Misplacement of hemodialysis catheter to brachiocephalic artery required urgent sternotomy
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《血管的通路杂志》
Department of Cardiothoracic Surgery, John Hunter Hospital, Lookout Road, New Lambton, NSW, 2305, Australia
Abstract
Objective: The cuffed, tunnelled hemodialysis catheterization through the right internal jugular vein is widely used for mid- to long-term hemodialysis for patients with renal failure. The purpose of this report is to address the potentially lethal complication among the variety of surgical problems in conjunction with this procedure. The case also illustrates the potential pitfalls in the management of renal failure. Methods: A 65-year-old woman had a misplaced 14F-sized hemodialysis catheter insertion to the ascending aorta via the neck of brachiocephalic artery. The patient underwent urgent removal of the catheter through median sternotomy. Results: It was found that the catheter went into the brachiocephalic artery just 1–2 cm distally from the aortic arch. She recovered slowly despite the fact that she developed a cerebellar infarct, which was thought to be caused by a thromboembolism from the catheter, she also developed heart failure, pneumonia and septic shock postoperatively. Conclusions: Arterial catheter misplacement inside of the chest is a potentially lethal complication. Open surgical treatment should be considered for the major chest arterial injury.
Key Words: Injury; Artery; Hemodialysis catheter; Renal failure; Aorta
1. Introduction
Immediate complications of central venous catheterisation are not rare. The cuffed, tunnelled hemodialysis catheter for the patient suffering from renal failure has been widely used for mid- to long-term hemodialysis. However, once a complication occurs with these catheters it is often serious due to the large size and increased risk of the bleeding at the time of dialysis. We describe a case of injury to the brachiocephalic artery which is one of the most severe complications of this procedure.
2. Case report
A 65-year-old woman was transferred from a hospital for management of a misplaced 14F-size, cuffed, tunnelled hemodialysis catheter (permacath). She had a background of end-stage renal failure (ESRF) on continuous ambulatory peritoneal dialysis, insulin dependent diabetes mellitus, obesity, and heart failure due to ischemic heart disease. She was admitted to the hospital for treatment of resistant peritonitis due to methicillin resistant staphylococcus aureus. Her Tenckhoff catheter was removed and a permacath was attempted to be placed to the right internal jugular vein using the modified Seldinger technique, after the failed attempts from the left side. The catheter ended up in the ascending aorta and she was transferred to our hospital the day after its placement.
Chest X-ray showed a permacath placed deep into the ascending aorta (Fig. 1A). Chest computed tomographic (CT) angiogram showed that the catheter was inserted to the brachiocephalic artery just after the bifurcation from the aorta. There was no sign of bleeding and no obvious injury of other vessels. The patient underwent removal of the permacath through median sternotomy. Cardio-pulmonary bypass was on standby due to the high risk of removing the permacath from the orifice of the right brachiocephalic artery. Transesophageal echocardiogram showed that the permacath was positioned just above the aortic valve (Fig. 1B) and also showed her poor left ventricular function. The permacath was passed just behind the right side of the sternum through the back of innominate vein and inserted to the right side of the right brachiocephalic artery (Fig. 2). The insertion point was 1–2 cm distally from the aortic arch and no active bleeding was found. After placing a pursestring suture the permacath was removed. A temporary untunnelled hemodialysis catheter was inserted in the left subclavian vein.
Postoperatively, she developed dysarthria and an uncoordinate swallow on day 3 post-op. Head CT scan showed a right inferior cerebellar infarct, the cause of which was thought to be the thromboembolism from the catheter. She recovered slowly, although she developed heart failure, pneumonia and septic shock. After the successful open permacatheterisation via the right internal jugular vein she was sent back to the home hospital for further treatment.
3. Discussion
Patients suffering from ESRF, especially due to diabetes mellitus, have a higher risk once complications occur. Although these patients can safely undergo surgery with careful peri-operative management, they still have increased morbidity and mortality rates, especially for emergency open heart operations [1]. This patient developed most of the postoperative major complications, such as severe infection, thromboembolism and heart failure, but managed to recover.
