Discussion

This is the first report of a child in whom a central venous catheter that could not be removed by traction due to adhesions was successfully removed using an Evolution Rotating Dilator.

There are several indications for the removal of CV catheters in patients with long-term indwelling CV catheters, such as occlusion, malposition, kinking, completion of treatment, and infection. ^{Reference Barnacle, Arthurs and Derek4} Infection is the most significant complication of catheter placement in children. In the study on paediatric oncology patients, a high infection rate of 1.21 per 1000 catheter days was reported. ^{Reference Taveira, Lima and de5} The United States guidelines recommend central venous catheter removal in the presence of persistent bacteremia; ^{Reference Mermel, Allon and Emilio6} however, it is estimated that approximately 4% of long-term implanted central venous catheter become stuck to blood vessels and are difficult to remove. ^{Reference Patel, Parra and Ramnik7} Open-chest surgery is invasive, and balloon dilatation technique is used for removal. ^{Reference Forneris, Savio and Pietro2} Rotating dilators, introduced in 2015, use a drill to detach adherent pacemaker leads and are considered more useful for highly calcified lesions. ^{Reference Cay, Ozeke, Ozcan, Topaloglu and Aras8} There are few reports of its use against central venous catheter. In adult patients, only one report of removal of an adherent central venous catheter using rotating dilators showed safe removal. ^{Reference Mer, Darcy and Kim3}

The central venous catheter is easier to retrieve when the lumen is open; if the central venous catheter lumen is obstructed, it is not possible to guide the mechanical sheath or rotating dilator by passing a guidewire through the lumen, so some ingenuity is required. In this case, the central venous catheter could be guided through the mechanical sheath by tying a ligature to the end of the central venous catheter. However, the lack of a guidewire may have prevented sufficient force from being applied and the use of a mechanical sheath may have resulted in insufficient dissection of the adhesions. In addition, the use of a guide wire during the use of the rotating dilator may have increased safety. While the rotating dilator is designed for pacemaker leads and is not typically associated with high rates of damage, there is a risk of damage when using it with a softer silicone central venous catheter. In this case, the central venous catheter disconnected from the adhesion site during detachment, but the migration was prevented by holding the other end with a snare catheter. If the lumen was open and a guide wire could pass through, the risk of catheter damage would have been lower. However, when using the rotating dilator alone with a central venous catheter, as in this case, it is safer to hold the opposite side with a snare catheter or similar device to prevent potential damage. If the catheter is considered difficult to remove, it is desirable to manage the catheter with the lumen open for percutaneous removal, as the lumen will be occluded by thrombus and the guidewire will not be able to pass through if the lumen is closed by dissecting the catheter.

In conclusion, percutaneous removal using a rotating dilator should be considered as an option when central venous catheters are difficult to remove due to adhesions to the vessel.