Recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein: A case report.

A fibrin sheath with central venous occlusion is a common complication after central venous catheterization, and these patients often experience catheter dysfunction. A calcified fibrin sheath can cause a catheter to be stuck, and typically necessitates catheter removal or replacement. From another point of view, a calcified fibrin sheath can be seen in ultrasound and computed tomography, and the original fibrin sheath channel between the internal jugular vein and the atrium is unusually strong. When central vein occlusion occurs, the remnant calcified fibrin sheath of the internal jugular vein can be punctured under ultrasound guidance, allowing the guidewire to enter the atrium directly through the fibrin sheath. Here, we report a case in which we achieved easy recanalization of a long segment occluded superior vena cava by puncturing the remnant calcified fibrin sheath of the internal jugular vein.

Stripping the catheter: A new device for an old technique.

Fibroblastic sleeve is a common pathophysiological phenomenon characterized by the formation of a mixed fibrous-collagen tissue encasing the outside of venous access devices. Although it nearly always presents asymptomatically, this catheter-related complication represents one of the leading culprits of venous catheters malfunction. Several techniques have been described for the management of dysfunctional catheters secondary to fibroblastic sleeve, including medical therapy, catheter exchange, balloon angioplasty, and percutaneous stripping. However, there is no common consensus for the treatment management in patients who present contraindications to surgical port removal. This report illustrates the case of a port catheter malfunction due to a fibroblastic sleeve in an oncological patient with a high risk of bleeding. This was effectively treated with a minimally invasive stripping technique using an off-label device for mechanical thrombectomy, namely the ClotTriever system (Inari Medical, Irvine, CA).

Successful Removal and Replacement of a Stuck Hemodialysis Catheter via Thoracotomy: Report of Two Cases and Literature Review.

Introduction: Stuck tunneled central venous catheters (CVCs) have been increasingly reported. In rare cases, the impossibility of extracting the CVC from the central vein after regular traction is the result of rigid adhesions to the surrounding fibrin sheath. Forced traction during catheter removal can cause serious complications, including cardiac tamponade, hemothorax, and hemorrhagic shock. Knowledge and experience on how to properly manage the stuck catheter are still limited. Case Presentation: Here, we present two cases that highlight the successful removal of the stuck tunneled CVC via thoracotomy through the close collaboration of multidisciplinary specialists in the best possible way. Both patients underwent an unsuccessful attempt at thrombolytic therapy with urokinase, catheter traction under the guidance of digital subtraction angiography and intraluminal balloon dilation. And we reviewed the literature on stuck catheters in the hope of providing knowledge and effective approaches to attempted removal of stuck catheters. Conclusion: There is no standardized procedure for dealing with stuck catheters. Intraluminal percutaneous transluminal angioplasty should be considered as the first-line treatment, while open surgery represents a second option only in the event of failure. Care must be taken that forced extubation can cause patients life-threatening.

[Calcified Fibrin Sheath After Stuck Catheter Removal: Case Report and Literature Review].

The prevalence of central venous catheters (CVC) in hemodialysis patients is around 20-30%. In this scenario, complications related to the use of the CVC are commonly observed, requiring active management by nephrologists. These include infectious complications as well as those related to CVC malfunction. Among the latter, the formation of a fibrin sheath around the catheter linked to foreign body reaction could cause CVC malfunction in various ways. Even after the removal of the catheter, the fibrin sheath can remain inside the vascular lumen (ghost fibrin sheath) and rarely undergo calcification. We describe the clinical case of a hemodialysis patient who, following the removal of a malfunctioning, stuck CVC, presented a calcified tubular structure in the lumen of the superior vena cava, diagnosed as calcified fibrin sheath (CFS). This rare occurrence, described in the literature in 8 other cases, although rare, is certainly underdiagnosed and can lead to complications such as sepsis resulting from CFS, pulmonary embolisms, and vascular thrombosis. Therapeutic approaches should be considered only in symptomatic cases and involve an invasive surgical approach.

Case review and imaging: Treatment of central venous catheter associated fibrin sheath and chronic thrombus with the ClotTriever system.

