A RARE CASE: CHEMOPORT TIP DISPLACEMENT FROM PERSISTENT VOMITING AND RETCHING

Abstract

SESSION TITLE: Uncommon Procedures and Procedure Complications Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: In many cancer patients, totally implantable central venous devices (CVD) of the port-a-Cath type (chemo-port [CP]) is commonly utilized for parenteral nutrition, taking blood samples, administration of cytotoxic agents and antibiotics. Since first introduced in 1982, they not only improved the quality of life of terminally sick patients but also the risk of complications and technical difficulties. Overall, it is a safe procedure and mostly lasts for two-six years with good efficacy and minimal complications especially catheter-related deep venous thrombosis compared to PICCs. We report an unusual circumstance of spontaneous tip displacement of CP caused by intractable retching and vomiting.CASE PRESENTATION: A 60-year-old man with history of colonic neoplasm on chemotherapy (CHT) with DM, s/p R-hemicolectomy/ileocolic resection complicated by partial small bowel obstruction presented to ED with persistent nausea, vomiting, intermittent vague abdominal pain, constipation with weight loss for 5 months. He had a R-chest CP placed 4 months prior through which he has been receiving CHT and was held for 1 month due to CP malfunction. Previous PET for tumor staging a month earlier and admission's CXR both revealed that the CP tip in reversed course and flipped into R-internal jugular vein from previous location at SVC, compared to prior CXRs. Vascular surgery team removed the CP and he was stable during hospitalization.DISCUSSION: Regardless of surgical operators’ experience, use of sterile techniques and point of care ultrasound (POCUS), CVD related complications could still lead to potentially fatal outcomes and are still observed in recurrent studies. Proper evaluation of catheter function should be performed before initiating each CHT session although there are no specific guidelines for CP placement monitoring in a patient receiving extended CHT. If persistent withdrawal occlusion (PWO) is observed, appropriate measures to identify underlying causes must be performed immediately. Catheter tip migration can easily be identified by POCUS "bubble test", or other imaging. It is rare but its occurrence could be related to excessive weight, intense physical efforts and increased intrathoracic/intraabdominal pressure (IAP). Our patient's secondary CP malposition was likely due to CHT-induced protracted vomiting leading to increased IAP. Malposition of the catheter mandated immediate intervention.CONCLUSIONS: Secondary malposition of CVDs is an uncommon complication where tip migration is commonly present. This should raise red flags whenever PWO is observed. Our patient not only had CP malfunction but also PET confirmed which was unnoticed for a month. As persistent retching and vomiting are common in cancer patients on CHT, providers should always have high suspicion for secondary malposition, and a low threshold to obtain and review imaging thoroughly whenever CP malfunction is reported.Reference #1: Jothiprasad Venkatesan, Noufal TB, Karthikesh K, Surees Kumar Subramaniam, Venugopal Sarveswaran. A Prospective observational study on use of chemo-port in cancer patients in a tertiary care hospital. International Journal of Contemporary Medicine Surgery and Radiology.2020;5(3):C62-C64.Reference #2: Pikwer A, Bååth L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients. Anaesth Intensive Care. 2008 Jan;36(1):30-7. doi: 10.1177/0310057X0803600106. PMID: 18326129.Reference #3: D'Arrigo S, Annetta MG, Musarò A, Distefano M, Pittiruti M. Secondary malposition of a PICC-port due to heavy physical exercise: A case report. The Journal of Vascular Access. August 2021. doi:10.1177/11297298211039445DISCLOSURES: No relevant relationships by Adam AdamNo relevant relationships by Moses BachanNo relevant relationships by Zin Min HtetNo relevant relationships by Zinobia KhanNo relevant relationships by Zin Oo SESSION TITLE: Uncommon Procedures and Procedure Complications Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: In many cancer patients, totally implantable central venous devices (CVD) of the port-a-Cath type (chemo-port [CP]) is commonly utilized for parenteral nutrition, taking blood samples, administration of cytotoxic agents and antibiotics. Since first introduced in 1982, they not only improved the quality of life of terminally sick patients but also the risk of complications and technical difficulties. Overall, it is a safe procedure and mostly lasts for two-six years with good efficacy and minimal complications especially catheter-related deep venous thrombosis compared to PICCs. We report an unusual circumstance of spontaneous tip displacement of CP caused by intractable retching and vomiting. CASE PRESENTATION: A 60-year-old man with history of colonic neoplasm on chemotherapy (CHT) with DM, s/p R-hemicolectomy/ileocolic resection complicated by partial small bowel obstruction presented to ED with persistent nausea, vomiting, intermittent vague abdominal pain, constipation with weight loss for 5 months. He had a R-chest CP placed 4 months prior through which he has been receiving CHT and was held for 1 month due to CP malfunction. Previous PET for tumor staging a month earlier and admission's CXR both revealed that the CP tip in reversed course and flipped into R-internal jugular vein from previous location at SVC, compared to prior CXRs. Vascular surgery team removed the CP and he was stable during hospitalization. DISCUSSION: Regardless of surgical operators’ experience, use of sterile techniques and point of care ultrasound (POCUS), CVD related complications could still lead to potentially fatal outcomes and are still observed in recurrent studies. Proper evaluation of catheter function should be performed before initiating each CHT session although there are no specific guidelines for CP placement monitoring in a patient receiving extended CHT. If persistent withdrawal occlusion (PWO) is observed, appropriate measures to identify underlying causes must be performed immediately. Catheter tip migration can easily be identified by POCUS "bubble test", or other imaging. It is rare but its occurrence could be related to excessive weight, intense physical efforts and increased intrathoracic/intraabdominal pressure (IAP). Our patient's secondary CP malposition was likely due to CHT-induced protracted vomiting leading to increased IAP. Malposition of the catheter mandated immediate intervention. CONCLUSIONS: Secondary malposition of CVDs is an uncommon complication where tip migration is commonly present. This should raise red flags whenever PWO is observed. Our patient not only had CP malfunction but also PET confirmed which was unnoticed for a month. As persistent retching and vomiting are common in cancer patients on CHT, providers should always have high suspicion for secondary malposition, and a low threshold to obtain and review imaging thoroughly whenever CP malfunction is reported. Reference #1: Jothiprasad Venkatesan, Noufal TB, Karthikesh K, Surees Kumar Subramaniam, Venugopal Sarveswaran. A Prospective observational study on use of chemo-port in cancer patients in a tertiary care hospital. International Journal of Contemporary Medicine Surgery and Radiology.2020;5(3):C62-C64. Reference #2: Pikwer A, Bååth L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients. Anaesth Intensive Care. 2008 Jan;36(1):30-7. doi: 10.1177/0310057X0803600106. PMID: 18326129. Reference #3: D'Arrigo S, Annetta MG, Musarò A, Distefano M, Pittiruti M. Secondary malposition of a PICC-port due to heavy physical exercise: A case report. The Journal of Vascular Access. August 2021. doi:10.1177/11297298211039445 DISCLOSURES: No relevant relationships by Adam Adam No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Zinobia Khan No relevant relationships by Zin Oo