Upsala J Med Sci 87: 175-177, 1982 Peripheral Embolization of Separated Angiographic Catheter B. Almgren’ and A. Hemmingsson’ Departments of Surgery’ and Diagnostic Radiology‘, University Hospiial, Uppscrlcr, SwcJJen ABSTRACT A c o m p l i c a t i o n o f s e p a r a t i o n o f an a n g i o g r a p h i c c a t h e t e r i s described. Con- t r i b u t i n g f a c t o r s and p r e v e n t i v e measures a r e discussed. INTRODUCTION C a t h e t e r s e p a r a t i o n i s an e x t r e m e l y r a r e compl c a t i o n o f angiography. An i n - c i d e n c e o f 0.0008 p e r c e n t has been r e p o r t e d ( 3 ) , b u t a l s o a h i g h e r o f 2 p e r c e n t , when angiography has been performed t h r o u g h s y n t h e t i c v a s c u l a r g r a f t s ( 2 ) . I n a l l p r e v i o u s l y r e p o r t e d cases t h e broken end o f t h e c a t h e t e r has r e - m a i n e d , a t t a c h e d t o t h e v e s s e l o r g r a f t w a l l a t t h e c a t h e t e r e n t r y s i t e and i n no case p e r i p h e r a l e m b o l i z a t i o n has occurred. We h e r e r e p o r t a case u n i q u e i n t h a t t h e separated fragment embolized t o t h e p e r o n e a l a r t e r y v i a bypass g r a f t . CASE REPORT A 35-year o l d man had undergone a f e m o r o t i b i a l bypass w i t h autogenous sa- phenous v e i n g r a f t o f t h e r i g h t l e g because o f a r t e r i o s c l e r o s i s 21 months be- f o r e t h i s admission. Angiography was now requested because o f r e c u r r e n t r e s t p a i n and u l c e r a t i o n o f t h e g r e a t toe. Angiography was performed u s i n g a p o l y e t h e n e c a t h e t e r , i.d. 1.58 mm, 0.d. 2.08 mm ( R a d i c a t h ) w i t h 4 s i d e h o l e s a f t e r p u n c t u r e o f t h e r i g h t common femoral a r t e r y . No d i f f i c u l t i e s were encountered d u r i n g t h e i n s e r t i o n o r t h e study. D u r i n g w i t h d r a w a l f o l l o w i n g c o m p l e t i o n o f a r t e r i o g r a p h y t h e c a t h e t e r became f i x e d a t t h e p u n c t u r e s i t e and r e s i s t e d f u r t h e r removal. A g u i d e w i r e was r e - i n s e r t e d t o r e l e a s e t h e f i x a t i o n and t h e c a t h e t e r was g e n t l y p u l l e d . D u r i n g t h i s m a n i p u l a t i o n t h e c a t h e t e r separated a t t h e l e v e l o f t h e f i r s t s i d e h o l e , l e a v i n g a p p r o x i m a t e l y 2 cm o f t h e c a t h e t e r i n t h e common femoral a r t e r y . This was c o n f i r m e d by f l u o r o s c o p y . The fragment was t h e n c a r r i e d by t h e b l o o d stream a l o n g t h e bypass g r a f t down i n t o t h e p e r o n e a l a r t e r y , which was t h e o n l y p a t e n t a r t e r y o f t h e l o w e r l e g . A r a d i o g r a p h demonstrated t h e fragment i n t h e m i d d l e p a r t o f t h e a r t e r y j u s t p r o x i m a l t o an o c c l u s i o n ( F i g 1 ) . The a r t e r y was s u r g i c - R I75 a l l y e x p l o r e d and t h e c a t h e t e r t i p removed. The p a t i e n t r e c o v e r e d w i t h o u t com- p l i c a t i o n . DISCUSSION Our case demonstrates t h a t p e r i p h e r a l e m b o l i z a t i o n o f a c a t h e t e r fragment i s a p o s s i b l e c o m p l i c a t i o n o f c a t h e t e r s e p a r a t i o n d u r i n g angiography. S i n c e em- b o l i z a t i o n d i d n o t occur i n any o f t h e s i x d e s c r i b e d cases o f c a t h e t e r separa- t i o n (1,2,4,5,6), some p r e v e n t i v e f a c t o r s must e x i s t . I n t h o s e cases t h e broken segments were 5 cm up t o 28 cm i n l e n g t h , compared t o 2 cm i n our case, and r e - mained f i x e d a t t h e c a t h e t e r e n t r y s i t e , F i g . 