Central venous catheterisation is frequently performed for peri-operative management and long-term intravenous access, including the access for hemodialysis, and is an essential part of patient management in a variety of clinical settings. In a prospective study, acute complications occurred in almost 10% of patients who were assigned to subclavian vein catheterisation, including misplacement, subclavian arterial puncture, pneumothorax, and mediastinal hematoma [2]. Although recent studies show improved results for central venous access using ultrasound guides [3], some complications such as arterial punctures still occur. Several major injuries to the aorta or the heart have been reported [4,5]. In most cases reported, major arterial injury occurred after right subclavicular approach, possibly due to the close anatomic positions between the right brachiocephalic venous trunk and the right lateral side of the ascending aorta [6]. Except for the ultrasound guided technique [3], there are practical recommendations for the central venous catheterisation to avoid the complication. One major predictor of complication was a failed catheterisation attempt [2]. The complication rate was more than 5-times more for three or more needle passes compared with 1 pass. The failed attempt by an operator does not mean the increased risk of complication at the same site by another operator. Radiological confirmation of the position of the guide wire might prevent the misplacement of the bigger catheter.
Our patient was hemodynamically stable and there was no sign of bleeding, because the catheter was left inserted into the aorta. Withdrawal of the permacath under indirect vision from the aorta or major arteries inside of the chest could be lethal [4]. A surgical or other interventional procedure would be necessary to remove the catheter.
Endovascular stent graft surgery has been successfully adapted for the repair of arterial injuries with better outcome compared with open conventional surgery [7,8]. Endovascular stenting is an ideal procedure especially for high risk patients. A vascular surgeon was originally involved in this treatment until CT angiogram showed that the insertion point was the bifurcation of brachiocephalic artery from the aorta. If the injured point was the subclavian artery, an endovascular approach could be used. The brachiocephalic artery is not a suitable place for placing a stent graft and, especially, the orifice of the brachiocephalic artery has to be covered. The percutaneous closure device to assist with the hemostasis after femoral arterial access, also has been used for the management of inadvertent arterial catheterisation, such as subclavian artery, with good results [7,9]. However, this procedure often requires adjunctive prolonged balloon tamponade, which may have led to brain ischemia if this was used in our case. We think that despite the latest technological advances, the traditional surgical procedure still has some benefits in selected cases like ours.
In conclusion, arterial misplacement inside of the chest of a permacath is a potentially lethal complication, especially for the patient suffering from ESRF. Once this is suspected, the catheter should be left inside the artery and the exact position should be established by CT scan or angiography. Emergency surgical removal is mandatory to prevent further complications.
References
Bhattacharyya N, Cheung AH, Dang CR, Wong LL, Myers SA, Ng RC, McNamara JJ. Open heart surgery in patients with end-stage renal disease. Am J Nephrol 1997; 17:435–439.
Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994; 331:1735–1738.
Mey U, Glasmacher A, Hahn C, Gorschluter M, Ziske C, Mergelsberg M, Sauerbruch T, Schmidt-Wolf IG. Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients. Support Care Cancer 2003; 11:148–155.
Pan D, Moore HG 3rd, Angood P, Rabinovici R. Aortic injury resulting from attempted subclavian central venous catheter placement. J Trauma 1999; 47:403–405.
Walser EM, Crow WN, Zwischenberger JB, Conti VR. Percutaneous tamponade of inadvertent transthoracic catheterization of the aorta. Ann Thorac Surg 1996; 62:895–896.
Fangio P, Mourgeon E, Romelaer A, Goarin JP, Coriat P, Rouby JJ. Aortic injury and cardiac tamponade as a complication of subclavian venous catheterization. Anesthesiology 2002; 96:1520–1522.
Nicholson T, Ettles D, Robinson G. Managing inadvertent arterial catheterization during central venous access procedures. Cardiovasc Intervent Radiol 2004; 27:21–25.
Castelli P, Caronno R, Piffaretti G, Tozzi M, Lagana D, Carrafiello G, Cuffari S. Endovascular repair of traumatic injuries of the subclavian and axillary arteries. Injury 2005; 36:778–782.
