LETTER TO THE EDITOR
J Vasc Access 2014 ; 15 ( 4): 327- 328 DOI: 10.5301/jva.5000197
Inferior vena cava thrombosis due to tunneled hemodialysis catheter inserted in the internal jugular vein Dear Editor, Despite efforts to have hemodialysis patients begin renal replacement therapy with a mature arteriovenous fistula, many patients begin dialysis with a tunneled catheter as their access. Catheter malfunction and infectious complications continue to limit access survival (1). In this report, we describe the case of inferior vena cava (IVC) thrombosis due to a malpositioned tunneled hemodialysis catheter which was inserted in the right interior jugular vein, but was sent too far in the right atrium and entered the IVC. Our aim is to underline the importance of a good hemodialysis catheter placement procedure to lower the incidence of complications. An 84-year-old woman on hemodialysis was admitted to the intensive care unit after her dialysis session for a hemodynamic shock. In her medical record we find type II diabetes mellitus, essential arterial hypertension, obesity, hypothyroidism and stroke. She had been treated for end-stage kidney disease with hemodialysis three times per week for 6 months. It was impossible to create an arteriovenous fistula due to bad vascular condition. Her vascular access is a noncuffed silicon tunneled dialysis catheter inserted in the right internal jugular vein. On admission her systolic arterial blood pressure was 60 mm Hg. A chest X-ray showed that the tip of the catheter was in the IVC (Fig. 1). The patient was stabilized and an abdominal computed tomography scan (CT) was ordered due to elevated hepatic enzymes and abdominal pain in the hepatic region. The CT scan showed a massive venous thrombosis stretching from the tip of the catheter into the IVC and to the femoral veins, with radiologic evidence of Budd-Chiari syndrome. The catheter was removed and treatment with heparin was applied. Temporary jugular hemodialysis catheter was inserted 24 hours after the admission. The patient stayed in the ICU for 15 days, after which a CT scan was performed and showed no trace of thrombosis in the veins, so she was transferred to the nephrology ward. A new tunneled hemodialysis catheter was inserted in the right internal jugular vein and treatment with warfarin was started.
Fig. 1 - Tunneled hemodialysis tip in the inferior vena cava.
The patient was discharged 10 days after her admission to the nephrology ward. Internal jugular vein cannulation has become the preferred approach for temporary hemodialysis catheter placement following reports of an increased incidence of subclavian vein stenosis due to subclavian vein catheterization (2, 3). The ultrasound-guided technique has been utilized to improve the success rate and to reduce the complication rate of central venous catheterization in medical and surgical patients (4). The catheter tip should be adjusted to the level of the cavoatrial junction or into the right atrium to ensure optimal blood flow; atrial positioning is only recommended for catheters composed of soft compliant material, such as silicone (5). Central venous occlusion occurs particularly in patients under hemodialysis and with a history of multiple central venous catheterizations with largediameter catheters and/or long total indwelling time periods (6). Vascular access complications contribute increasingly to the cumulative morbidity and cost in chronic hemodialysis patients (7). In this case report we tried to show the importance of the correct positioning of the hemodialysis catheter to avoid serious complications, which could be fatal. Financial support: None. Conflict of interest: None.
Saleh Kaysi, Julien Aniort Department of Nephrology, University Hospital of ClermontFerrand, Clermont-Ferrand - France [email protected]
© 2014 Wichtig Publishing - ISSN 1129-7298
327
Vena cava thrombosis due to hemodialysis catheter
REFERENCES
4.
1. Rocklin MA, Dwight CA, Callen LJ, Bispham BZ, Spiegel DM. Comparison of cuffed tunneled hemodialysis catheter survival. Am J Kidney Dis. 2001;37(3):557-563. 2. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant. 1991;6(10): 722-724. 3. Agraharkar M, Isaacson S, Mendelssohn D, et al. Percutaneously inserted silastic jugular hemodialysis catheters seldom cause jugular vein thrombosis. ASAIO J. 1995;41(2): 169-172.
328
Lin BS, Huang TP, Tang GJ, Tarng DC, Kong CW. Ultrasoundguided cannulation of the internal jugular vein for dialysis vascular access in uremic patients. Nephron. 1998;78(4): 423-428. 5. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis. 2006;48(Suppl 1): 176-247. 6. Pikwer A, Acosta S, Kölbel T, Åkeson J. Endovascular intervention for central venous cannulation in patients with vascular occlusion after previous catheterization. J Vasc Access. 2010;11(4):323-328. 7. Mayers JD, Markell MS, Cohen IS, Hong J, Lundin P, Friedman EA. Vascular access surgery for maintenance hemodialysis. Am Soc Artif Organs J. 1992;38:113-115.
