Abstract
Misplacement of pericardiocentesis catheter in central veins is a rare complication that can be managed with several methods. In this case, we report a percutaneous image-guided plug-assisted management of a misplaced pericardiocentesis catheter into the inferior vena cava through a transhepatic tract successfully occluded. This minimally invasive technique was not previously described in this setting and had a favorable long-term outcome.
Plain language summary
This clinical case reports how to manage, using a minimally invasive technique guided by imaging, an accidental puncture of the liver and the inferior vena cava during a pericardial hemorrhage drainage. The outcome was good, with technical success and a favorable outcome for the patient.
Introduction
Pericardiocentesis is a usual technique for treating patients with moderate or large symptomatic pericardial effusion and/or cardiac tamponade. 1 This technique showed its effectiveness and safety, mainly when performed under transthoracic echocardiography guidance, with a procedure-related complication rate of 4–10%.2,3 The aberrant trajectory of the drainage catheter may occur into the vena cava, reported in two cases, and managed with simple removal of the pericardiac catheter or surgically.3,4
We report a case of an ectopic intra-caval placement of a pericardiocentesis catheter through a transhepatic trajectory managed percutaneously by deploying an intravascular plug in the transhepatic tract of the drain catheter.
Case report
A 90-year-old woman was admitted for tamponade with a large hemopericardium that occurred after the rupture of the right coronary artery during a coronary angioplasty with drug-eluting stent placement for acute myocardial infarction. Immediately, a pericardiocentesis with an 8 Fr pigtail drain (Perivac™, Boston Scientific Corporation, Natick, MA, USA) was attempted by an interventional cardiologist under transthoracic echocardiographic monitoring. Due to the abnormally high amount of drained blood, a fluoroscopy control performed with contrast medium injection showed the tip of the drain positioned into the inferior vena cava (IVC). The drain was placed and attached to the skin to secure the pathway. The second attempt of ultrasounds-fluoroscopy-guided pericardiocentesis was successful. The fluoroscopy guidance ensured that the drain was positioned correctly in the pericardiac area. Following the procedure, the patient was transferred to the intensive care unit after 200 mL of hemorrhagic pericardial fluid was withdrawn through the pericardial drain.
A computed tomography (CT) confirmed the misplacement of the drainage catheter with a transhepatic (segment II) trajectory ending in the IVC through the left hepatic vein. A slight perihepatic peritoneal effusion was also noted without active bleeding signs (Figure 1).
Axial (a) and sagittal (b) multiplanar reconstructions with maximum intensity projection of portal venous contrast-enhanced computed tomography scan done immediately after the misplacement of the pericardiocentesis drain (arrow) showing its route through the hepatic parenchyma to the left hepatic vein. The catheter tip is in the inferior vena cava. The second pericardiocentesis drain is well positioned into the pericardium (arrowhead).
Considering the peritoneal effusion, the size of the drain catheter, and the periprocedural high doses of anticoagulant and anti-platelet medication, including aspirin (Kardegic; Sanofi, Paris, France), clopidogrel (Plavix; Sanofi, Paris, France), and heparin (Heparine sodique Panpharma; Panpharma, Luitré, France), a percutaneous retrieval of the drain under fluoroscopic monitoring with occlusion of the transhepatic tract was decided after multidisciplinary discussion.
The patient was transferred in an angiosuite equipped with a flat panel detector (Allura Clarity; Philips Healthcare, Best, The Netherlands). The procedure was performed under cardiorespiratory monitoring and local anesthesia. The first hepatic arteriogram performed through right-femoral artery access and selective catheterization of the hepatic artery showed no evidence of active extravasation of contrast media or arterial injury. Then, a fluoroscopy performed with contrast injection through the drainage catheter confirmed the intra-caval position of its tip with a partial transhepatic venous route of the distal third of the catheter. We placed a 0.035-inch super-stiff guidewire (Amplatz Super Stiff; Boston Scientific Corporation, Natick, MA, USA) through the catheter drain, which was carefully withdrawn, letting the guidewire in place. We placed then an 8 Fr/10 cm sheath (Terumo, Tokyo, Japan) throughout the guidewire. A digital subtracted angiography via the sheath showed the transhepatic route and a contrast leakage in the peritoneal space (Figure 2).
