The sandwich technique used for retrieving embolized catheter fragment dislodged in the pulmonary artery

Introduction

Peripherally inserted central catheter (PICC) is recommended for patients who need long-term intravenous therapy, particularly in the delivery of chemotherapeutic-cytotoxic drugs (1,2); it improves patient satisfaction. However, in some situations, the PICC could fracture, with the fragments becoming dislodged in the vena cava, right heart, or pulmonary artery (3,4). This situation could result in serious complications such as arrhythmia, clotting, myocardial infarction, valvular perforation, and cardiac arrest. To mitigate the potential risks, retrieving the fragment is the best choice.

In most cases, the fragment can be retrieved by using a well-known two-step method. The method involves first making a free end with a pigtail catheter, and second seizing it with a snare loop. There are several modified methods based on this technique, such as the new boomerang loop-snare technique, a novel two-step technique, a modified twostep technique, a modified two-step “pigtail through snare” technique, the double transfemoral access technique and so on (5-9). However, these techniques have several disadvantages. First, sometimes the free end of the fracture is lodged in the vessel wall or floating during procedure, making it difficult to catch with the snare loop. Second, the main procedure is completed in the right ventricle, which can result in arrhythmia, valvular perforation, and cardiac arrest.

Sometimes, difficulties are encountered when trying to the retrieve the fragments. Therefore, other techniques need to be available when performing the procedure. Here we present a case report utilizing a three-step method, named the “sandwich technique”, which exhibits several advantages compared to two-step procedure. We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-337/rc).

Preoperative preparations and requirements

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This surgical approach was approved by the Ethics Committee of Taizhou Hospital Affiliated to Wenzhou Medical University (No. KL20250136). The Second People’s Hospital of Linhai was informed and agreed with this study. Informed consent was taken from the patient.

The performance was completed in the intervention center of the Second People’s Hospital of Linhai, which is affiliated with the Taizhou Enze Medical Center, a tertiary hospital in the Taizhou region. The degree of cleanliness of the intervention center is ranked as International Organization for Standardization (ISO) class 3, and all intervention are performed at the intervention center.

The procedure was completed using the Innova IGS 530 (General Electric Company, GE, Buc, France). Iodine contrast agent, catheters, guide wires and a snare loop were used during the procedure. These materials included iodixanol injection (Shanghai Starry Pharmaceutical Co., Ltd., Shanghai, China) 100 mL ×2 bottles, a 5-F sheath (Terumo Co., Ltd., Tokyo, Japan), a 5-F multifunctional catheter (Cordis Corporation, Hialeah, FL, USA), a 0.035-inch guidewire (Radifocus^®, Terumo Co., Ltd.), an Amplatz super stiff wire (Boston Scientific, Marlborough, MA, USA), a 10-F sheath 70 cm in length (Barty Medical, Hangzhou, China), a 5-F pigtail catheter (Optiflash^®, Terumo Co., Ltd.), super core wire (Terumo Co., Ltd.), and a snare loop (EN Snare, SHEEN MAN, Shanghai Shape Memory Alloy Co., Ltd., Shanghai, China).

The surgical team includes two surgeons, one nurse and one radiographer. The chief surgeon has experience with pulmonary artery catheter thrombectomy. The assistant surgeon has experience with arterial and venous interventions in the lower extremities, and also served as the anesthetist during the procedure. The nurse has several years of experience monitoring blood pressure and administering fluid infusions in the intervention center. The radiographer also has several years of experience with angiography.

Step-by-step description

The patient was an 80-year-old male, who underwent surgery for gastric carcinoma on April, 2023. He has been receiving 3 weekly S-1 and oxaliplatin (SOX) chemotherapy through a PICC in his right basilic vein since May 2023. The last chemotherapy session was performed on September, 2023, and no problems had occurred during that time. On October, 2023, he was referred to our partner hospital after a check-up computed tomography (CT) scan detected a foreign body in the right pulmonary artery (Figure 1). Although the patient was asymptomatic, the risk of catheter embolization was associated with several serious complications, such as blood infection and venous thrombosis. These complications can result in high rates of mortality, so the removal of the fragment was planned.

Figure 1 Preoperative chest CT demonstrated embolized PICC coiled in the right main pulmonary artery on the day of retrieval (white arrow). CT, computed tomography; PICC, peripherally inserted central catheter.

