Two-Port VATS Technique to Retrieve a Fractured Chemo Port Catheter from the Left Pulmonary Artery

A forty-seven-year-old male with a known case of advanced retroperitoneum leiomyosarcoma developed a sudden right shoulder pain with unusual resistance upon flushing of his chemo port. An immediate chest X-ray showed evidence of a chemo port catheter fracture that was situated behind a cardiac shadow. A CT scan confirmed that the fractured distal portion of the chemo port catheter, measuring 6.5cm, had dislodged into the left lower lobe PA.

Surgical intervention was offered to patient, as the interventional radiology team deemed percutaneous retrieval unfeasible. The patient was under general anesthesia with single lung ventilation, and the tip of the catheter could be seen inside basal segmental pulmonary artery. After dissection of the vascular sheath, the pulmonary arteries to the lingular and left lower lobe were exposed. The posterior fissure was then dissected carefully and isolated with vascular slings, followed by complete division of the fissure with an Endo GIA Purple 60 stapler, to fully expose the pulmonary arteries involved. The tip of the stapler was inspected to ensure to would not catch other important structures. It was then fired at steady speed to ensure a good seal of the lung tissue.

Subsequently, the inferior pulmonary ligament was identified and dissected carefully using LigaSure so that the left inferior pulmonary vein was adequately exposed. Then, also using LigaSure, the posterior mediastinal pleural reflection was freed. Isolation of the inferior pulmonary vein using a vascular sling was then performed. After this, the vascular sling was looped around the inferior pulmonary vein twice. Next, the pulmonary arteries were identified as per labeling. The same technique was applied for isolation of the interlobar pulmonary artery. A red vascular sling was gently looped around the interlobar pulmonary artery twice. It was important to perform this in a gentle manner because the pulmonary arteries are thin, fragile, and very close to each other. This step ensured a bloodless field upon exploration of basal segment pulmonary artery for the later retrieval of catheter fracture. Subsequently, the lingular pulmonary artery was isolated with a blue vascular sling.

After heparinization with 5,000 units of heparin, a vascular sling for the lingular pulmonary artery and interlobar pulmonary artery were tightened and reinforced by using Ligamax clips. This was performed using the same technique that was applied to inferior pulmonary vein. The basal segmental pulmonary artery was cut opened using a blade followed by scissors, and the pulmonary artery was inspected thoroughly but the fractured catheter was not found. The basal segmental pulmonary artery was then repaired using Prolene 5-0 sutures. It was a single layer continuous suturing, and the knotting was done with a knot pusher. It was then deaired by releasing the inferior pulmonary vein first before the pulmonary artery.

After the repair of the basal segmental pulmonary artery, a thorough inspection was performed. The tip of the fractured catheter was seen floating inside the lingular pulmonary artery. The catheter had migrated there during retraction of the lower lobe superiorly when the inferior pulmonary vein was isolated. Next, the V1–V3 pulmonary vein was isolated with a blue vascular sling, followed by the V4–V5 pulmonary vein using red vascular slings. These vessels were slung and tightened using Liga MX. The same technique was used as before. The tip of the catheter fracture could be seen from the thin wall of the lingular pulmonary artery. Subsequently, the lingular pulmonary artery was cut open using a blade. Back pressure of the blood pushed the catheter out immediately, and the catheter fracture was retrieved successfully.

After complete removal of the fractured chemo port catheter, the lingular pulmonary artery was repaired using a single layer of Prolene 5-0 sutures. All vascular slings around the pulmonary veins and lingular pulmonary artery were loosened and removed carefully. Haemostasis was then secured. Estimated blood loss was less than 200cc, and closure was routine. The 6.5cm catheter fracture was successfully retrieved, and the post-operative CXR showed no remaining remnants. The patient was discharged on post-operative day 4 and restarted her chemotherapy two weeks after surgery. The remaining chemo port chamber over the right anterior chest wall was removed under local anesthesia, and the fractured point showed deformed lumen suggestive of pinch-off syndrome.

Reference

1. Aitken DR, Minton JP. The “pinch-off sign”: a warning of impending problems with permanent subclavian catheters. The American journal of surgery. 1984 Nov 1;148(5):633-6.

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