(a) Fluoroscopy images performed with contrast injection through the 8 Fr sheath (white Asterix) showing the intra-parenchymal tract through the left hepatic vein (white arrow). (b) DSA shows the intrahepatic tract (arrow’s head) connected to the IVC through the left hepatic vein. (c) Deployment of AVP 2 into the intrahepatic tract (black arrows). (d) DSA after intrahepatic injection of media contrast shows no extravasation of contrast in the hepatic tract well occluded by the AVP 2 device (black arrows). Note the third disk of the AVP deployed against the hepatic capsule.
Regarding these findings, we decided to occlude the transhepatic route using a 14-mm Amplatzer Vascular Plug II (AVP 2; Abbott, North Chicago, Illinois, USA). The Amplatzer plug was released between the intrahepatic parenchyma and the left hepatic vein. A cone-beam CT confirmed the correct positioning of the vascular plug. No complications occurred after the procedure. The clinical follow-up revealed no discrepancies, and a CT scan 4 days after the procedure showed correct plug placement with no evidence of peritoneal suffusion (Figure 3). The patient was discharged 10 days later with a complete recovery. The 6-month clinical follow-up after the procedure showed no evidence of complications related to the procedure.
Axial (a) and sagittal (b) multiplanar reconstructions of a non-enhanced CT performed 4 days after the procedure: vascular plug well deployed in the hepatic tract (arrow). Note that the proximal disk of the AVP 2 is applied against the hepatic capsule (arrow’s head).
Discussion
Although the efficacy and safety of echocardiographically guided pericardiocentesis are well reported in the literature, 1 this procedure could be associated with a wide range of complications, such as cardiac perforation, cardiac laceration, and intercostal, internal mammary or coronary arteries injuries. 5 Misplacement of a pericardiocentesis catheter in the central veins is an exceptional complication reported only in two cases.3,4 This complication was also described in two cases of percutaneous drainage of abdominal collections6,7 and a case of misplacement of a chest tube. 5 The management of this complication during pericardiocentesis was a simple withdrawal of the catheter under close clinical supervision in one case 3 and surgical removal under extracorporeal circulation in the other. The surgery was indicated in this patient because the catheter tip was in the right atrium, and a myocardial wall perforation was suspected but not confirmed perioperatively. 4
Liver tract embolization was described to prevent bleeding risk in several transhepatic procedures, such as percutaneous liver biopsy with hemostasis disorders, percutaneous transhepatic portal interventions, or transhepatic biliary drain placement.6,8 This technique was also described to occlude the transhepatic tract after retrieval of a misplaced thoracic tube in the right ventricle through the right hepatic vein and the IVC, using a pull-through technique and a balloon-assisted hepatic tract coil embolization. 5 In our patient, we opted for the occlusion of the transhepatic tract given the catheter size (8 Fr), the perihepatic effusion on the CT scan, and the antiaggregant-induced hypocoagulability after coronary angioplasty. The confirmation of the misplaced drain location by CT and the determination of its exact route through the hepatic parenchyma and the left hepatic vein were crucial in the treatment planning.
Several embolic agents can be used for transhepatic tract embolization, such as coils, vascular plugs, or vascular closure devices. 8 We chose the vascular occluder plug based on its three-disk configuration, allowing a good fit in the hepatic parenchymal route with the deployment of the proximal disk flat against the hepatic capsule as a ‘push-button’.
Conclusion
Controlled withdrawal of a misplaced drainage catheter in the central venous system under radiological monitoring with a vascular plug’s embolization of the transparenchymal trajectory could be proposed as an effective and safe technique. This percutaneous management of intra-caval misplacement of the pericardial drain allowed immediate technical success and no delayed complications. This case also highlighted the importance of pre-interventional imaging, allowing accurate analysis of the misplaced drain route and treatment planification.
