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Weekly Chest CasesArchive of Old Cases

Case No : 728 Date 2011-10-11

  • Courtesy of Hee Kang, Ho Yun Lee / Samsung Medical Center, Sungkyunkwan University School of Medicine
  • Age/Sex 41 / F
  • Chief ComplaintWhat is the difference between these two chest radiographs?
  • Figure 1
  • Figure 2

Figure 1. One month ago

Diagnosis With Brief Discussion

Diagnosis
Pinch-off sign
Radiologic Findings
This patient had received chemo-port implantation for chemotherapy with a history of breast cancer. A chemo-port catheter was placed through the left subclavian vein (figure 1). On the present radiograph (figure 2 and 3), the catheter shows the ‘pinch-off sign’, which represents focal luminal narrowing at the proximal portion while passing beneath the clavicle (figure 3). On follow-up chest radiography one month later (figure 4), the catheter was transected and the fragment of catheter located in the right side of the heart (arrows). The distal part of the catheter was retrieved by using snare technique via the right femoral vein (not shown here). The proximal part of the catheter was removed without effort.

Figure 3.

Figure 4.

Brief Review
Catheter fracture/embolization is a rare (0.1–2.8%) complication of subclavian venous catheters with a long indwelling time. According to the literature, chronic and intermittent mechanical compression of the catheter between the clavicle and the first rib (pinch-off syndrome) is a frequent cause of catheter trauma. In the retrospective analysis of Ouaklnine-Orlando et al, chronic compression of the catheter between the clavicle and the first rib was found in 42.8% of cases with catheter rupture. Regarding other study of 41 patients with chemo-port catheter, pinch-off syndrome was retrospectively seen in 75.6% of the cases of catheter fracture and embolism.
Early warning symptoms of catheter compression and fracture are intermittent resistance and variable reaction to drug injection, chest wall swelling at the insertion site, and premature ventricular contractions in case of embolization to the heart. The complications include arrhythmia, endocarditis, perforation of the heart and pulmonary embolism. The problem is that many patients are asymptomatic, probably because the usual sites of fragment migration are the right ventricle and pulmonary artery, which have few sensory nerve endings.
This pinch-off sign can be recognized on chest radiograph by observing luminal narrowing as the catheter passes through the costoclavicular space. Prompt removal of the catheter should be needed to avoid catheter fracture/embolization. It is important to recognize this ‘pinch-off sign’, which means impending catheter fracture on chest radiograph.
References
1. de Graaff JC, Bras LJ, Vos JA. Early transection of a central venous catheter in a sedated ICU patient. 2006;97(1):832-834
2. Ouaknine-Orlando B, Desruennes E, Cosset MF, et al. Syndrome de la pince costoclaviculaire: principale cause dembolie de catheter. Ann Fr Anesth Reanim 1999;18:949-955.
3. Surov A, Buerke M, John E, Kosling S, et al. Intravenous port catheter embolization: mechanisms, clinical features, and management. Angiology 2008;59(1):90-97
Keywords
mediastinum, iatrogenic,

No. of Applicants : 90

▶ Correct Answer : 53/90,  58.9%
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - Okayama University , Japan Akihiro Tada
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - James Paget Hospital , U.K , United Kingdom nabil mahmood
  • - Fr Mullers Medical College , India Deepu Thomas
  • - stanley medical college, india , India vanitha gnanasoundran
  • - stanley medical college , India arivudai nambi
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - Chonnam National University , Korea (South) se hee Jung
  • - Central Queensland Medical Imaging , Australia Sandeep Joshi
  • - FATHER MULLER MEDICAL COLLEGE , India JAI SHAH
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Inha University Hospital , Korea (South) Ju Won Lee
  • - Severance hospital , Korea (South) Saerom Hong
  • - BGS Global Hospital , India sanjeev mudakavi
  • - Fukuyama daiichi Hospital , Japan Mototsugu Saeki
  • - McGill University Health Center , Canada Alexandre Semionov
  • - focus hyd , India sanjeev choudri
  • - Virgin Mary Hospital Burgas , Bulgaria VLADISLAV RUSINOV
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - Az Osp Santa Maria Terni , Italy angelo carloni
  • - UWO , Canada S Lee
  • - Iwate Medical University , Japan Akio Akahane
  • - Hospital Moinhos de Ventos , Brazil Felipe Hertz
  • - Emory University Department of Radiology , United States Travis Henry
  • - Chonnam National University Hospital , Korea (South) Daun Lee
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - Chonnam national university hospital , Korea (South) Jang-hyeon Song
  • - Seoul national university hospital , Korea (South) Jae Hwan Lee
  • - Asan medical center , Korea (South) sang young oh
  • - Asan Medical Center , Korea (South) Jae-Woo Song
  • - grmc gwalior , India shailesh gupta
  • - National Jewish Health , United States Jonathan Chung
  • - Chungnam National University hospital , Korea (South) sunkyoung you
  • - IRSA , France jean-luc BIGOT
  • - University of British Columbia , Canada Amr Ajlan
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Asan medical center , Korea (South) Cherry Kim
  • - Hanyang university medical center , Korea (South) YOONAH SONG
  • - Azienda Ospedaliera San Gerardo , Italy Gabriele DAndrea
  • - CHA Bundang hospital , Korea (South) Hyerin Kim
  • - Toranomon Hospital , Japan Takana Yamakawa
  • - Radiologie Brabois adultes , France ROPION helene
  • - CH de la C�te Basque , France Paul ARDILOUZE
  • - NASA SCANS , India RAKESH BHATIA
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Private sector , Greece Vasilios Tzilas
  • - Vikram hospital , India Pravin Mahadevappa
  • - Chonnam national univ. hospital , Korea (South) Choi Seul Gi
▶ Correct Answer as Differential Diagnosis : 4/90,  4.4%
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Chuncheon Sacred Heart Hospital , Korea (South) Park Su-young
  • - All India Institute of medical sciences , India Justin Moses
▶ Semi-Correct Answer : 1/90,  1.1%
  • - Hopital Louis Pradel LYON , France matthieu ROUSSET
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