Parvez Ahmed, Badshah Khan, Khalil Ullah, Waqas Ahmed, Iftikhar Hussain, Asif Ali Khan, Masood Anwar.
Hickman Catheter Embolism in a child during Stem Cell Transplantation.
J Coll Physicians Surg Pak Jan ;13(3):168-9.

The majority of stem cell recipients rely on indwelling central venous catheters situated in superior vena cava or right atrium. Semi-permanent tunneled silicone rubber Hickman catheters are widely used to provide durable central venous access for patients undergoing stem cell transplantation. A case of 5 years old child with diagnosis of severe aplastic anemia is reported. The patient received peripheral blood stem cells (PBSC) and had successful engraftment with complete hematological recovery. He had Hickman catheter embolism in the pulmonary circulation following unsuccessful attempt to remove the line. The catheter was successfully removed by midsternostomy operation. The child is normal with sustained remission on day +218 post stem cell transplant.

Case Reports: A 5 years old male child with diagnosis of severe aplastic anemia underwent peripheral blood stem cell transplant (PBSC) on 27 May, 2002 from his HLA-matched 10 years old sister. Before transplantation double lumen Hickman catheter was inserted percutaneously through the left subclavian vein under general anesthesia and fluoroscopic control. The catheter tip was placed in the inferior part of superior vena cava. The exact position of catheter tip was determined by reviewing postinsertion radiograph. Conditioning was done with cyclophosphamide 200 mg/kg and anti thymocyte globulin (ATG) 45 mg/kg. GVHD prophylaxis was given with cyclosporin, short course of prednisolon and methotrexate on day+1, +3 and+6. Mononuclear cell (MNC) dose was 11.4 x 108/kg, while CD 34 cell dose was 5.8 x 106/kg body weight of the recipient. The posttransplant period was complicated by neutropenic fever and cyclosporin induced hypertension. He achieved neutrophil recovery of ANC >1.0x109/l by day +12. Patient was discharged on day +15 and was subsequently followed-up in the outpatient department. Bone marrow done on day +22 revealed successful engraftment while cytogenetics study showed 46XX karyotype. Since patient belonged to a remote area with inadequate health facilities and his parents were not educated enough to take a proper care of the Hickman line, it was decided to remove the line on day +31. The catheter was broken while attempting to remove it and the fragment embolized in the pulmonary circulation. Echocardiography showed proximal end of the catheter in main pulmonary artery 1 cm distal to the pulmonary valve while the distal end was found to be in proximal left pulmonary artery. Patient underwent midsternostomy on the same day and a 7 cm long piece of the catheter was removed successfully. Following the operation patient developed a moderate pericardial effusion without temponade, and a left pleural effusion. Both resolved spontaneously. He also had fever that required administration of cefipime and Teichoplanin. Fever resolved after 6 days and he was discharged on day +45 post stem cell transplant. The patient achieved complete hematological recovery and is on routine follow-up.

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