Percutaneous retrieval of the fragment was performed as follows: under local anesthesia, the right femoral vein was punctured and a 5-F sheath (Terumo Co., Ltd.) was placed. First, a 5-F multifunctional catheter (Cordis Corporation) was inserted over a 0.035-inch guidewire (Radifocus^®, Terumo Co., Ltd.) into the sheath and advanced into the inferior vena cava (IVC) near the right atrium. Second, the guidewire was exchanged for an Amplatz super stiff wire (Boston Scientific), and the 5-F sheath and multifunctional catheter were retrieved. Third, a 10-F sheath 70 cm in length (Barty Medical) was advanced to the IVC near the right atrium. A 5-F pigtail catheter (Optiflash^®, Terumo Co., Ltd.) was inserted into the sheath. Then, it was advanced into the right pulmonary artery by a 0.035-inch guidewire under multidirectional fluoroscopic guidance. The guidewire was exchanged with a super core wire (Terumo Co., Ltd.) and the pigtail catheter was retrieved. A snare loop was inserted into the right pulmonary artery over the super core wire, but it could not grasp the free ends of the fragment (Figure 2). Subsequently, the snare loop was retrieved and the pigtail catheter was re-advanced to the right pulmonary artery by the super core wire. The fragment was then hooked and pulled into the right ventricle by the pigtail catheter. Since the fragment was coiled together and it was not possible to keep it still in the right atrium, its free ends were unable to be caught by the snare loop (Figure 3). In order to reduce the risk of damaging the right ventricle and right atrium during the procedure, the fragment was pulled into the IVC (Figure 4). The fragment was fluttering due to the blood stream, so it was not easy to catch its free ends using the snare loop. Therefore, we pulled the fragment to the right iliac common vein (Figure 5). Then we advanced the snare loop to the common iliac vein. Finally, we inserted another 0.014-inch guidewire though the coiled fragment via the same sheath and the guidewire was easily caught by the snare loop (Figure 6). In the end, we retrieved the snare loop and the 0.014-inch guidewire from the iliac common vein, the fragment was also removed (Figure 7). The puncture hemostasis was completed by oppression.

Figure 2 The two-step method for fragment retrieval proved unsuccessful as the free ends of the PICC were unattainable for the snare loop to seize (indicated by the white arrow). PICC, peripherally inserted central catheter.

Figure 3 Despite being hooked by the pigtail catheter and directed towards the right atrium (as denoted by the white arrow), the free ends of the PICC fragment remained difficult to seize with the snare loop. PICC, peripherally inserted central catheter.

Figure 4 The PICC was directed towards the inferior vena cava using a pigtail catheter (indicated by a white arrow), yet due to the blood flow, the free ends remained difficult to capture with the snare loop. PICC, peripherally inserted central catheter.

Figure 5 The PICC was directed into the right common iliac vein by the pigtail catheter (white arrow), allowing it to remain fixed in place due to its coiling. PICC, peripherally inserted central catheter.

Figure 6 Another 0.014-inch guidewire was advanced through the coiled fragment into the right common iliac vein, ultimately being captured by the snare loop at its tip (indicated by the white arrow).

Figure 7 The guidewire, snare loop, and the fragment of the PICC were simultaneously extracted (indicated by the white arrow). PICC, peripherally inserted central catheter.

The procedure last for approximately 40 minutes. No special materials or techniques were required during the operation process. During the procedure, a pigtail catheter was used to hook the fragment of the PICC to the external iliac vein, thereby reducing the difficulty of capturing the fragment due to its drifting with the blood flow. The process of capturing the PICC moves away from the right ventricle, reducing the risk of malignant arrhythmias during surgery. The process of extracting the PICC fragment from the common iliac vein was illustrated in Figure S1. Our technique has been termed the “sandwich technique”.

Postoperative considerations and tasks

Postoperative cardiac monitoring is essential to observe changes in heart rhythm. Additionally, a follow-up chest CT scan should be conducted to confirm the presence of any residual foreign bodies, assess for potential pulmonary artery perforation, and evaluate for the presence of pericardial effusion. Early discharge can be considered after a postoperative CT scan has ruled out any complications.

