheath formation around the central venous catheter is a common biological response leading to port malfunction in the form of inability to aspirate but preserved capacity for infusion of fluids. If fibrinolytic therapy fails, percutaneous fibrin sheath stripping via transfemoral route or replacement with a new mediport are routine/conventional treatments for a fibrin sheath. We describe a novel technique for removing a fibrin sheath by exteriorizing the catheter through the neck entry site, stripping the fibrin sheath from the catheter manually under sterile conditions and replacing the catheter via a peel-away sheath introduced through the same skin incision as an alternative to complete port replacement or attempted catheter stripping.

Relationship Between Central Venous Catheter Protein Adsorption and Water Infused Surface Protection Mechanisms.

Central venous catheters (CVCs) are implanted in the majority of dialysis patients despite increased patient risk due to thrombotic occlusion and biofilm formation. Current solutions remain ineffective at preventing these complications and treatment options are limited and often harmful. We present further analysis of the previously proposed water infused surface protection (WISP) technology, an active method to reduce protein adsorption and effectively disrupt adsorbed protein sheaths on the inner surface of CVCs. A WISP CVC is modeled by a hollow fiber membrane (HFM) in a benchtop device which continuously infuses a saline solution across the membrane wall into the blood flow, creating a blood-free boundary layer at the lumen surface. Total protein adsorption is measured under various experimental conditions to further test WISP performance. The WISP device shows reduced protein adsorption as blood and WISP flow rates increase (P < 0.040) with up to a 96% reduction in adsorption over the no WISP condition. When heparin is added to the WISP flow, protein adsorption (0.097[+0.035/-0.055] µg/mm2 ) is reduced when compared to both bolus administration and nondoped WISP, 0.406(+0.056/-0.065) µg/mm2 (P = 0.001) and 0.191 (+0.076/-0.126) (P = 0.029), respectively. Additionally, when heparinized WISP is applied to a preadsorbed protein layer, 0.375(+0.114/-0.164) µg/mm2 , it displays the ability to reduce the previously-adsorbed protein, 0.186(+0.058/-0.084) µg/mm2 (P = 0.0012), suggesting aptitude for intermittent treatments. The WISP technology not only shows the ability to reduce protein adsorption, but also the ability to remove preadsorbed material by effectively delivering drugs to the point of adsorption; functionalities that could greatly improve clinical outcomes.

Water Infused Surface Protection as an Active Mechanism for Fibrin Sheath Prevention in Central Venous Catheters.

Protein adhesion in central venous catheters (CVCs) leads to fibrin sheath formation, the precursor to thrombotic and biofilm-related CVC failures. Advances in material properties and surface coatings do not completely prevent fibrin sheath formation and post-formation treatment options are limited and expensive. We propose water infused surface protection (WISP), an active method for prevention of fibrin sheath formation on CVCs, which creates a blood-free boundary layer on the inner surface of the CVC, limiting blood contact with the CVC lumen wall. A hollow fiber membrane (HFM) in a benchtop device served as a CVC testing model to demonstrate the WISP concept. Porcine blood was pumped through the HFM while phosphate buffered saline (PBS) was infused through the HFM wall, creating the WISP boundary layer. Protein adherences on model CVC surfaces were measured and imaged. Analytical and finite volume lubrication models were used to justify the assumption of a blood-free boundary layer. We found a 92.2% reduction in average adherent protein density when WISP is used, compared with our model CVC without WISP flow. Lubrication models matched our experimental pressure drop measurements suggesting that a blood-free boundary layer was created. The WISP technique also provides a novel strategy for drug administration for biofilm treatment. Reduction in adherent protein indicates a restriction on long-term fibrin sheath and biofilm formation making WISP a promising technology which improves a wide range of vascular access treatments.

[Calcified Fibrin Sheath After Stuck Catheter Removal: Case Report and Literature Review].

The prevalence of central venous catheters (CVC) in hemodialysis patients is around 20-30%. In this scenario, complications related to the use of the CVC are commonly observed, requiring active management by nephrologists. These include infectious complications as well as those related to CVC malfunction. Among the latter, the formation of a fibrin sheath around the catheter linked to foreign body reaction could cause CVC malfunction in various ways. Even after the removal of the catheter, the fibrin sheath can remain inside the vascular lumen (ghost fibrin sheath) and rarely undergo calcification. We describe the clinical case of a hemodialysis patient who, following the removal of a malfunctioning, stuck CVC, presented a calcified tubular structure in the lumen of the superior vena cava, diagnosed as calcified fibrin sheath (CFS). This rare occurrence, described in the literature in 8 other cases, although rare, is certainly underdiagnosed and can lead to complications such as sepsis resulting from CFS, pulmonary embolisms, and vascular thrombosis. Therapeutic approaches should be considered only in symptomatic cases and involve an invasive surgical approach.

Recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein: A case report.

A fibrin sheath with central venous occlusion is a common complication after central venous catheterization, and these patients often experience catheter dysfunction. A calcified fibrin sheath can cause a catheter to be stuck, and typically necessitates catheter removal or replacement. From another point of view, a calcified fibrin sheath can be seen in ultrasound and computed tomography, and the original fibrin sheath channel between the internal jugular vein and the atrium is unusually strong. When central vein occlusion occurs, the remnant calcified fibrin sheath of the internal jugular vein can be punctured under ultrasound guidance, allowing the guidewire to enter the atrium directly through the fibrin sheath. Here, we report a case in which we achieved easy recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein.

Successful Removal and Replacement of a Stuck Hemodialysis Catheter via Thoracotomy: Report of Two Cases and Literature Review.

Introduction: Stuck tunneled central venous catheters (CVCs) have been increasingly reported. In rare cases, the impossibility of extracting the CVC from the central vein after regular traction is the result of rigid adhesions to the surrounding fibrin sheath. Forced traction during catheter removal can cause serious complications, including cardiac tamponade, hemothorax, and hemorrhagic shock. Knowledge and experience on how to properly manage the stuck catheter are still limited. Case Presentation: Here, we present two cases that highlight the successful removal of the stuck tunneled CVC via thoracotomy through the close collaboration of multidisciplinary specialists in the best possible way. Both patients underwent an unsuccessful attempt at thrombolytic therapy with urokinase, catheter traction under the guidance of digital subtraction angiography and intraluminal balloon dilation. And we reviewed the literature on stuck catheters in the hope of providing knowledge and effective approaches to attempted removal of stuck catheters. Conclusion: There is no standardized procedure for dealing with stuck catheters. Intraluminal percutaneous transluminal angioplasty should be considered as the first-line treatment, while open surgery represents a second option only in the event of failure. Care must be taken that forced extubation can cause patients life-threatening.

Stripping the catheter: A new device for an old technique.

Fibroblastic sleeve is a common pathophysiological phenomenon characterized by the formation of a mixed fibrous-collagen tissue encasing the outside of venous access devices. Although it nearly always presents asymptomatically, this catheter-related complication represents one of the leading culprits of venous catheters malfunction. Several techniques have been described for the management of dysfunctional catheters secondary to fibroblastic sleeve, including medical therapy, catheter exchange, balloon angioplasty, and percutaneous stripping. However, there is no common consensus for the treatment management in patients who present contraindications to surgical port removal. This report illustrates the case of a port catheter malfunction due to a fibroblastic sleeve in an oncological patient with a high risk of bleeding. This was effectively treated with a minimally invasive stripping technique using an off-label device for mechanical thrombectomy, namely the ClotTriever system (Inari Medical, Irvine, CA).

Case review and imaging: Treatment of central venous catheter associated fibrin sheath and chronic thrombus with the ClotTriever system.

Fibrin sheath formation is a leading culprit of central venous catheter malfunction. The complete removal of fibrin sheaths is an essential component of maintaining catheter patency, preventing future restenosis, and decreasing the risk of bloodborne infections. Treatment of fibrin sheaths includes pharmacologic therapy, balloon angioplasty, catheter exchange, and mechanical stripping. In this article 3 cases are reviewed, 2 patients had long-term hemodialysis catheter malfunction and 1 had complications related to a chest port. On imaging, superior vena cava stenosis, occlusion, and/or filling defect were identified for all patients, as well as findings suggesting the presence of fibrin sheath. Description of these cases detail a new technique for fibrin sheath removal utilizing the ClotTriever System (Inari Medical, Irvine, CA), which is a mechanical thrombectomy device used for the treatment of deep vein thrombosis. This technique allowed for complete removal of the fibrin sheath via a minimally invasive interventional procedure which did not require access through the central venous catheter lumen.

Comparison of the complications and long-term results of heparin-coated and non-heparin-coated symmetric-tip hemodialysis catheters.

