Ultrasound-guided Surgical Retrieval of Broken Arterial Catheter

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Cannulation of the radial artery for continuous monitoring of blood pressure and frequent blood gas analysis is generally preferred due to its easy accessibility, predictable anatomy, and low complication rates, supported by collateral circulation, which helps minimize ischemic risk. However, arterial cannulation can unexpectedly lead to serious complications such as bleeding, hematoma, pseudoaneurysm, thrombosis, infection, tissue ischemia, and nerve injury.^[1] We present an uncommon complication of a radial arterial catheter during its attempted removal.

A 58-year-old man with coronary artery disease was scheduled for coronary artery bypass graft surgery. Under local anesthesia, right radial artery cannulation was performed (20-G arterial cannula, BD Floswitch^TM, Becton Dickinson, Ireland) in the first attempt, using the digital palpation method. The cannula was secured with a sterile, transparent Tegaderm^TM dressing. The arterial catheter was connected to the continuous saline-flush system. On the 2^nd post-operative day, during the attempted removal of the arterial catheter, an accidental fracture of the catheter was noted. The removed arterial catheter had a length of only about 5 mm attached to its hub, and the remaining part of the catheter was suspected to be lost in the artery. Urgent vascular consultation was sought. On ultrasound evaluation (12L-RS Linear Vascular Probe, GE Medical Systems, Jiangsu, China), the broken arterial catheter was located in the radial artery [Figure 1]. Under sterile conditions, using local anesthesia and ultrasound guidance, the proximal and distal controls of the radial artery were taken, an arteriotomy was performed, and the catheter was surgically retrieved [Figure 2]. A 2-French embolectomy catheter was inserted, good forward and backward blood flows were ensured, and the arteriotomy site was closed. The patient made an uneventful recovery without vascular compromise.

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Figure 1:

Ultrasound images showing retained catheter (arrows) in the radial artery, (a): Long-axis view, (b): Short-axis view.

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Figure 2:

Arterial cannula with broken hub and retrieved part of the catheter.

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Loss of a catheter to a vessel is a rare complication of arterial cannulation and has only been reported in sporadic case reports.^[2-4] The exact mechanism leading to catheter fracture is not fully understood. The possible reasons described in the literature include a malfunction during device design, prolonged cannulation time, catheter shearing by needle during cannulation, kinking during securement, damage by the needle while sewing the catheter to the skin, cutting the securing suture by the scissors, anatomical variation (tortuous or small vessel), a combination of these factors, or unknown etiology.^[5] The risks of vascular complications arising from percutaneous radial artery cannulation, including arterial occlusion, cannula dysfunction, and thrombus formation, increase markedly after 3 days. Repeated movements of the wrist during recovery from anesthesia are also postulated to cause shearing and fracture of the arterial catheter.^[3] Seldinger technique, as compared to the modified Seldinger technique, is a faster and more predictable radial artery access technique, with no increase in bleeding or radial artery occlusion. For the radial artery cannulation, both the guidewire-based and ultrasound-guided methods are superior to the direct palpation method, and significantly improve the success rate in the first attempt. However, they do not significantly increase the overall success rate or reduce the risk of complications. With regard to the type of arterial catheter, the polyurethane catheter is favored for its balance of stiffness and flexibility, reducing kinking and spasm compared to Teflon material. The reason for the broken catheter in this case was unknown.

It is important to find out the precise location of the retained arterial catheter. Local vascular spasm can prevent further embolization of the broken catheter. Some of the previous authors have performed surgical exploration without any imaging proof.^[3] Others have used an X-ray of the wrist to localize the arterial catheter, which does not give a clear picture. A three-dimensional reconstruction of computed tomography has been used to identify a foreign body in the radial artery.^[2] Real-time ultrasound imaging allows rapid localization of the intraluminal arterial foreign body. The use of ultrasound is preferred over radiograph or computed tomography because it is real-time, inexpensive, and does not expose the patient to radiation. The potential benefits of the use of ultrasound include (i) confirmation of intra-arterial location of the catheter, (ii) confirmation of distal migration into the palmar arteries, (iii) identification of proximal and distal ends of the catheter, (iv) precise cutaneous incision, (v) exact location of the arteriotomy site, and (vi) minimized surgical time.^[6]

An intra-arterial fragment can either be retrieved by an endovascular technique or surgical method. Distal migration can make direct surgical incision difficult to perform. If the fragment migrates more distally toward the deep palmar arch, the possibility of ischemic complications could increase. Distal thrombosis and embolization resulting in digital ischemia and subsequent infection can also occur if the surgical exploration is delayed.^[7] In conclusion, it is emphasized that the integrity of every medical object is checked after its removal from a patient.