Tips and pearls

Pay attention to intraoperative cardiac rhythm changes, and if any arrhythmia occurs, promptly cease the procedure. Persistent arrhythmias may indicate myocardial damage or precipitate ventricular fibrillation, posing a danger to the patient. In such cases, the procedure should be terminated. It is necessary to reassess the benefits and risks of interventions for patients, as well as the potential harm of foreign bodies to patients. For embolized foreign bodies may be associated with serious complications, such as arrhythmia, perforation, clotting, infections and even death. So the fragments should be retrieved regardless of how long it has been dislodged. In cases where percutaneous transcatheter retrieval is unsuccessful, consideration should be given to thoracotomy for fragment retrieval. Postoperative cardiac monitoring is essential to observe changes in heart rhythm. Additionally, a follow-up chest CT scan should be conducted to confirm the presence of any residual foreign bodies, assess for potential pulmonary artery perforation, and evaluate for the presence of pericardial effusion. Early discharge can be considered after a postoperative CT scan has ruled out any complications.

Discussion

Catheter fracture and migration are rare, with an incidence of less than 0.4% (1). However, it may result in serious complications, such as arrhythmia, perforation, cardiac tamponade, thrombosis, infections, and even death (10,11). In general, the managements of catheter fracture include long-term anticoagulation therapy, percutaneous transcatheter retrieval, and open thoracotomy retrieval. Considering the potential risks and benefits, percutaneous transcatheter retrieval is the preferred approach (12).

There are several causes of catheter fracture, such as fatigue of the catheter, compression of the catheter, bad connection between the port and catheter, distortion of the anastomosis site, improper catheter position and catheter washing with high-pressure water. The point of fracture in this patient is located at the junction of the ports and the catheter. It is consistent with the typical fracture location reported in literature (13). We believe that the constant shear stress at that specific location is the most likely cause at that site. Upon fracturing, the catheter fragment is thought to have migrated distally via blood flow, ultimately becoming lodged in the pulmonary vasculature.

In general, the well-known two-step method is suitable for most cases; however, sometimes the free ends can penetrate the heart or become inaccessible during the procedure. In such a situation, it is hard to use the two-step method to retrieve the fragments. In recent years, several modified techniques have been developed in order to solve these problems, such as pigtail through snare technique, boomerang loop-snare technique, and other modified methods (5,6,14). Table 1 shows the recent modified methods based on the two-step method.

All of the abovementioned techniques are based on grasping the free ends of the fragment. In some situations, the catheter fracture may be coiled together or the free ends attached to the vessel wall, making it difficult to grasp the free ends with snare loop. Hence, there is a need to develop other techniques to improve the success rate of retrieval of the fragment.

In our case, the fragment was coiled together and lodged to the right pulmonary artery, and its free ends were impossible to grasp. We used the pigtail catheter to hook the fracture and draw it into the right atrium. Since the fragment was fluttering due to the blood stream, it was not easy to catch its free ends. In order to avoid damaging the right atrium and quickly grasp the fragment, we pulled the fragment to the right iliac common vein, then we inserted another 0.014-inch guidewire though the coiled fragment by the same sheath. The 0.014-inch guidewire was easily caught by the snare catheter. When we retrieved the snare catheter and the 0.014-inch guidewire from the iliac common vein, the fragment was also brought out (Figure 7). In the end, we inserted a 0.035-inch guidewire over the pigtail catheter into the IVC and removed the guidewire, pigtail catheter, and sheath together. The puncture hemostasis was completed by oppression. Compared with the common retrieval techniques, there are two advantages to our method. First, it does not require the creation of free ends of the fragment. It may be useful when the free ends are difficult to create by pigtail catheter or gasped by the snare loop. Second, the grasping procedure is finished in the right common iliac vein; it could avoid damaging the pulmonary artery and right atrium during the procedure. Although we need an extra wire guide wire, the method is safer and easier when compared with the well-known two-step method. We have named our method the “sandwich technique”.

This article has several limitations. First, this is a single report, needing further investigation to confirm whether this technique is feasible in most situation. Second, as this technique needs another wire when compared with the two-step method, the complexity of the procedure may be increased. Third, we did not make a long-term follow-up plan, so we did not show whether the patient would develop late adverse events.