BACKGROUND: Tunneled catheters are effectively used in patients receiving chronic dialysis due to end-stage renal disease. However, the dysfunction of catheters caused by infection or thrombus requires repetitive procedures. In this study, we aimed to compare the long-term results of heparin-coated and non-heparin-coated tunneled dialysis catheters. METHOD: The study included a total of 161 patients who underwent tunneled dialysis catheter placement. Heparin-coated and non-heparin-coated tunneled catheters were placed in 81 and 80 patients, respectively. Of all the patients, 89 (55.3%) were male and 72 (44.7%) were female. The mean age of the patients was 64.3 ± 15.3 years. The patients were followed up for 12 months. RESULTS: Catheter infection developed in 10 (6.2%) of the cases, of which seven (70%) resolved with antibiotic therapy and the remaining three (30%) required catheter replacement. There was no significant difference between the groups in terms of the catheter infection rate (p = 0.84). Fibrin sheaths developed in nine (5.5%) patients. Fibrin sheath development was found to be significantly higher in the non-heparin-coated catheters (p = 0.017). There was no significant difference in fibrin sheath formation between the patients with and without systemic antiaggregant use (p = 0.864). The mean catheter durability time was determined to be 11 months in both groups (p = 0.704). Catheter survival was similar in heparin-coated and non-heparin coated catheters. CONCLUSION: This study showed that the rate of fibrin sheath development was significantly lower in heparin-coated tunneled catheters than non-heparin-coated catheters. There was no significant difference between the two catheters in terms of the rates of infection and mechanical complications.

Variance in management of extracorporeal membrane oxygenation-associated fibrin sheaths at a single institution.

Objective: Extracorporeal membrane oxygenation (ECMO) support for patients with cardiac or respiratory failure has been increasingly used by advanced critical care practitioners. The thromboembolic complications of ECMO have been extensively discussed and researched; however, research and discussion on the development, risks, and management of cannulae-associated fibrin sheaths are lacking. Methods: Institutional review board approval was not required. We have presented three cases detailing the identification and individualized management of ECMO-associated fibrin sheaths at our institution. The three patients provided written informed consent for the report of their case details and imaging studies. Results: Of our three patients with ECMO-associated fibrin sheaths, two were managed successfully with anticoagulation alone. One could not receive anticoagulation therapy and underwent inferior vena cava filter placement. Conclusions: Fibrin sheath formation around indwelling ECMO cannulae is an unresearched complication of ECMO cannulation. We would recommend an individualized approach to the management of these fibrin sheaths and have provided three examples of successful management.

Calcified Fibrin Sheath Embolism of Bilateral Pulmonary Arteries: A Second Case of the Literature.

INTRODUCTION/BACKGROUND: Central venous catheters, which provide a unique convenience in the management of critical patients, have many advantages, as well as early and late complications. Early complications include pneumothorax, vascular perforation, hematoma formation, air embolism, or catheter malposition that may occur during or shortly after catheter insertion. Late complications include infection, venous stenosis, catheter thrombosis, and catheter tip migration. In the literature, embolization of a calcified fibrin sheath due to a central venous catheter to the pulmonary artery has been reported only in one case. CASE PRESENTATION: The purpose of this report is to present bilateral pulmonary artery embolism in a patient who presented with cough and chest pain caused by calcified fibrin sheath of the port catheter removed before that was used for regular chemotherapeutic infusions due to liposarcoma, as the second case in the literature with imaging findings. The patient underwent medical treatment, and as a result of the treatment, symptoms regressed. CONCLUSION: Central venous catheters have many complications, and although it is rare, pulmonary embolism is one of them. The embolism of a calcified sheath is even rare, but it is still possible. However, an embolism can cause significant morbidity and even mortality for a patient if it occurs. As physicians, we should be aware of this entity to diagnose.

Infectious outcomes of fibrin sheath disruption in tunneled dialysis catheters.

BACKGROUND AND OBJECTIVES: Fibrin sheath (FS) formation around tunneled central venous catheters (CVC) increases the risk of catheter-related bloodstream infections due to bacterial adherence to a biofilm. We sought to investigate whether FS disruption (FSD) at the time of CVC removal or exchange affects infectious outcomes in patients with CVC-related infections. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Retrospective cohort study of 307 adult maintenance hemodialysis patients aged 18 years or older at a single center academic-based hemodialysis program (UHN, Toronto) who developed CVC-related infections requiring CVC removal or exchange between January 2000 and January 2019. Exposure was FSD at the time of CVC removal or exchange. Outcomes were infectious metastatic complications, recurrent infection with the same organism within 1 year, or death due to infection. We created a Markov Multi-State Model (MMSM) to assess patients' trajectories through time as they transitioned between states. A time-to-event analysis was performed, adjusted for clinically relevant factors. RESULTS: There was no significant relationship between FSD status at the time of CVC removal, the development of infectious complications in the multivariable model (adjusted HR = 0.71, 95% CI 0.09-5.80, p = 0.76), or mortality from infection (HR = 0.84, 95% CI 0.34-2.11, p = 0.73). CONCLUSIONS: FSD at the time of CVC removal was not associated with increased risk of infectious complications or death due to infection. Further prospective study is needed to determine whether FSD contributes to reducing CVC infectious related complications.

