Inadvertently migrated fractured chemo port in pulmonary artery: A rare complication

A 35 yr old maleꬷ, known case of metastatic carcinoma rectum, presented to the department of Gastrointestinal Oncology, All India Institute of Medical Sciences, New Delhi, on November 6, 2018. After a thorough clinical evaluation and workup, he was planned for palliative chemotherapy. Venous chemo port catheterization was done in the left internal jugular vein on November 28, 2018. Because of obstructive flow through chemo port before the administration of the fifth cycle, the chest X-ray showed discontinued chemo port catheter with a fractured segment in the left pulmonary artery. The chemo port chamber with the proximal part of the catheter was removed from the previous incision under local anaesthesia on April 17, 2019. A peripherally inserted central catheter (PICC) was inserted into his left antecubital vein placed for future use. Non-contrast computed tomography of the chest with three-dimensional reconstruction was done for the exact localization and exteriorization of the foreign body. Figure shows the fragmented distal fragment of the chemo port in the main pulmonary artery and right pulmonary artery (red arrows; panel A-D) with the remaining PICC catheter in the left subclavian vein (green arrows; panel A and B). The interventional radiologist’s opinion was sought for the prompt removal of the fractured dislodged segment of the chemo port. However, the fractured port fragment was not retrieved because of the patient’s unwillingness. The patient was advised for immunotherapy under medical oncology services till the last follow up in April 2020. He was alive with the disease till last follow up which was approximately 18 months from the date of diagnosis.

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Figure

Migrated fractured chemotherapy line in the pulmonary artery. (A) CT topogram, (B) coronal, (C) axial, and (D) volume-rendered reconstructed images showing migrated fractured chemo port line (red arrows) in the main pulmonary artery and right pulmonary artery. Left remaining PICC depicted in the left subclavian vein (green arrows; panel A and B). CT, computed tomography; PICC, peripherally inserted central catheter

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Catheter fracture and embolization is extremely uncommon complication. The compression of the subclavian venous catheter between the clavicle and first rib may be the probable cause of catheter fracture. The most common clinical sign is difficulty in flushing the chemo port. Early identification of these complications may prevent devastating sequelae. Most dislodged catheter fragments are usually extracted using percutaneous interventional techniques through the femoral vein. These complications can be prevented with proper intraoperative gentle handling and good post-operative wound care. It should be advised to mention chemo port catheter fracture as a relatively uncommon but potentially serious complication when obtaining informed consent before its insertion.