Conclusions

Sandwich technique is one method by which to retrieve the catheter fragment dislodged to the heart or the pulmonary artery and is recommended in select patients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-337/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-337/prf

Funding: This study was sponsored by Taizhou Hospital of Zhejiang Province, Zhejiang University. The study was financially supported by the Taizhou Enze Medical Center (Group) Main Research Plan (No. 2022EZZD02), the Taizhou Municipal Bureau of Science, Technology (No. 22ywb03), and the Zhejiang Province Public Welfare Application Technology Research Plan (No. LGF20H020007).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-337/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This surgical approach was approved by the Ethics Committee of Taizhou Hospital Affiliated to Wenzhou Medical University (No. KL20250136).The Second People’s Hospital of Linhai was informed and agreed with this study. Informed consent was taken from the patient.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Azeemuddin M, Khan A, Ansari I, et al. Percutaneous endovascular removal of a broken port-a-catheter from right atrium using manual made snare. Radiol Case Rep 2022;17:2437-40. [Crossref] [PubMed]
2. Diamantidis D, Papatheodorou N, Perente S, et al. Asymptomatic Spontaneous Migration of the Tip of Port-A-Cath System Into the Right Internal Jugular Vein: A Case Report of an Uncommon Complication. Cureus 2022;14:e26937. [Crossref] [PubMed]
3. Chen GQ, Wu Y, Zhao KF, et al. Removal of "ruptured" pulmonary artery infusion port catheter by pigtail catheter combined with gooseneck trap: A case report. World J Clin Cases 2021;9:8820-4. [Crossref] [PubMed]
4. Ribeiro FS, Kumakura H, da Silva ES, et al. Removal of Intravascular Foreign Bodies With a Simple Low-Cost Method: A Report of 5 Cases. J Endovasc Ther 2021;28:474-80. [Crossref] [PubMed]
5. Kamisako A, Ikoma A, Suzuki T, et al. Successful retrieval of a foreign body in an infant's right pulmonary artery using the new boomerang loop-snare technique: A case report. Radiol Case Rep 2024;19:1965-9. [Crossref] [PubMed]
6. Mori K, Somagawa C, Kagaya S, et al. "Pigtail through snare" technique: an easy and fast way to retrieve a catheter fragment with inaccessible ends. CVIR Endovasc 2021;4:24. [Crossref] [PubMed]
7. Papa A, Tammaro D, Monda V. Retrieval of fragmented peripherally inserted central catheter (PICC) with a double transfemoral access technique. Clin Case Rep 2020;8:e3189. [Crossref] [PubMed]
8. Sokwalla NK, Sagoo R, Moussa A, et al. A modified two-step technique for the retrieval of a chemoport catheter fragment with inaccesible ends. CVIR Endovasc 2022;5:61. [Crossref] [PubMed]
9. Sood S, Srinivasan S. Retrieving embolized peripherally inserted central catheter - A novel two step technique. Radiol Case Rep 2022;17:531-6. [Crossref] [PubMed]
10. Ghaderian M, Sabri MR, Ahmadi AR. Percutaneous retrieval of an intracardiac central venous port fragment using snare with triple loops. J Res Med Sci 2015;20:97-9.
11. Machat S, Eisenhuber E, Pfarl G, et al. Complications of central venous port systems: a pictorial review. Insights Imaging 2019;10:86. [Crossref] [PubMed]
12. Bessoud B, de Baere T, Kuoch V, et al. Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol 2003;180:527-32. [Crossref] [PubMed]
13. Cheng CC, Tsai TN, Yang CC, et al. Percutaneous retrieval of dislodged totally implantable central venous access system in 92 cases: experience in a single hospital. Eur J Radiol 2009;69:346-50. [Crossref] [PubMed]
14. Haga M, Shindo S. A modified loop snare technique for the retrieval of a dislodged central venous catheter. Radiol Case Rep 2020;15:2706-9. [Crossref] [PubMed]
15. Greenfield DH, McMullan GK, Parisi AF, et al. Snare retrieval of a catheter fragment with inaccessible ends from the pulmonary artery. Cathet Cardiovasc Diagn 1978;4:87-90. [Crossref] [PubMed]
16. Teragawa H, Sueda T, Fujii Y, et al. Endovascular technique using a snare and suture for retrieving a migrated peripherally inserted central catheter in the left pulmonary artery. World J Cardiol 2013;5:369-72. [Crossref] [PubMed]
17. Shah SC, Radadiya R, Patel A, et al. Percutaneous Retrieval of Dislodged Chemo Port Catheter With Inaccessible Tips by a Simplified Technique. Cureus 2022;14:e21692. [Crossref] [PubMed]
18. Papatheodorou N Sr, Argyriou C, Botaitis S, et al. Endovascular Retrieval of a Detached and Dislocated Venous Port Catheter in the Right Heart Chamber Using a Triple-Loop Snare Device. Cureus 2023;15:e33681. [Crossref] [PubMed]