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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 61-65

Case report on the management of failed tunneled hemodialysis catheter insertion: The challenges and utility of fluoroscopy


1 Department of Medicine, College of Medicine, University of Ibadan; Departments of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
2 Department of Radiology, University College Hospital; Departments of Radiology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
3 Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria

Date of Submission06-Mar-2021
Date of Acceptance10-Jun-2021
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Yemi Raheem Raji
Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wajr.wajr_7_21

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  Abstract 


Hemodialysis vascular access is critical to ensuring adequate hemodialysis sessions. Tunneled internal jugular vascular (IJV) access is a type of intermediate access that has become increasingly useful in low- and middle-income countries, where there are not many vascular surgeons with expertise in arteriovenous fistula creation. We presented a 69-year-old male who had complicated IJV catheter insertion, with the catheter located in the pulmonary vascular bed of the left lung and associated left-sided hemothorax. He was managed by multidisciplinary team of nephrologists, radiologists, and cardiothoracic surgeons, who removed the catheter under fluoroscopic guidance without any complication or need for open thoracotomy. The case highlighted the utility of fluoroscopy in aiding hemodialysis catheter insertion, removal, and management of its complications.

Keywords: Dialysis catheter, end-stage renal disease, hemodialysis, vascular access


How to cite this article:
Raji YR, Osobu BE, Abiola BI, Efuntoye OO, Adekanmi AJ, Ajayi SO, Adeyinka AO. Case report on the management of failed tunneled hemodialysis catheter insertion: The challenges and utility of fluoroscopy. West Afr J Radiol 2021;28:61-5

How to cite this URL:
Raji YR, Osobu BE, Abiola BI, Efuntoye OO, Adekanmi AJ, Ajayi SO, Adeyinka AO. Case report on the management of failed tunneled hemodialysis catheter insertion: The challenges and utility of fluoroscopy. West Afr J Radiol [serial online] 2021 [cited 2022 Aug 17];28:61-5. Available from: https://www.wajradiology.org/text.asp?2021/28/2/61/337517




  Introduction Top


Hemodialysis is an important modality of treatment for end-stage kidney disease (ESKD) worldwide, particularly in the period before kidney transplantation.[1] Maintenance hemodialysis has also been used in the treatment of patients with ESKD, who may have contraindications to kidney transplantation.[2] Hemodialysis vascular access is critical to ensuring adequate hemodialysis sessions and there are temporary and permanent vascular accesses.[3] Tunneled internal jugular vascular (IJV) access is a type of temporary access that has become increasingly useful in low- and middle-income countries (LMICs) where there are not many vascular surgeons who have expertise in arteriovenous (AV) fistula creation.[4] At the University College Hospital, Ibadan, Nigeria, tunneled internal jugular venous (TIJV) catheter is the most common vascular access being used for patients on hemodialysis, and the renal unit of the hospital has placed over 500 TIJV catheter for patients with ESKD on maintenance hemodialysis. A few complications have been reported during catheter placement or during its usage.[5] We present a case with failed TIJV hemodialysis catheter at the University College Hospital, Ibadan.


  Case Report Top


Mr. O. B, a 69-year-old male, retired civil servant who was diagnosed with ESKD secondary to uncontrolled systemic hypertension in June 2018 and was placed on twice weekly maintenance hemodialysis with the right TIJV catheter. He was diagnosed with hypertension 15 years earlier and diagnosed with carcinoma of the prostate 2 years before the index admission, based on clinical, laboratory, and histological evidence. He was being comanaged with the urology team of the hospital. His current medications were three monthly goserelin injection, subcutaneous erythropoietin twice weekly, and intravenous iron sucrose monthly. Other medications included amlodipine, lisinopril, alpha methyldopa, furosemide, alpha meditriol, calcium carbonate, and folic acid.

Two months before the index admission, his TIJV hemodialysis vascular access was observed to be malfunctioning, despite the catheter being locked with anticoagulant and antibiotics after every dialysis session. The catheter became completely blocked and was removed 2 weeks before the index presentation, and the decision to place another catheter was discussed and agreed with the patient. The procedure was explained to the patient and informed consent obtained from the patient. The vital signs before the procedure were represent Respiratory Rate (RR) – 18 breath/min, pulse – 86 beats/min, SpO2 – 96% (room air), and blood pressure (BP) – 150/90 mmHg, while his laboratory parameters were packed cell volume – 32%, urea – 132 mg/dl, and creatinine as 5.2 mg/dl. Echocardiography showed ejection fraction of 60%.