Fibrin sheath formation is a leading culprit of central venous catheter malfunction. The complete removal of fibrin sheaths is an essential component of maintaining catheter patency, preventing future restenosis, and decreasing the risk of bloodborne infections. Treatment of fibrin sheaths includes pharmacologic therapy, balloon angioplasty, catheter exchange, and mechanical stripping. In this article 3 cases are reviewed, 2 patients had long-term hemodialysis catheter malfunction and 1 had complications related to a chest port. On imaging, superior vena cava stenosis, occlusion, and/or filling defect were identified for all patients, as well as findings suggesting the presence of fibrin sheath. Description of these cases detail a new technique for fibrin sheath removal utilizing the ClotTriever System (Inari Medical, Irvine, CA), which is a mechanical thrombectomy device used for the treatment of deep vein thrombosis. This technique allowed for complete removal of the fibrin sheath via a minimally invasive interventional procedure which did not require access through the central venous catheter lumen.

Comparison of the complications and long-term results of heparin-coated and non-heparin-coated symmetric-tip hemodialysis catheters.

BACKGROUND: Tunneled catheters are effectively used in patients receiving chronic dialysis due to end-stage renal disease. However, the dysfunction of catheters caused by infection or thrombus requires repetitive procedures. In this study, we aimed to compare the long-term results of heparin-coated and non-heparin-coated tunneled dialysis catheters. METHOD: The study included a total of 161 patients who underwent tunneled dialysis catheter placement. Heparin-coated and non-heparin-coated tunneled catheters were placed in 81 and 80 patients, respectively. Of all the patients, 89 (55.3%) were male and 72 (44.7%) were female. The mean age of the patients was 64.3 ± 15.3 years. The patients were followed up for 12 months. RESULTS: Catheter infection developed in 10 (6.2%) of the cases, of which seven (70%) resolved with antibiotic therapy and the remaining three (30%) required catheter replacement. There was no significant difference between the groups in terms of the catheter infection rate (p = 0.84). Fibrin sheaths developed in nine (5.5%) patients. Fibrin sheath development was found to be significantly higher in the non-heparin-coated catheters (p = 0.017). There was no significant difference in fibrin sheath formation between the patients with and without systemic antiaggregant use (p = 0.864). The mean catheter durability time was determined to be 11 months in both groups (p = 0.704). Catheter survival was similar in heparin-coated and non-heparin coated catheters. CONCLUSION: This study showed that the rate of fibrin sheath development was significantly lower in heparin-coated tunneled catheters than non-heparin-coated catheters. There was no significant difference between the two catheters in terms of the rates of infection and mechanical complications.

Fibrin Sheath Catheter-Related Endovascular Right-Sided Heart Infection in Heart Failure With Reduced Ejection Fraction: A Case Report.

Patients with end-stage renal disease (ESRD) receive dialysis through either hemodialysis (HD) or peritoneal dialysis (PD). HD has challenges associated with vascular access and catheter-associated complications. The development of a fibrin sheath is a common complication with tunneled catheters. However, infection of the fibrin sheath is not usually encountered. We discuss the case of a 60-year-old female with ESRD and heart failure with reduced ejection fraction (HFrEF) receiving HD via tunneled right internal jugular (RIJ) Permcath who was diagnosed with an infected fibrin sheath located in the cavoatrial junction via a transesophageal echocardiogram (TEE). Compared to a transthoracic echocardiogram (TTE), a transesophageal echocardiogram provides a much more accurate diagnosis of this rare condition. Treatment primarily involves administering antibiotics based on sensitivity cultures and closely monitoring for any potential complications.

Variance in management of extracorporeal membrane oxygenation-associated fibrin sheaths at a single institution.

Objective: Extracorporeal membrane oxygenation (ECMO) support for patients with cardiac or respiratory failure has been increasingly used by advanced critical care practitioners. The thromboembolic complications of ECMO have been extensively discussed and researched; however, research and discussion on the development, risks, and management of cannulae-associated fibrin sheaths are lacking. Methods: Institutional review board approval was not required. We have presented three cases detailing the identification and individualized management of ECMO-associated fibrin sheaths at our institution. The three patients provided written informed consent for the report of their case details and imaging studies. Results: Of our three patients with ECMO-associated fibrin sheaths, two were managed successfully with anticoagulation alone. One could not receive anticoagulation therapy and underwent inferior vena cava filter placement. Conclusions: Fibrin sheath formation around indwelling ECMO cannulae is an unresearched complication of ECMO cannulation. We would recommend an individualized approach to the management of these fibrin sheaths and have provided three examples of successful management.

