Broken umbilical artery catheter lodged in internal iliac artery: A rare case report of a serious complication and successful retrieval

INTRODUCTION

Reliable vascular access is essential in the management of sick newborns admitted in the neonatal intensive care unit (NICU). One of the most reliable and commonly used vascular accesses is umbilical arterial and venous catheterization (UAC and UVC, respectively). UVC is used for intravenous fluid administration and UAC is used for intravenous blood pressure monitoring and as an access for blood samples for essential investigations in neonates. The procedure for UVC and UAC is relatively safe; however, some complications might develop such as infection, disseminated intravascular coagulation, arrhythmia, and perforation. Rarely, a serious complication such as rupture or fracture of catheter occurs and most of the time retrieval is unsuccessful. In literature, about 22 cases of umbilical catheter rupture have been reported including the latest one in April 2020 by Khasawneh et al.^[1] from Jordan.

Here, we describe a case of fracture of UAC, its dislocation into internal iliac artery, and its successful endovascular retrieval without any complication on follow-up.

CASE REPORT

A 7-day-old female, early term neonate of 37 weeks gestational age with birth weight of 2836 g, born through lower segment cesarean section developed respiratory distress at 2 h of life. Chest X-ray showed bilateral pneumonia which required intravenous antibiotics for 7 days. The baby developed persistent pulmonary hypertension (PPHN) at 28 h of life which was confirmed by functional 2D Echocardiogram (ECHO). Umbilical catheters (UAC of 3.5 French and UVC of 5 French) were inserted on day 2 of life as the neonate was critically ill and required management for PPHN. On day 6 of life, UAC was accidentally removed and was broken at 15 cm mark. The remaining catheter measuring about 15 cm was inside the umbilical artery which was confirmed by computed tomography angiography (distal tip in thoracic descending aorta at D6–D7 level and proximal tip in the right umbilical artery approximately 2 cm beneath the umbilical stump) [Figures 1 and 2]. Pediatric surgery and cardiovascular thoracic surgery teams were approached for further management of the lodged UAC. Combined decision was made by the neonatologist, pediatric surgeons, and cardiothoracic surgeons for surgical removal of the lodged catheter.

Close

Figure 1:

3D computed tomography finding of dislodged umbilical catheter.

Export to PPT

Close

Figure 2:

Plain computed tomography finding of dislodged umbilical catheter (arrows).

Export to PPT

Baby was transported to operating room within 24 h and administered general anesthesia. Initially, catheter was transfixed in the deep umbilical stump through an infraumbilical incision. However, the catheter slipped in to the right common iliac artery which was then transfixed and endovascular retrieval of the whole 15 cm UAC along with the tip was done [Figure 3]. There was minimal blood loss (5 mL) during the procedure [Video 1].

Close

Figure 3:

Intraoperative finding of the fractured catheter and removal. Arrow shows sharp tip of the umbilical catheter

Export to PPT

Immediately, post-surgery, vasospasm of the right common iliac artery occurred which led to poor perfusion and low saturation readings on the right lower limb. However, it improved to normal values after 6 h of surgical retrieval. Baby’s perfusion, pulses, blood pressure, and saturation were monitored on the right lower limb and compared with the left lower limb for a period of 24 h [Figures 4 and 5].

Close

Figure 4:

Comparison of Doppler findings of the right and left femoral vessels (post-operative).

Export to PPT

Close

Figure 5:

Post-operative retrieval of 15.3 cm umbilical artery catheterization.

Export to PPT

Doppler flow of the femoral vessels of the right lower limb was measured and compared with the left limb [Video 2]. Inj. Heparin was given postoperatively for 48 h to prevent post-operative thrombosis. The baby was observed for 2 weeks and successfully discharged from NICU. She was followed up for a month post discharge and had no complications.

DISCUSSION

Umbilical catheters are important IV access for sick term and preterm neonates. However, complications such as central line associated blood stream infection, thrombosis, embolism, vasospasm, and vascular perforations are common. A much worrisome complication such as fracture and broken catheter is rare. It require a multidisciplinary team involvement for retrieval of catheter. Sometime retrieval is not successful and life-threatening. Literature search revealed only 14 articles with <20 cases of broken umbilical lines in neonates, details of which are depicted in Table 1.^[1-19]

Total of 10 UAC fracture cases and 13 UVC fracture cases documented of which Dhua et al.^[2] 2013 from Ghaziabad had similar broken UVC and dislodged into inferior vena cava (IVC) and then to superior vena cava (SVC). Goose neck snare catheter needed to remove the dislodged piece of UVC from SVC.

Gasparis et al.^[3] described a successful retrieval of a dislodged UVC through the umbilical vein using endovascular Amplatz loop snare. This minimally invasive route was also used by Ruiz et al.,^[11] who reported a successful retrieval of a broken UVC dislodged at the left superior pulmonary vein of a 30 weeks, 1117 g baby.

Venkatesh,^[4] 2015, from Karnataka, India, described retrieval of broken UVC which was dislodged up to a region below liver in IVC through supra umbilical exploration.

Khasawneh et al.,^[1] in 2020, from Jordan reported two cases of umbilical line dislodgement in two late pre-terms, one for respiratory distress syndrome and another for meconium aspiration syndrome. In the first case, both UVC and UAC were put, during removal (removal occurred with some difficulty) 1.5 cm of UAC retained in side umbilical stump, which protrude from the stump after sometime and it was retrieved through forceps from umbilical stump.

Second case UVC fragment was retained in the umbilical stump (2 cm away from umbilical stump). This fragment was retrieved with supraumbilical exploration through forceps.

The mechanism of umbilical catheter breakage has been proposed and discussed by Choi et al.^[5] He reported two cases of broken umbilical catheter. First one inadvertent damage of catheter by needles and scissors or scalpels during catheter insertion and fixation. Subsequent attempts of removal of this weakened catheter may cause breakage. Second case was due to overzealous tightening of the purse string suture which can also weakens the wall of the catheter.

In our case, the possible cause of catheter breakage might be due to some sharp induced damage (may be due to a surgical blade/scissors induced) that was unnoticed at fixation of catheter, leading to weakening of the catheter wall and a trivial force needed to break in to two pieces. Proximal part (15 mm) got dislodged into umbilical stump. This underscores the importance of using fine scissors or surgical blades especially in an active neonate who may be difficult tore strain.

Mitchell et al.,^[6] in 2007, described various steps to avoid this type of complications. As a standard practice, one should always inspect the tip of the removed catheter for checking its intactness and also insist for a check radiograph, since small broken fragment tip from these long catheters can be overlooked and missed.

CONCLUSION

Although UAC/UVC fracture is a rare event, there should be high index of suspicion of these kind of events. Health care providers should be cautious with the insertion and removal of catheters and well-trained personnel should be responsible for conducting this procedure in the NICU. Implementation of central line bundles have overall contributed to less side effects mainly infection.

Fine tip scissors should be used during the process of removal instead of sharp blades. Surgical clamps and hemostats should be readily available in the removal kit and providers should be trained to use them immediately in case of an accidental break, before the view is obstructed by massive bleeding.