© 2014 Wichtig Publishing - ISSN 1129-7298
J Vasc Access 2014 ; 15 ( 4): 327- 328 DOI: 10.5301/jva.5000197
Inferior vena cava thrombosis due to tunneled hemodialysis catheter inserted in the internal jugular vein Dear Editor, Despite efforts to have hemodialysis patients begin renal replacement therapy with a mature arteriovenous fistula, many patients begin dialysis with a tunneled catheter as their access. Catheter malfunction and infectious complications continue to limit access survival (1). In this report, we describe the case of inferior vena cava (IVC) thrombosis due to a malpositioned tunneled hemodialysis catheter which was inserted in the right interior jugular vein, but was sent too far in the right atrium and entered the IVC. Our aim is to underline the importance of a good hemodialysis catheter placement procedure to lower the incidence of complications. An 84-year-old woman on hemodialysis was admitted to the intensive care unit after her dialysis session for a hemodynamic shock. In her medical record we find type II diabetes mellitus, essential arterial hypertension, obesity, hypothyroidism and stroke. She had been treated for end-stage kidney disease with hemodialysis three times per week for 6 months. It was impossible to create an arteriovenous fistula due to bad vascular condition. Her vascular access is a noncuffed silicon tunneled dialysis catheter inserted in the right internal jugular vein. On admission her systolic arterial blood pressure was 60 mm Hg. A chest X-ray showed that the tip of the catheter was in the IVC (Fig. 1). The patient was stabilized and an abdominal computed tomography scan (CT) was ordered due to elevated hepatic enzymes and abdominal pain in the hepatic region. The CT scan showed a massive venous thrombosis stretching from the tip of the catheter into the IVC and to the femoral veins, with radiologic evidence of Budd-Chiari syndrome. The catheter was removed and treatment with heparin was applied. Temporary jugular hemodialysis catheter was inserted 24 hours after the admission. The patient stayed in the ICU for 15 days, after which a CT scan was performed and showed no trace of thrombosis in the veins, so she was transferred to the nephrology ward. A new tunneled hemodialysis catheter was inserted in the right internal jugular vein and treatment with warfarin was started.
Fig. 1 - Tunneled hemodialysis tip in the inferior vena cava.
The patient was discharged 10 days after her admission to the nephrology ward. Internal jugular vein cannulation has become the preferred approach for temporary hemodialysis catheter placement following reports of an increased incidence of subclavian vein stenosis due to subclavian vein catheterization (2, 3). The ultrasound-guided technique has been utilized to improve the success rate and to reduce the complication rate of central venous catheterization in medical and surgical patients (4). The catheter tip should be adjusted to the level of the cavoatrial junction or into the right atrium to ensure optimal blood flow; atrial positioning is only recommended for catheters composed of soft compliant material, such as silicone (5). Central venous occlusion occurs particularly in patients under hemodialysis and with a history of multiple central venous catheterizations with largediameter catheters and/or long total indwelling time periods (6). Vascular access complications contribute increasingly to the cumulative morbidity and cost in chronic hemodialysis patients (7). In this case report we tried to show the importance of the correct positioning of the hemodialysis catheter to avoid serious complications, which could be fatal. Financial support: None. Conflict of interest: None.
Saleh Kaysi, Julien Aniort Department of Nephrology, University Hospital of ClermontFerrand, Clermont-Ferrand - France [email protected]
© 2014 Wichtig Publishing - ISSN 1129-7298
327
Vena cava thrombosis due to hemodialysis catheter
REFERENCES
4.
1. Rocklin MA, Dwight CA, Callen LJ, Bispham BZ, Spiegel DM. Comparison of cuffed tunneled hemodialysis catheter survival. Am J Kidney Dis. 2001;37(3):557-563. 2. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant. 1991;6(10): 722-724. 3. Agraharkar M, Isaacson S, Mendelssohn D, et al. Percutaneously inserted silastic jugular hemodialysis catheters seldom cause jugular vein thrombosis. ASAIO J. 1995;41(2): 169-172.
328
Lin BS, Huang TP, Tang GJ, Tarng DC, Kong CW. Ultrasoundguided cannulation of the internal jugular vein for dialysis vascular access in uremic patients. Nephron. 1998;78(4): 423-428. 5. Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis. 2006;48(Suppl 1): 176-247. 6. Pikwer A, Acosta S, Kölbel T, Åkeson J. Endovascular intervention for central venous cannulation in patients with vascular occlusion after previous catheterization. J Vasc Access. 2010;11(4):323-328. 7. Mayers JD, Markell MS, Cohen IS, Hong J, Lundin P, Friedman EA. Vascular access surgery for maintenance hemodialysis. Am Soc Artif Organs J. 1992;38:113-115.
© 2014 Wichtig Publishing - ISSN 1129-7298