Calcified Fibrin Sheath Embolism of Bilateral Pulmonary Arteries: A Second Case of the Literature.

INTRODUCTION/BACKGROUND: Central venous catheters, which provide a unique convenience in the management of critical patients, have many advantages, as well as early and late complications. Early complications include pneumothorax, vascular perforation, hematoma formation, air embolism, or catheter malposition that may occur during or shortly after catheter insertion. Late complications include infection, venous stenosis, catheter thrombosis, and catheter tip migration. In the literature, embolization of a calcified fibrin sheath due to a central venous catheter to the pulmonary artery has been reported only in one case. CASE PRESENTATION: The purpose of this report is to present bilateral pulmonary artery embolism in a patient who presented with cough and chest pain caused by calcified fibrin sheath of the port catheter removed before that was used for regular chemotherapeutic infusions due to liposarcoma, as the second case in the literature with imaging findings. The patient underwent medical treatment, and as a result of the treatment, symptoms regressed. CONCLUSION: Central venous catheters have many complications, and although it is rare, pulmonary embolism is one of them. The embolism of a calcified sheath is even rare, but it is still possible. However, an embolism can cause significant morbidity and even mortality for a patient if it occurs. As physicians, we should be aware of this entity to diagnose.

Infectious outcomes of fibrin sheath disruption in tunneled dialysis catheters.

BACKGROUND AND OBJECTIVES: Fibrin sheath (FS) formation around tunneled central venous catheters (CVC) increases the risk of catheter-related bloodstream infections due to bacterial adherence to a biofilm. We sought to investigate whether FS disruption (FSD) at the time of CVC removal or exchange affects infectious outcomes in patients with CVC-related infections. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Retrospective cohort study of 307 adult maintenance hemodialysis patients aged 18 years or older at a single center academic-based hemodialysis program (UHN, Toronto) who developed CVC-related infections requiring CVC removal or exchange between January 2000 and January 2019. Exposure was FSD at the time of CVC removal or exchange. Outcomes were infectious metastatic complications, recurrent infection with the same organism within 1 year, or death due to infection. We created a Markov Multi-State Model (MMSM) to assess patients' trajectories through time as they transitioned between states. A time-to-event analysis was performed, adjusted for clinically relevant factors. RESULTS: There was no significant relationship between FSD status at the time of CVC removal, the development of infectious complications in the multivariable model (adjusted HR = 0.71, 95% CI 0.09-5.80, p = 0.76), or mortality from infection (HR = 0.84, 95% CI 0.34-2.11, p = 0.73). CONCLUSIONS: FSD at the time of CVC removal was not associated with increased risk of infectious complications or death due to infection. Further prospective study is needed to determine whether FSD contributes to reducing CVC infectious related complications.

Removal of central venous port-catheter by the combination of interventional radiological procedures.

We encountered a patient with an infection related to an implanted central venous port-catheter that necessitated removal of the system. As the catheter had tightly adhered to the venous wall, removal was impossible with standard methods. After trial and error, we used a guiding catheter that was advanced over the implanted catheter to detach the fibrin sheath on the implanted catheter that had adhered to the vessel wall. At that time, a pull-through technique was used. After we succeeded in detaching the adhesion with the guiding catheter, we were able to withdraw the implanted catheter.

[Catheter Replacement Methods in Hemodialysis Patients With Dysfunctional Tunneled-Cuffed Catheters With Fibrin Sheaths]. / 对形成纤维蛋白鞘的带涤纶套和隧道透析导管的更换方式探索.

