Complications of cardiac catheterization needing emergency surgery.
Cardiac catheterization has been performed with increasing frequency since the first report by Cournand and Ranges in 1941. It is now a relatively safe procedure but it is important for those who perform catheterization to be aware of its. possible complications. We report in this paper seven cases who had unusual complications following cardiac catheterization. All these seven cases were referred to the Department of Cardiovascular Surgery of the KEM Hospital for emergency management.
During the period 1972-84, seven cases of serious complications following catheterization of the heart and. major vessels were referred to us for emergency management. In the same period approximately 8000 cardiac catheterizations and aortograms were done in the KEM Hospital.
Case 1: Broken catheter lying in the atrial septal defect:
This was an adult male who was catheterised to confirm the clinical diagnosis of atrial septal defect. During the procedure, the catheter broke at the atrial septal defect. The patient had to be subjected for emergency surgery. Under conventional cardio-pulmonary bypass the right atrium was opened; the catheter could be easily taken out. The ASD was closed with a patch. Post-operative course was uneventful.
Case 2: Perforation of the coarcted aorta by the catheter:
An 18 year old adult male was subjected to aortography to confirm the diagnosis of coarctation of the aorta. The catheter was passed by Seldinger's technique through the left femoral artery. An attempt was made to go across the coarcted segment of the aorta; the catheter perforated the thin wall of the aorta. The patient had profuse bleeding and had to be opened up immediately. The coarcted segment was patched with a dacron graft. The perforation was sutured. The post-operative period was stormy because of continuous fever due to infection, and the patient had to be hospitalised for nearly 2 months.
Case 3: Perforation of the myocardium and subsequent cardiac tamponade during cardiac catheterisation:
A 22 year old young female was diagnosed clinically as having pulmonary stenosis and right heart catheterization was done. The catheter perforated the right ventricle. The perforation was confirmed by spilling of the dye into the pericardial cavity. The catheter was immediately withdrawn. However, the patient developed cardiac tamponade. Immediate surgery was performed. The pericardium was opened by a median sternotomy and the tamponade was relieved. A large dermoid cyst sat over the right ventricular out-flow tract. After excising the cyst, the thrill over the pulmonary artery disappeared. The post-operative course was uneventful.
Case 4: Broken catheter in the left subclavian artery:
A 44 year old adult male was investigated for cerebrovascular insufficiency. A selective vertebral injection was being attempted. However, the catheter broke in the left subclavian artery. The catheter could be easily taken out by exposing the subclavian artery through a standard supraclavicular approach. The postoperative course was smooth.
Case :5: Broken catheter in the patent ductus arteriosus:
A young female patient aged 3 years was subjected to cardiac catheterization in another hospital to establish the diagnosis of patent ductus arteriosus. The catheter broke when it way being negotiated across the ductus. The child was immediately brought to the KEM Hospital Fluoroscopy revealed that the catheter was rotating along its long axis inside the ductus with each heart beat. The child was subjected to emergency surgery. A median sternotomy was done and the ductus was dissected close to the left hilum. However in the meantime, the catheter moved into the right pulmonary artery along the blood stream. The ductus was ligated and under conventional cardiopulmonary bypass the main pulmonary artery was opened The catheter could be easily pulled out from the right pulmonary artery ostium. This patient had smooth post-operative recovery.
Case 6: Broken catheter slipped into superior vena cava:
A 48 year old. male underwent coronary artery bypass grafting. When the neck line was being removed two days after surgery, the catheter broke inadvertantly. The broken catheter slipped into the SVC. This was confirmed by the X-ray of the chest. The sternum was reopened. The catheter could be easily palpated at the SVC-RA junction. It was removed by placing two stay sutures over the SVC. The patient developed sternal dehisence and mediastinitis on the 10th day after operation. He was discharged on the 20th day after operation after control of infection.
Case 7: Broken catheter in the inferior vena cava:
An adult male aged 35 years was investigated for IVC obstruction, which in the form of a diaphragm at the IVC-RA junction was delineated on the cavogram. An attempt was made to perforate the diphragm with the help of a rigid catheter. However, the catheter broke. The patient was offered surgery but he refused. When seen last (one year after the above event), the patient was none the worse for it.
Thus, 5 patients had broken intravascular catheters and two had vascular perforation. Six patients were operated upon; all survived. One patient (Case No. 7) refused surgery. Two patients (Case Nos. 2 and 6) had significant postoperative infection. One patient (Case No. 3) had to be subjected to surgery without establishing proper diagnosis as the catheterization had to be abandoned because of the complication.
During the period 1972-1984, approximately 8000 cardiac and major vessel catheterizations were performed in the KEM Hospital. Five broken catheters during this period compares favourably with the reported incidence of this complication (6 in 12,367) in the literature.
In view of the high morbidity (perforation of the heart, sepsis, pulmonary emboli and arrhythmias) and mortality caused by the broken catheters, emergency removal is always indicated.,, Case No. 1 from this series has already been published.
Pervenous retrieval of broken catheters requires a combination of techniques. It is mandatory to dislodge the catheter initially and later to ensnare it. Cardiac catheters, rigid bronchoscopic forceps endomyocardial biotomes and flexible endoscopy forceps, have all been used successfully to remove the retained catheters. The variety of pervenous retrieveal techniques that have been reported probably indicate lack of uniform success with any one.
In the present series, in most of the cases correction of the pathology was an equally important aspect of treatment of the complication. Hence, non-invasive techniques were not been employed for removing broken catheters. The broken catheters in the subclavian artery and superior vena cava possibly could have come out with non-invasive technique. However due to long length of catheter left incide the vessel, we preferred direct exploration.
The risk of perforation is around 8% during cardiac catheterisation. The right atrium and the right ventricle are the common sites of perforation. In our series, perforation was seen only in 2 cases.
Cardiac tamponade is uncommon following right heart catheterisation. Most of the reports pertain to the tamponade either following direct L V puncture or L A puncture,, Probably, high pressure in L V tends to cause more bleeding. In the present series, however, the tamponade occurred due to perforation of a normal right ventricle.
Monitoring of the central venous pressure is probably the commonest indication of cardiac catheterization and needs special mention. The subclavian jugular catheters have currently become popular for this purpose. They are nonirritant, radio-opaque and least likely to cause infection. However Case 6 in our series suggests that their smaller calibre and nonirritant nature allows embolization if they fracture inadvertently.
Presence of a foreign body in the circulation and bacterimia during cardiac catheterization are the predisposing factors for infection. Inflamatory reaction and bacterimia account for 5-8% of all complications following cardiac catheterisation. The risk is in fact far more when the patient undergoes emergency cardiac surgery following complication of cardiac catheterization. Two out of six cases in our series who underwent surgery had severe infection in the postoperative period. The need for utmost asepsis during cardiac catheterization cannot be overemphasised.
Case 7 is unique in this series in that he developed no further complication in spite of the retained broken catheter in the inferior vena cava. This was probably because of the protection given by the diaphragm at the junction of the IVC and the right atrium against further embolization.