Jesse Naghi M.D.

Ryan Reeves M.D., FACC

Ehtisham Mahmud M.D., FACC

A 34 year old male with a history of diffuse large B cell lymphoma and superior vena cava syndrome presented for SVC angioplasty

SVC Angioplasty was complicated by inadvertent formation of a SVC to Pericardial tract.

Patient developed pericardial effusion and symptomatic tamponade

Interventional Cardiology was contacted for emergent pericardiocentesis

Performed standard pericardiocentesis from the subxiphoid approach utilizing a 6-F ACT sheath and 6-F Pigtail catheter given our concern for the need of prolonged pericardial drainage.

500 cc of sanguineous fluid removed and drain left in place.

Hemodynamics and symptoms improved immediately

Drain remained in place and required frequent manipulation to maintain drainage.

On day 9 drain was removed due to cessation of fluid extraction and sheath was left in place with sporadic fluid extraction still possible via the sheath side arm.

On Day 18, sheath unable to draw fluid back despite re-accumulation of effusion on echocardiography

Patient developed recurrent symptomatic tamponade

Patient returned to catheterization laboratory for planned replacement of pericardial drain under fluoroscopic guidance

After minor manipulation of the pericardial sheath we noted that the proximal sheath had fractured from the distal end.

Despite attempts at superficial tract exploration we were unable to retrieve the distal sheath segment.

Fluoroscopy confirmed our suspicion that the distal sheath had fully migrated into the pericardial space.

Cardiothoracic Surgery was contacted and made aware of the potential need for pericardial window and foreign body extraction.

Simultaneously we prepared for attempt at percutaneous retrieval of sheath segment.

Fortunately, the soft tissue tract remained patent and communicated with the pericardium so that a 0.035 inch standard J-wire was able to be advanced into the pericardial space on fluoroscopy.

• A 8-F sheath was inserted over this wire.

• Next a One Snare 4 French 10 mm snare was inserted through the sheath in to the pericardial space and was able to successfully capture the retained pericardial sheath segment.

An attempt at removal through the 8-Fsheath was unsuccessful due to the caliber of the 6-F sheath in a folded configuration

Therefore, we upsized our pericardial sheath size to 12-F to guarantee successful removal.

An Amplatz Super stiff 0.035 inch wire was inserted through the 8 F sheath alongside the shaft of the snare while maintaining control of the fractured sheath segment.

Next, we circumferentially sliced and removed the proximal portion of the snare retrieval catheter to allow the 8-F sheath to be removed from both the Amplatzwire and the snare system and reinserted a 12-F Sheath over both the modified snare and Amplatz wire.

• Once this sheath was in place, we were able to successfully retract and remove the snare with the folded 6-F sheath segment from the pericardial space.

Confirmation of complete removal of the sheath was confirmed by comparing the length of the removed segments with a new 6-French sheath

We ultimately replaced the 12-F sheath for an 8-F sheath and 6-F pigtail catheter and 20 mL of fluid was immediately removed.

Prophylactic antibiotic therapy was given for 24 hours.

The drainage subsequently decreased over the next two weeks and both the drain and sheath were removed on hospital day 30

Our case is novel in that it demonstrates the potential mechanical complications of a prolonged pericardial sheath

A sheath and catheter combination was initially placed because a sheath may be more optimally secured to the patient with sutures compared to standard pericardial drains.

However, without a catheter in place, the sheath is less durable and more prone to kinking.

We believe that the lengthy duration of the subxiphoidpericardial sheath combined with the patient’s mobility during this time resulted in sheath fracture

Management would generally require surgical exploration into the pericardial space and removal of the retained foreign body with loss of access to the pericardial space.

Removing only a small amount of pericardial fluid during flushing of the new sheath prior to attempting removal of the retained segment allowed for manipulation of the snare within the pericardial space to facilitate capture.

We were then able to percutaneously remove the foreign body using a common snare device.

The caveat to this success was that it required a large caliber pericardial sheath size to accommodate the folding of a 6-F sheath during removal

We believe that in this rare complication, percutaneous management offers the patient an avoidance of major surgery and can be performed in any catheterization laboratory.

Recognition of this condition and early management is of importance to prevent potential infectious pericarditis.

Percutaneous removal of the retained foreign body can be performed using a large bore pericardial sheath for access and an endovascular snare device.

1. Callahan JA, Seward JB, Nishimura RA et al. Two-dimensional echocardiographically guided pericardiocentesis: experience in 117 consecutive patients. The American journal of cardiology 1985;55:476-9.

2. Kopecky SL, Callahan JA, Tajik AJ, Seward JB. Percutaneous pericardial catheter drainage: report of 42 consecutive cases. The American journal of cardiology 1986;58:633-5.

3. Vayre F, Lardoux H, Pezzano M, Bourdarias JP, Dubourg O. Subxiphoid pericardiocentesis guided by contrast two-dimensional echocardiography in cardiac tamponade: experience of 110 consecutive patients. European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology 2000;1:66-71.

4. Tsang TS, Enriquez-Sarano M, Freeman WK et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Mayo Clinic proceedings 2002;77:429-36.

5. Inglis R, King AJ, Gleave M, Bradlow W, Adlam D. Pericardiocentesis in contemporary practice. The Journal of invasive cardiology 2011;23:234-9.