Objective: Tunneled-cuffed catheters (TCCs) are frequently used for establishing hemodialysis access for maintenance hemodialysis in older patients with exhausted resources of peripheral vessels. Fibrin sheath formation around the catheter is one of the most common complications of long-term use of indwelling catheter, which may cause the malfunction of the catheter. In this study, we intend to compare the prognosis of two catheter replacement methods, in situ replacement and replacement through a fibrin sheath crevice, with both being assisted by balloon dilation, and to explore the optimal catheter replacement process. Methods: A retrospective study was conducted with 52 patients who underwent a replacement of their TCCs. Among them, 27 cases had their TCC replaced by the modified method of replacement through a fibrin sheath crevice and were referred to as the sheath crevice group, while 25 cases underwent in situ catheter replacement and were referred to as the in situ group. The primary outcome indicators included maximum blood flow in hemodialysis catheter and the urea clearance rate calculated by Kt/V values at the 1, 3, and 6-month follow-ups. The secondary outcomes included dialyzer alarms being set off and catheter-related infections during follow-up. Results: There was no significant difference between the general data of the two groups. There was no massive blood loss during the replacement procedure. Neither were there cardiac tamponade, catheter-associated infections, or other complications. Follow-ups were made 1, 3, and 6 months after the replacement procedure. The sheath crevice group had higher catheter blood flow and Kt/V values at the 6-month follow-up than the in situ group did ([241.85±9.62] mL/min vs. [234.40±11.21] mL/min, P=0.014 and 1.31±0.55 vs. 1.27±0.49, P=0.005, respectively). During the follow-up process, access alarms were reported in 5 patients (three in the in situ group and two in the sheath crevice group) during dialysis. No catheter-associated infection occurred in either group. Conclusion: The catheter replacement method of balloon dilation-assisted catheter insertion through a fibrin sheath crevice is safe and effective, resulting in better long-term catheter blood flow compared with that of in situ catheter replacement.

Embolized fibrin sheath material presenting as intraluminal calcifications within the pulmonary arteries on CT.

Fibrin sheath formation is a well-described sequela of an indwelling central venous catheter. Fibrin sheaths may also develop around other foreign bodies within the venous system. We describe a case of fibrin sheath formation within the left brachiocephalic vein secondary to automatic implantable cardioverter-defibrillator (AICD) leads with subsequent embolization of sheath material presenting as calcifications within the pulmonary vasculature on computed tomography (CT). Most of the relevant literature focuses on catheter-related sheath formation and associated complications while reports on fibrin sheaths from other foreign bodies are sparse. We advise that radiologists who encounter intraluminal calcifications within the pulmonary arteries on CT should consider the possibility of a fibrin sheath as the source and search for its remnants in the central venous system for confirmation.

CT and Sonographic Findings of a Calcified Fibrin Sheath From an Umbilical Venous Catheter in a Neonate.

Central venous catheters are ubiquitous in current medical practice in intensive care units and for long-term nutrition, chemotherapy, and antibiotic therapies. Umbilical venous catheters provide short-term central vascular access and are used in the neonatal period. This case presents sonographic and CT imaging findings of an intrahepatic and intracardiac calcified fibrin sheath following removal of a short-term umbilical venous catheter in a 32-day-old premature neonate.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications.

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

Evaluation of the antithrombogenicity of poly-2-methoxyethylacrylate-coated catheters.

BACKGROUND AND OBJECTIVES: The blood compatibility of indwelling intravascular catheters is facilitated by the use of antithrombogenic materials. Heparin has typically been used for this purpose; however, since heparin-coated catheters are considered combination products, difficulties meeting the relevant Food and Drug Administration safety recommendations have disrupted commercialization. Other issues include coating durability and the occurrence of heparin-induced thrombocytopenia. Polymer coatings are a potential alternative; however, polymer antithrombogenicity in circulating human blood has yet to be demonstrated. The present study aimed to establish the ex vivo antithrombogenicity of a poly-2-methoxyethylacrylate (PMEA) polymer coating applied to a central venous catheter using an artificial human blood circulation system. METHODS: The present study used an artificial human blood circulation system to conduct an ex vivo evaluation of the antithrombogenicity of poly-2-methoxyethylacrylate (PMEA)-coated catheters. Human blood samples obtained from volunteer donors were loaded into a circulation system fitted with either a PMEA-coated or uncoated catheter. After 3-h, the catheter was removed and examined using scanning electron microscopy. Protein adsorption on the catheter surface was investigated by shredding the catheter that had contacted the blood inside the circulation system and immersing the pieces in 1 mL of 0.5 N NaOH for 2 days. The amount of protein in the 0.5 N NaOH was determined according to the Lowry method. RESULTS: Adherent fibrin, which forms a sheath on the catheter surface, was observed on uncoated, but not PMEA-coated catheters. Furthermore, the amount of protein adsorption was significantly less with PMEA-coated than uncoated catheters (p = 0.043). CONCLUSIONS: The present findings demonstrated the antithrombogenicity of PMEA-coated catheters in circulating human blood.