Wallace MJ, Ahrar K. Percutaneous closure of a subclavian artery injury after inadvertent catheterization. J Vasc Interv Radiol 2001; 12:1227–1230.(Tsutomu Matsushita, Anh T)
Abstract
Objective: The cuffed, tunnelled hemodialysis catheterization through the right internal jugular vein is widely used for mid- to long-term hemodialysis for patients with renal failure. The purpose of this report is to address the potentially lethal complication among the variety of surgical problems in conjunction with this procedure. The case also illustrates the potential pitfalls in the management of renal failure. Methods: A 65-year-old woman had a misplaced 14F-sized hemodialysis catheter insertion to the ascending aorta via the neck of brachiocephalic artery. The patient underwent urgent removal of the catheter through median sternotomy. Results: It was found that the catheter went into the brachiocephalic artery just 1–2 cm distally from the aortic arch. She recovered slowly despite the fact that she developed a cerebellar infarct, which was thought to be caused by a thromboembolism from the catheter, she also developed heart failure, pneumonia and septic shock postoperatively. Conclusions: Arterial catheter misplacement inside of the chest is a potentially lethal complication. Open surgical treatment should be considered for the major chest arterial injury.
Key Words: Injury; Artery; Hemodialysis catheter; Renal failure; Aorta
1. Introduction
Immediate complications of central venous catheterisation are not rare. The cuffed, tunnelled hemodialysis catheter for the patient suffering from renal failure has been widely used for mid- to long-term hemodialysis. However, once a complication occurs with these catheters it is often serious due to the large size and increased risk of the bleeding at the time of dialysis. We describe a case of injury to the brachiocephalic artery which is one of the most severe complications of this procedure.
2. Case report
A 65-year-old woman was transferred from a hospital for management of a misplaced 14F-size, cuffed, tunnelled hemodialysis catheter (permacath). She had a background of end-stage renal failure (ESRF) on continuous ambulatory peritoneal dialysis, insulin dependent diabetes mellitus, obesity, and heart failure due to ischemic heart disease. She was admitted to the hospital for treatment of resistant peritonitis due to methicillin resistant staphylococcus aureus. Her Tenckhoff catheter was removed and a permacath was attempted to be placed to the right internal jugular vein using the modified Seldinger technique, after the failed attempts from the left side. The catheter ended up in the ascending aorta and she was transferred to our hospital the day after its placement.
Chest X-ray showed a permacath placed deep into the ascending aorta (Fig. 1A). Chest computed tomographic (CT) angiogram showed that the catheter was inserted to the brachiocephalic artery just after the bifurcation from the aorta. There was no sign of bleeding and no obvious injury of other vessels. The patient underwent removal of the permacath through median sternotomy. Cardio-pulmonary bypass was on standby due to the high risk of removing the permacath from the orifice of the right brachiocephalic artery. Transesophageal echocardiogram showed that the permacath was positioned just above the aortic valve (Fig. 1B) and also showed her poor left ventricular function. The permacath was passed just behind the right side of the sternum through the back of innominate vein and inserted to the right side of the right brachiocephalic artery (Fig. 2). The insertion point was 1–2 cm distally from the aortic arch and no active bleeding was found. After placing a pursestring suture the permacath was removed. A temporary untunnelled hemodialysis catheter was inserted in the left subclavian vein.
Postoperatively, she developed dysarthria and an uncoordinate swallow on day 3 post-op. Head CT scan showed a right inferior cerebellar infarct, the cause of which was thought to be the thromboembolism from the catheter. She recovered slowly, although she developed heart failure, pneumonia and septic shock. After the successful open permacatheterisation via the right internal jugular vein she was sent back to the home hospital for further treatment.
3. Discussion
Patients suffering from ESRF, especially due to diabetes mellitus, have a higher risk once complications occur. Although these patients can safely undergo surgery with careful peri-operative management, they still have increased morbidity and mortality rates, especially for emergency open heart operations [1]. This patient developed most of the postoperative major complications, such as severe infection, thromboembolism and heart failure, but managed to recover.
