The dark side of the fibroblastic sleeve: Case report and literature review

The fibroblastic sleeve is a structure potentially enveloping any intravascular device. At ultrasound scan, it typically presents as a thin layer of variably echogenic material covering the catheter surface, which usually tends to remain into the vessel after the catheter removal. However, several case reports have documented its migration toward the heart or pulmonary artery after a central venous catheter removal. No case of fibroblastic sleeve embolization has ever been documented after a peripheral catheter removal. Here we report the case of a 76-year-old woman with a 3 Fr/20 cm polyurethane midline catheter on which the development of a surrounding fibroblastic sleeve was documented during serial, routine ultrasound follow-up. A few minutes after the catheter removal, a 7 cm-echogenic floating mass attached to the anterior leaflet of the tricuspid valve-which was absent the days before-was noticed by a routinely-planned transthoracic cardiac ultrasonography. Due to the very close interval between the catheter removal and the appearance of the tricuspidal mass, together with the disappearance of the fibroblastic sleeve from the cannulated vein, the ultrasound finding was attributed to the acute embolization of the fibroblastic sleeve. No respiratory, cardiovascular, or septic complication was documented in the following weeks, during which the fibroblastic tricuspidal mass progressively reduced and completely disappeared after 45 days. Despite being an extremely frequent and totally expected occurrence associated to any intravascular device, fibroblastic sleeve may occasionally lead to potentially serious complications. An accurate ultrasound follow-up of catheters positioned either in central or in deep peripheral veins should be recommended to monitor the development and the evolution of a fibroblastic sleeve or thrombosis, both during the catheter dwelling time and after its removal.