Fibrin Sheath Catheter-Related Endovascular Right-Sided Heart Infection in Heart Failure With Reduced Ejection Fraction: A Case Report.

Patients with end-stage renal disease (ESRD) receive dialysis through either hemodialysis (HD) or peritoneal dialysis (PD). HD has challenges associated with vascular access and catheter-associated complications. The development of a fibrin sheath is a common complication with tunneled catheters. However, infection of the fibrin sheath is not usually encountered. We discuss the case of a 60-year-old female with ESRD and heart failure with reduced ejection fraction (HFrEF) receiving HD via tunneled right internal jugular (RIJ) Permcath who was diagnosed with an infected fibrin sheath located in the cavoatrial junction via a transesophageal echocardiogram (TEE). Compared to a transthoracic echocardiogram (TTE), a transesophageal echocardiogram provides a much more accurate diagnosis of this rare condition. Treatment primarily involves administering antibiotics based on sensitivity cultures and closely monitoring for any potential complications.

CT and Sonographic Findings of a Calcified Fibrin Sheath From an Umbilical Venous Catheter in a Neonate.

Central venous catheters are ubiquitous in current medical practice in intensive care units and for long-term nutrition, chemotherapy, and antibiotic therapies. Umbilical venous catheters provide short-term central vascular access and are used in the neonatal period. This case presents sonographic and CT imaging findings of an intrahepatic and intracardiac calcified fibrin sheath following removal of a short-term umbilical venous catheter in a 32-day-old premature neonate.

Embolized fibrin sheath material presenting as intraluminal calcifications within the pulmonary arteries on CT.

Fibrin sheath formation is a well-described sequela of an indwelling central venous catheter. Fibrin sheaths may also develop around other foreign bodies within the venous system. We describe a case of fibrin sheath formation within the left brachiocephalic vein secondary to automatic implantable cardioverter-defibrillator (AICD) leads with subsequent embolization of sheath material presenting as calcifications within the pulmonary vasculature on computed tomography (CT). Most of the relevant literature focuses on catheter-related sheath formation and associated complications while reports on fibrin sheaths from other foreign bodies are sparse. We advise that radiologists who encounter intraluminal calcifications within the pulmonary arteries on CT should consider the possibility of a fibrin sheath as the source and search for its remnants in the central venous system for confirmation.

Evaluation of the antithrombogenicity of poly-2-methoxyethylacrylate-coated catheters.

BACKGROUND AND OBJECTIVES: The blood compatibility of indwelling intravascular catheters is facilitated by the use of antithrombogenic materials. Heparin has typically been used for this purpose; however, since heparin-coated catheters are considered combination products, difficulties meeting the relevant Food and Drug Administration safety recommendations have disrupted commercialization. Other issues include coating durability and the occurrence of heparin-induced thrombocytopenia. Polymer coatings are a potential alternative; however, polymer antithrombogenicity in circulating human blood has yet to be demonstrated. The present study aimed to establish the ex vivo antithrombogenicity of a poly-2-methoxyethylacrylate (PMEA) polymer coating applied to a central venous catheter using an artificial human blood circulation system. METHODS: The present study used an artificial human blood circulation system to conduct an ex vivo evaluation of the antithrombogenicity of poly-2-methoxyethylacrylate (PMEA)-coated catheters. Human blood samples obtained from volunteer donors were loaded into a circulation system fitted with either a PMEA-coated or uncoated catheter. After 3-h, the catheter was removed and examined using scanning electron microscopy. Protein adsorption on the catheter surface was investigated by shredding the catheter that had contacted the blood inside the circulation system and immersing the pieces in 1 mL of 0.5 N NaOH for 2 days. The amount of protein in the 0.5 N NaOH was determined according to the Lowry method. RESULTS: Adherent fibrin, which forms a sheath on the catheter surface, was observed on uncoated, but not PMEA-coated catheters. Furthermore, the amount of protein adsorption was significantly less with PMEA-coated than uncoated catheters (p = 0.043). CONCLUSIONS: The present findings demonstrated the antithrombogenicity of PMEA-coated catheters in circulating human blood.