Presence of retained calcified fibrin sheath after central venous catheter removal: A systematic literature review.

Central venous catheters (CVC) are used in many clinical settings for a variety of indications. We performed a systematic literature review concerning case reports of retained calcified fibrin sheaths after dialysis CVC removal. The aim of our study was to systematize the knowledge regarding clinical management of this phenomenon, placing special emphasis on diagnostic radiological features in different imaging modalities, including chest radiography, echocardiography, computed tomography, and magnetic resonance imaging. We discuss the most common risk factors associated with this CVC complication. In our review, we found eight cases of hemodialysis patients. The most common risk factors associated with calcified fibrin sheath formation in the analyzed cases were pro-thrombotic and pro-calcification factors related to patient comorbidities, and prolonged catheter dwell time. Differentiating between a calcified fibrin sheath (present in about 6% of patients with long-term indwelling CVC as diagnosed by computed tomography) and a retained catheter tip can be challenging. The initial diagnosis based on imaging methods was incorrect in most of the analyzed cases. This suggests that some cases of retained fibrin sheaths may remain undetected or misinterpreted. This is important in patients with known pro-thrombotic and pro-calcification risk factors and prolonged catheter dwell time. Therefore, implementation of preventive strategies, familiarity with radiological findings of this phenomenon, comparison with previous imaging studies, and an overall comprehensive assessment with clinical data is imperative.

Fibrin sheath disruption during guidewire exchange for bacteremia: Low recurrence of infection and preservation of vascular access sites.

BACKGROUND: Catheter-associated bacteremia (CAB) often leads to removal of tunneled dialysis catheters with delayed insertion (RDI). Exchange over a guidewire (ExW) can be considered for access site preservation. Fibrin sheath disruption (FSD) during exchange is not standard practice for infected catheters. Here we present the first analysis of outcomes after such exchanges (ExW-FSD). METHODS: Retrospective analysis of catheter exchanges and removals performed by interventional nephrology for bacteremia in 2008-2011 observed for 20.5 months. Charts were reviewed for recurrent or new bacteremia and death at 3 months, and for occurrence of thrombosis or stenosis along the catheter site. Catheter exchange with central venogram and fibrin sheath disruption was our standard of care in all patients presenting for CAB. RDI was performed either for tunnel infection, non-clearing of infection or at the request of referring physicians. RESULTS: Over 4 years, 66 patients were treated for CAB. Forty-two patients underwent ExW-FSD, which was performed even for Staph. aureus, gram negative bacteremia or candidemia. RDI was performed in 24 cases. Bacteremia recurred in 3 (7%) patients after ExW-FSD, and in 7 (30%) cases after RDI (p = 0.02). There was no significant difference in new infections: 5 (12%) after ExW-FSD and 2 (8%) after RDI. There was no death within 3 months after ExW-FSD and 4 (27%) (p = 0.005) deaths in the RDI group.There was one new central venous stenosis in the ExW-FSD group (2%) with no loss of access site, and 8 (33%) patients developed thrombosis/stenosis along the prior catheter track after RDI (33%) (p = 0.006) with loss of access site in (21%). CONCLUSIONS: In this retrospective analysis of treatment of CAB, ExW-FSD was associated with lower recurrence of bacteremia, lower death rate and a lower incidence of access site loss compared to RDI. These data support ExW-FSD use in patients with CAB.

The fibroblastic sleeve, the neglected complication of venous access devices: A narrative review.

The presence of a vascular access device (or of any intravascular foreign body) inside the bloodstream is often associated with the formation of a connective tissue sleeve around the catheter (often named-erroneously-"fibrin sleeve"). Such sleeve is usually a physiological phenomenon with little or no clinical relevance, but its pathogenesis is still unclear, so that it is frequently confused with venous thrombosis; also, its relationship with other major catheter-related complications, such as venous thrombosis and bloodstream infection, is uncertain. This narrative review tries to convey in a systematic form the current knowledge about pathogenesis, incidence, clinical manifestations, diagnosis, and management of this phenomenon.