Central venous catheter fragments have been reported to cause complications such as arrhythmias, perforation, clotting, infection and even death, and should be removed even if the patient is asymptomatic [1].
The two-step technique using a pigtail catheter and a snare loop catheter in retrieving a dislodged catheter fragment with no accessible free ends was first described by Greenfield et al in 1978 [2]. The pigtail catheter is used to make at least one end free that can then be grasped by the snare catheter. Many interventional radiologists have reported on the usefulness of the two-step method, however, one problem of the two-step method is that sometimes, once freed, the free end would pass into the heart and once again become inaccessible before or during the snaring procedure [3, 4, 5, 6]. A modified two-step “pigtail through snare” technique has recently been described to minimize the chances of this happening [7]. Another modification of the two-step technique has also been recently reported, whereby a catheter fragment with inaccessible ends in the right atrium and ventricle was retrieved by crossing a wire across the fragment in the right ventricle and returning it to the right atrium where it was snared [8].
In the present case we initially tried the modified two step “pigtail through snare” technique, however, the pigtail catheter kept unfolding over the displaced catheter fragment. We then resorted to modifying the original two-step technique by placing the pigtail catheter and snare catheter side to side (figure 3a), then hooking the pigtail catheter around the catheter fragment (figure 3b), followed by passing a Terumo hydrophilic glidewire through the pigtail and snaring it (figure 3c). The pigtail catheter and snare catheter were then pulled to free an end of the catheter fragment (figure 3d, 3e).
Whilst passing an adequate length of the hydrophilic glidewire through the pigtail catheter without unfolding it and snaring and holding a hydrophilic glidewire with enough traction without the wire slipping out can be technically challenging, this technique can be considered when difficulty is encountered in making an end of the displaced catheter fragment free with the use of a pigtail catheter alone. This technique can result in the freed end passing back into the heart and becoming inaccessible, as there is some time taken in disengaging the wire from the snare and then snaring the free end of the catheter fragment, and we would only advocate it for those cases where the pigtail catheter was not able to free an end of the catheter fragment.