Asian Cardiovasc Thorac Ann 2008;16:321-323
© 2008 Asia Publishing EXchange Ltd
Retrieval of Broken Paravertebral Catheter by Video-Assisted Thoracic Surgery
Alan DL Sihoe, FRCSEd(CTh),
Subid R Das, FCAnaes1,
Leong-Chow Ling, FHKAM1,
Lik-Cheung Cheng, FRCS(Ed)
Division of Cardiothoracic Surgery, Department of Surgery
1 Department of Anesthesiology, Grantham Hospital, The University of Hong Kong, Hong Kong SAR, China
For reprint information contact: Alan DL Sihoe, FRCSEd(CTh), Tel: 852 2518 2699, Fax: 852 2647 3512, Email: adls1{at}lycos.com, Division of Cardiothoracic Surgery, Department of Surgery, Grantham Hospital, The University of Hong Kong, Aberdeen, Hong Kong SAR, China.
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ABSTRACT
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A paravertebral catheter was placed in a 34-year-old man to provide analgesia after a right upper lobectomy. On removal, the catheter broke within the chest wall. Although bedside exploration and computed tomography scanning failed to locate it, the 13-cm long retained fragment was easily retrieved by video-assisted thoracic surgery, using a single-port technique.
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INTRODUCTION
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Paravertebral blockade provides effective postoperative analgesia following thoracic surgery, with fewer side effects than other regional anesthetic modalities such as epidural blockade.1 Few complications have been reported. To our knowledge, this is the first case of a paravertebral catheter breaking during removal.
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CASE REPORT
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A 34-year-old man with unremarkable medical history underwent an elective right upper lobectomy for T2N0M0 squamous cell carcinoma. Pre-incisional analgesia, as per our routine practice, included right paravertebral injections of 20 mL 0.5% bupivacaine, with adrenaline, given in divided doses at the T3, T5 and T7 vertebral levels. Surgical exploration was performed initially using video-assisted thoracic surgery (VATS). However, because of exceptionally dense pleural adhesions, conversion to a limited 10-cm lateral thoracotomy through the 4th intercostal space was required. Because of the thoracotomy with rib-spreading, a paravertebral catheter was placed for additional postoperative analgesia. The catheter was placed using a previously described technique for creating a paravertebral extrapleural pocket.2 A Minipack System 1 epidural system (SIMS Portex Ltd, Hythe, Kent, UK) containing an 18G Tuohy needle and a flexible clear catheter was used. The catheter was inserted through the right posterior chest wall, and the distal ‘soaking’ end of the catheter was placed in a right paravertebral subpleural pocket across the 3rd–6th intercostal spaces. The proximal end of the catheter was threaded through a 1-cm long subcutaneous tunnel, and connected to a syringe pump delivering 0.5% bupivacaine at 4–8 mL·h–1. Postoperatively, the patient experienced minimal pain and no complications from the paravertebral blockade. On the 2nd postoperative day, the paravertebral catheter was removed with the patient sitting upright. However, the catheter broke immediately on attempted withdrawal. Examination of the removed part of the catheter suggested that a fragment at least 11-cm long remained within the patient. No part of the fragment was visible or palpable on the skin. Immediate exploration under local anesthesia via a skin incision and scanning by computed tomography both failed to locate the retained fragment. Although the retained fragment caused no attributable symptoms, a VATS exploration was offered to retrieve it. Because the patient was initially reluctant, VATS exploration did not take place until 8 days after the first surgery. A video thoracoscope was placed via the single chest drain wound from the first operation. The fragment was readily identified in its original paravertebral subpleural pocket, and easily removed with endoscopic forceps, using a single-port VATS technique (Figures 1
and 2). No wounds other than the original chest drain wound were required. The entire procedure took <15 min to perform. The patient recovered quickly and was discharged home 2 days after the second operation.
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Figure 1. (A) A single-port technique was used to locate and retrieve the catheter fragment; (B) By sliding the rigid trocar cannula (arrowed) out of the wound along the video-thoracoscope, an endoscopic biopsy forceps can be introduced into the chest; (C) The forceps was used to grasp the retained fragment under video-thoracoscope guidance.
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Figure 2. The retained catheter fragment was 13-cm long, with no obvious evidence of stretching, kinking, or knotting; (A) The longer arm of the L-shaped fragment lay in the subpleural pocket, and the shorter arm lay within the chest wall; (B) The broken (proximal) end of the catheter had a "pinched-off" appearance.
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DISCUSSION
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Although this may be the first report of paravertebral catheter breakage during removal, similar breakage of an epidural catheter has been reported rarely in other surgical specialties.3–8 Epidural catheter breakage has been associated with faulty design, a faulty insertion or withdrawal technique, and entrapment by bony or ligamentous tissues during removal.5,6,8 In our case, it cannot be proved whether similar factors contributed to the breakage. During insertion, shearing damage to the catheter may have been inflicted by the Tuohy needle. The catheter may have become kinked or tethered by the subcutaneous tunnel. We now avoid using a subcutaneous tunnel in all patients. Catheter entrapment by bony or soft issue may also be possible, even though paravertebral catheters pass through wide intercostal spaces only, and not tight intervertebral spaces, as with epidural catheters. Nonetheless, adopting the flexed lateral decubitus position favored for epidural catheter removal may be advisable when removing paravertebral catheters. Inspection of the broken end of the catheter showed an appearance compatible with – but not conclusive for – a "pinch off" phenomenon (Figure 2B
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Controversy exists over whether retained fragments should be removed. For broken epidural catheters, leakage of cerebrospinal fluid, radicular pain, and lumbar stenosis have been reported, but retrieval of fragments may require complex neural and spinal surgery such as vertebral laminectomy.3–5,7,8 For paravertebral catheters, there is no experience of sequelae from retained fragments. Because infection, foreign body reactions, or nerve impingement remain possible, patients should be appropriately counseled regarding retrieval. Retrieval of broken epidural catheters via a skin incision at the insertion site is reportedly feasible in some cases.6,8 In our patient, this approach was unsuccessful, probably because the catheter broke deep in the chest wall. Radiological imaging such as computed tomography was previously advocated to locate broken epidural catheters, but recent reports suggest this to be of limited use, even for radiopaque catheters.5,8 Our case supports the latter view.
Location of the retained fragment by VATS proved to be straightforward in our patient. The intrathoracic part of the catheter was originally placed via the thoracotomy, so unsurprisingly it was readily visible inside the chest using the video-thoracoscope.2 The catheter was easily removed in minutes, and no incision other than the old drain wound was required. The only foreseeable difficulty with VATS retrieval is when a long delay after the initial operation allows extensive postoperative pleural adhesions to form. Because retrieval by VATS is so safe and simple in the event of this rare complication of catheter breakage, paravertebral blockade remains a safe modality for postthoracotomy analgesia.
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REFERENCES
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- Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth 1999;83:387–92.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