1. p e r o n e a l a r t e r y j u s t p r o x i m a l t o an o c c l u s i o n ( b ) . A r t e r i o g r a p h y o f r i g h t l o w e r l e g ( a ) . Separated c a t h e t e r t i p i n t h e I76 S u r g i c a l removal o f t h e separated fragment was necessary i n our case, as i n a l l o t h e r cases, b u t one ( 4 ) , which i n d i c a t e s t h a t c a t h e t e r s e p a r a t i o n i s a r a t h e r s e r i o u s c o m p l i c a t i o n o f angiography. We w i l l n o t r e p e a t t h e adequate d i s c u s s i o n s o f t h e p r e v i o u s r e p o r t s o f ca- t h e t e r s e p a r a t i o n , b u t o n l y p o i n t o u t some s a l i e n t f e a t u r e s , common t o a l l cases. C a t h e t e r s e p a r a t i o n has o c c u r r e d e x c l u s i v e l y d u r i n g w i t h d r a w a l , b o t h f r o m s y n t h e t i c v a s c u l a r g r a f t s and t h e p a t i e n t ' s n a t i v e v e s s e l . Regardless o f g r a f t o r v e s s e l , i n d u r a t i o n and f i b r o s i s have e x i s t e d a t t h e c a t h e t e r e n t r y s i t e s . I n most cases p o l y e t h y l e n e c a t h e t e r s , which a r e s o f t , p l i a b l e and e a s i l y s t r e t c h e d , have been used. The r i s k o f f i x a t i o n t o a rough edge i s g r e a t e r w i t h a c a t h e t e r w i t h s i d e h o l e s t h a n w i t h an endhole. The awareness o f these p o t e n t i a l l y p r o v o k i n g , b u t n o t i n e v i t a b l e f a c t o r s i n a d d i t i o n t o recommended p r e c a u t i o n s d u r i n g c a t h e t e r w i t h d r a w a l s h o u l d m i n i m i z e t h e r i s k o f c a t h e t e r s e p a r a t i o n and consequently p e r i p h e r a l e m b o l i z a t i o n o f broken fragments. 1. 2. 3. 4. 5. 6. REFERENCES Feigenbaum, L. & Grollman, J.H.: C a t h e t e r s e p a r a t i o n i n a o r t o f e m o r a l g r a f t s d e s p i t e w i r e p r o t e c t i o n . Am J Roentgenol 134:581-582, 1980. Mani, R.L. & C o s t i n , B.S.: C a t h e t e r angiography t h r o u g h a o r t o f e m o r a l g r a f t s : p r e v e n t i o n o f c a t h e t e r s e p a r a t i o n d u r i n g withdrawal. Am J Roentgenol 128: Ravin, C.E. & Koehler, P.R.: Reuse o f d i s p o s a b l e c a t h e t e r s and g u i d e w i r e s . Radiology 122:577-579, 1977. Soo, C.S., Chuang, V.P. & Wallace, S.: N o n s u r g i c a l r e t r i e v a l o f a severed c a t h e t e r from femoral a r t e r y u s i n g a m y l a r sheath. Am J Roentgenol 135: Weinshelbaum, A . & Carson, S.N.: S e p a r a t i o n o f a n q i o g r a p h i c c a t h e t e r d u r i n g a r t e r i o g r a p h y t h r o u g h v a s c u l a r g r a f t . Am J Roentgenol 134:583-584, 1980: Zablow, B.C., Gordon, D.H. & M a r t i n , E.C.: S e p a r a t i o n t o a femoral a r t e r y c a t h e t e r d u r i n g withdrawal. Radioloqy 133:244-245, 1979, 328-329, 1977. 400-401, 1980, Received Y e b r u a r y 20, 1 YU2 Address f o r r e p r i n t s : Bo Almgren, M.D. Department o f Surgery U n i v e r s i t y H o s p i t a l S-750 14 Uppsala Sweden 177