Meanwhile, attempts at repassing the new tunneled catheter into the same right jugular vein were unsuccessful, as the guidewire could not be advanced due to stenosis and fibrosis of the right jugular vein. Thus, a decision was taken to use the left jugular vein for the cannulation. During the procedure, the initial steps of passage of guidewire, dilatation, and insertion of catheter were successful. The access was checked, and free-flowing dark-colored blood was aspirated. About 10 min after the completion of the procedure, the patient had a transient loss of consciousness that was associated with sudden onset of breathlessness. The repeat vital signs were RR – 10 cycles/min, pulse – 114/m, BP – 90/50 mmHg, and SpO2 – 84%. Resuscitation was carried out with intravenous fluid and intranasal oxygen to revive the patients, and there were improvement in his vital signs; RR – 16 breath/min, pulse – 104 beats/min, BP – 110/70 mmHg, and SpO2 was 94%. In addition, the breath sound was reduced on the left lower lung zone.

Despite the blood freely flowing through the vascular access, the chest radiograph showed that catheter tip was within the lung field as against the expected location (the right atrium), and the catheter was also kinked close to the tip. The chest radiograph also showed blunting of left cardio and costophrenic angles suggestive of fluid accumulation in the pleural space [Figure 1]. Patient's hematocrit (packed cell volume [PCV]) had dropped to 23%, the rapid reduction in hematocrit may be due to the combined effects of the blood loss into the pleural cavity, and hemodilution from the fluid given during resuscitation. Hematocrit required optimization with two pints of packed red blood cell transfusion and the hemoglobin was optimized to a PCV of 29% after the transfusion with packed cells. Following the cardiothoracic surgery team review, it was agreed that the catheter was not in the expected anatomical location, and it is possible that the catheter was in the innominate vein or aberrant left superior vena cava. A chest computer tomographic (CT) angiogram was ordered for and a chest tube was passed with 200 ml of serosanguinous fluid drained. The CT angiogram was carried out immediately after a session of hemodialysis, using femoral vein as vascular access. The dialysis was offered to the patient before the contrast study to reduce the risk of contrast toxicity that may include nephrogenic systemic fibrosis. The CT angiogram showed the entry point of the catheter [Figure 2] and [Figure 3] in the left internal jugular vein (LIJV), traversing the LIJV into the left brachiocephalic vein from where it ended up in the vascular bed of the left lung with minimal pleural effusion [Figure 4] and [Figure 5]. At a joint review of the nephrology, cardiothoracic, and interventional radiology teams, it was agreed that the catheter removal should be carried out under fluoroscopic guidance with open thoracotomy as backup in case of bleeding. The catheter was traced with the administration of small volume of low osmolar nonionic intravascular contrast agent (to reduce the nephrotoxicity effect) to identify the exact location of the catheter, and it was gradually and successfully removed under fluoroscopy guidance with no complication. The chest tube was removed 5 days after the TIJV catheter removal, when it was no longer draining fluid actively, however, the repeat chest radiograph showed iatrogenic left pneumothorax. This warranted the placement of another chest tube, which was discontinued on the 14th day after catheter removal, with sustained improvement in the patient's clinical parameters.
Figure 1: Frontal chest radiograph of the patient showing the tunneled internal jugular vein catheter (green arrow) projected on the left lung field. There is left-sided hemothorax

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Figure 2: Coronal view of chest computed tomographic angiogram showing the tip of tunneled catheter at the origin of the left Brachiocephalic vein (orange arrow)

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Figure 3: Axial view of computed tomography of the chest showing tunneled catheter under the subcutaneous tissues (orange arrow) and the tip of the dislodged catheter outside the left Brachiocephalic vein (green arrow)

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Figure 4: Coronal view of computed tomography of the chest showing the tip of the dislodged tunneled catheter within the left lung parenchymal (blue arrow)

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Figure 5: Volume-rendered computer tomographic image of the chest showing the tunneled catheter with the tip (blue arrow) in the left lung

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  Discussion Top


This case report has demonstrated one of the early complications of tunneled internal jugular hemodialysis catheter insertion and how prompt intervention by multidisciplinary team can address the complications. The incidence of early complications following tunneled hemodialysis catheter insertion has been reported to be 5%–10%.[6] Most of these early complications were hematoma, hemothorax, failure of venous puncture, and wrong cannulation. The index case was a wrong cannulation as the catheter was inadvertently placed in the vascular bed of the left lung field, as against the right atrium. The incidence of complications is more common with the cannulation of LIJV compared to the RIJV. The cannulation resulting in the complication in the case presented was on the LIJV. Cannulation of the LIJV is technically more difficult and takes longer time to insert even under imaging guidance, and most nephrologists, interventional radiologists, or vascular surgeons will prefer to cannulate the RIJV, except when there are technical difficulties or contraindications to cannulation of the RIJV. During insertion of a LIJV catheter, two 90° turns must be negotiated: the junction with the subclavian vein and the junction with the superior vena cava. In addition, the left brachiocephalic vein is longer and has a greater number of smaller tributaries than the right brachiocephalic vein. A catheter can be misdirected into small tributaries of central veins, particularly when inserting a catheter on the left. In the case, presented the RIJV could not be cannulated because of stenosis from the previous catheter insertion. Aside the stenosis of the veins, variations in the internal jugular vein anatomy have also been reported to account for failed or wrong cannulation and the anomalies include small diameter vein. Previous studies have reported that 12% of the population have IJV variations and 15% of complications arising from IJV cannulations have been attributed to these abnormal variations.[7]