Central venous catheterisation is frequently performed for peri-operative management and long-term intravenous access, including the access for hemodialysis, and is an essential part of patient management in a variety of clinical settings. In a prospective study, acute complications occurred in almost 10% of patients who were assigned to subclavian vein catheterisation, including misplacement, subclavian arterial puncture, pneumothorax, and mediastinal hematoma [2]. Although recent studies show improved results for central venous access using ultrasound guides [3], some complications such as arterial punctures still occur. Several major injuries to the aorta or the heart have been reported [4,5]. In most cases reported, major arterial injury occurred after right subclavicular approach, possibly due to the close anatomic positions between the right brachiocephalic venous trunk and the right lateral side of the ascending aorta [6]. Except for the ultrasound guided technique [3], there are practical recommendations for the central venous catheterisation to avoid the complication. One major predictor of complication was a failed catheterisation attempt [2]. The complication rate was more than 5-times more for three or more needle passes compared with 1 pass. The failed attempt by an operator does not mean the increased risk of complication at the same site by another operator. Radiological confirmation of the position of the guide wire might prevent the misplacement of the bigger catheter.
Our patient was hemodynamically stable and there was no sign of bleeding, because the catheter was left inserted into the aorta. Withdrawal of the permacath under indirect vision from the aorta or major arteries inside of the chest could be lethal [4]. A surgical or other interventional procedure would be necessary to remove the catheter.
Endovascular stent graft surgery has been successfully adapted for the repair of arterial injuries with better outcome compared with open conventional surgery [7,8]. Endovascular stenting is an ideal procedure especially for high risk patients. A vascular surgeon was originally involved in this treatment until CT angiogram showed that the insertion point was the bifurcation of brachiocephalic artery from the aorta. If the injured point was the subclavian artery, an endovascular approach could be used. The brachiocephalic artery is not a suitable place for placing a stent graft and, especially, the orifice of the brachiocephalic artery has to be covered. The percutaneous closure device to assist with the hemostasis after femoral arterial access, also has been used for the management of inadvertent arterial catheterisation, such as subclavian artery, with good results [7,9]. However, this procedure often requires adjunctive prolonged balloon tamponade, which may have led to brain ischemia if this was used in our case. We think that despite the latest technological advances, the traditional surgical procedure still has some benefits in selected cases like ours.
In conclusion, arterial misplacement inside of the chest of a permacath is a potentially lethal complication, especially for the patient suffering from ESRF. Once this is suspected, the catheter should be left inside the artery and the exact position should be established by CT scan or angiography. Emergency surgical removal is mandatory to prevent further complications.
References
Bhattacharyya N, Cheung AH, Dang CR, Wong LL, Myers SA, Ng RC, McNamara JJ. Open heart surgery in patients with end-stage renal disease. Am J Nephrol 1997; 17:435–439.
Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994; 331:1735–1738.
Mey U, Glasmacher A, Hahn C, Gorschluter M, Ziske C, Mergelsberg M, Sauerbruch T, Schmidt-Wolf IG. Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients. Support Care Cancer 2003; 11:148–155.
Pan D, Moore HG 3rd, Angood P, Rabinovici R. Aortic injury resulting from attempted subclavian central venous catheter placement. J Trauma 1999; 47:403–405.
Walser EM, Crow WN, Zwischenberger JB, Conti VR. Percutaneous tamponade of inadvertent transthoracic catheterization of the aorta. Ann Thorac Surg 1996; 62:895–896.
Fangio P, Mourgeon E, Romelaer A, Goarin JP, Coriat P, Rouby JJ. Aortic injury and cardiac tamponade as a complication of subclavian venous catheterization. Anesthesiology 2002; 96:1520–1522.
Nicholson T, Ettles D, Robinson G. Managing inadvertent arterial catheterization during central venous access procedures. Cardiovasc Intervent Radiol 2004; 27:21–25.
Castelli P, Caronno R, Piffaretti G, Tozzi M, Lagana D, Carrafiello G, Cuffari S. Endovascular repair of traumatic injuries of the subclavian and axillary arteries. Injury 2005; 36:778–782.
Wallace MJ, Ahrar K. Percutaneous closure of a subclavian artery injury after inadvertent catheterization. J Vasc Interv Radiol 2001; 12:1227–1230.(Tsutomu Matsushita, Anh T)