The use of ultrasound-guided insertion of IJV catheter has significantly improved the success of IJV cannulation, in addition to reducing the complications associated with catheter insertion using the Seldinger's method. Denys et al.[8] in a prospective study of patients who had IJV cannulation, successful cannulation of the IJV was achieved in all patients (100%) using ultrasound, while only 88.1% had successful cannulation with anatomical landmark-guided technique. Although the immediate outcomes of ultrasound-guided IJV cannulations appear excellent, the long-term use of the catheter is associated with some long-term complications such as catheter kinking, migration, thrombosis, and infections.

New evidence is supporting a better catheter outcome with the combined use of ultrasound- and fluoroscopy-guided IJV catheter insertion.[9] Gebauer et al.[10] evaluated the outcomes of combined ultrasound and fluoroscopy-guided port catheter implantation. They observed a technical success rate of 99% (298/299) without any major complications. In addition, a total of 23 (0.33/1000 catheter days) complications were recorded in the follow-up period of a total of 72,727 indwelling catheter days. These complications were infectious (0.15), thrombotic for 0.07, and migration for 0.04 complications per 1000 catheter days.

Although the use of combined ultrasound- and fluoroscopy-guided catheter insertion has comparatively better outcomes, it is not available in most hospitals that offer kidney care services in the LMICs. The availability of fluoroscopy, the training of staff in its use, and multidisciplinary collaboration should be a priority for all nephrology units, offering hemodialysis care for patients with ESKD. The benefits of fluoroscopy in patients with ESKD are not only in the placement of catheter but also in its removal and management of complications, as it was the case in the index patient. Furthermore, the management of the wrongly placed TIJV catheter in the case presented employed the services of multidisciplinary teams that involve the nephrology, radiology, and cardiothoracic surgery teams. The collaborations that resulted in the optimal management of the patient's complication with excellent outcome, buttresses the need for continuous partnership by these teams not only in the management of complications but also in the insertion and removal of TIJV catheters.


  Conclusion Top


The case highlights a rare complication of IJV catheter insertion with the catheter located in the parenchymal of the left lung field and accompanied left hemothorax. The catheter removal was successfully carried out under fluoroscopic guidance without the need for open thoracotomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hazara AM, Bhandari S. Can incremental haemodialysis reduce early mortality rates in patients starting maintenance haemodialysis? Curr Opin Nephrol Hypertens 2019;28:641-7.  Back to cited text no. 1
    
2.
Robinson BM, Akizawa T, Jager KJ, Kerr PG, Saran R, Pisoni RL. Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: Differences in access to renal replacement therapy, modality use, and haemodialysis practices. Lancet 2016;388:294-306.  Back to cited text no. 2
    
3.
Konner K. History of vascular access for haemodialysis. Nephrol Dial Transplant 2005;20:2629-35.  Back to cited text no. 3
    
4.
Faponle AE, Olatise OO, Igbokwe M, Asaolu SO. Outcomes of tunneled and nontunneled internal jugular catheters for hemodialysis at Zenith Medical and Kidney centre, Nigeria. Niger J Med 2020;29:455.  Back to cited text no. 4
  [Full text]  
5.
Raji YR, Ajayi SO, Aminu O, Abiola B, Efuntoye O, Salako BL, et al. Outcomes of tunneled internal jugular venous catheters for chronic haemodialysis at the University College Hospital, Ibadan, Nigeria. Pan Afr Med J 2018;31:218.  Back to cited text no. 5
    
6.
Hyder SM, Iqbal J, Lutfi IA, Shazlee MK, Hamid K, Rashid S. Complications associated with permanent internal jugular hemodialysis catheter: A Retrospective Study. Cureus 2019;11:e4521.  Back to cited text no. 6
    
7.
Sulek CA, Blas ML, Lobato EB. A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth 2000;12:142-5.  Back to cited text no. 7
    
8.
Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 1993;87:1557-62.  Back to cited text no. 8
    
9.
Dede D, Akmangit I, Yildirim ZN, Sanverdi E, Sayin B. Ultrasonography and fluoroscopy-guided insertion of chest ports. Eur J Surg Oncol 2008;34:1340-3.  Back to cited text no. 9
    
10.
Gebauer B, El-Sheik M, Vogt M, Wagner HJ. Combined ultrasound and fluoroscopy guided port catheter implantation – High success and low complication rate. Eur J Radiol 2009;69:517-22.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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