THE INCORRECT PLACEMENT OF HEMODIALYSIS CATHETERS IN VEINS. THE NECESSITY FOR URGENT X-RAY EVALUATION FOR ITS POSITION

Abstract

We describe a 56-year-old woman with end stage renal failure, who has an unusual complication in relation to catheter placement. She started hemodialysis in 1992 and until October of 1996 had many arteriovenous fistulas in her upper arms and we placed a lot of grafts. Because she had no vascular access for hemodialysis, we decided to place a polyurethane catheter in the left internal jugular vein. The woman had been in good health for 15 months when the blood flow decreased rapidly, so we replaced the catheter with a new one stablized with silicone in the same place. Because the blood flow again was insufficient for a good dialysis session we decided to check the catheter position angiographically, and were surprised to ascertain that the catheter was placed in the internal thoracic (mammalian) vein. We discuss this patient because she is the first in the international bibliography.

INTRODUCTION

Many complications have been reported related to dialysis catheters implanted in central veins and especially in subclavians [1-3]. The incorrect placement of the catheter usually concerns the way they ascend (heterolateral internal jugular vein through the subclavian), the heterolateral subclavian, or other veins, like the superior intercostal vein, as was recently published [[4]]. The placement of a dialysis catheter in the internal thoracic (mammalian) vein, instead of in the homolateral internal jugular vein has never been reported to the international bibliography.

CASE REPORT

A 56-year-old woman with end stage renal failure, caused by adult dominant polycystic kidney disease, started hemodialysis in December of 1992 with a double lumen catheter implanted in the right subclavian vein. Afterward, an internal arteriovenous fistula was created in her left wrist, which was functional for six months. Then another catheter was inserted in her right subclavian vein and a new arteriovenous fistula was created in the same arm (proximally). During the next five years, many arteriovenous fistulas had to be created in both arms, and many arteriovenous grafts and subclavian catheters had to be placed in both the right and left arms. Finally, in October 1996, a dialysis catheter was inserted in the left subclavian vein through which the patient was dialyzed for about 15 months. It is noted that before, as after the placement of this catheter, the patient had intense epiflevon in both left and right superclavian and subclavian areas. Because of the poor blood flow from this catheter (150–180 ml/min), the duration of each dialysis session was increased by 30 minutes and thereafter by 15 minutes more, in order to achieve a satisfactory dialysis. Nevertheless, in January 1998 a permanent vein catheter (polyourethane) was placed surgically in the left internal jugular vein, because of inadequate blood flow and because it was impossible to change the catheter (it was impossible to pass the wire throughout the catheter), and to create a new vascular access. The new catheter was also dysfunctional, so radiographs and venograms were done in order to check the catheter's position and to investigate the possible cause of inadequate blood flow. The chest X-ray demonstrated that the catheter was located left and lateral from the cardiac shadow (Fig. 1). To perform the venogram, a vein in the left arm was cannulated and the contrast agent injected in it. The venogram revealed an intense collateral network in the front thoracic wall, but the left subclavian vein was not outlined (Fig. 2). Afterward the injection of the contrast agent was done through the vein catheter and showed that it was located in the left internal thoracic vein, and the blood from the left arm was drained in the right atria via the hemiazygos vein (Figs. 3-4. Relying on these data and given that it was impossible to maintain dialysis through this catheter, as to place a new one in the upper arms (bilateral epiflevon), a PTFE (polytetrafluoroethylene) graft was placed in the left upper thigh, that is functional at present.

Figure 1. Chest X-ray with the catheter located on the left of the cardiac shadow.

Figure 2. Venogram of the left arm veins showing an intense network in the front thoracic wall, but invisible subclavian vein.

Figure 3. The injection of the contrast media via the catheter shows the internal thoracic vein.

Figure 4. The pathway of the blood from the left arm (via epigastric and other veins).

DISCUSSION

The use of hemodialysis catheters since the late 1970s has solved the problem of vascular access in patients with acute or chronic renal failure [[5]]. However, reports of complications associated with their use, both short term (pneumothorax, damage to an artery) [2-3] and long term (mainly subclavian vein stenosis) [1-6], have been recognized. Nowadays, nephrologists relying on their accumulated experience agree that catheters must be placed only in the internal jugular vein [[7]] or in some cases in the femoral one, but never in the subclavian vein [8-9],). This avoids the possibility of developing a subclavian vein stenosis and protects the vessels of the upper arms in order to create an arteriovenous fistula in the future.

Some rare complications associated with dialysis catheters have been reported as well, such as superior vena cava obstruction [[10]], arteriovenous fistulas between the carotid artery and jugular vein [[11]], and cardiac tamponade [12-13]. A case of incorrect placement of a dialysis catheter in the internal thoracic vein has never been described until now in the international bibliography.

The internal thoracic vein accompanies the internal thoracic artery and drains into the brachiocephalic vein, and with the heterolateral innominate vein forms the superior vena cava. The superior phrenic vein drain into the brachiocephalic vein through the internal thoracic vein, as well, and accompanies the pericardiophrenic artery. In case of brachiocephalic vein obstruction, the azygos, hemiazygos, and the internal thoracic veins become important branches through which the blood from the arm veins drains into the superior vena cava system. These veins retain connections with the epigastric veins and with many other branches of the inferior vena cava.

This case is the first of incorrect placement of a catheter in the internal thoracic vein that has ever been reported. Perhaps because of the partial obstruction of the brachiocephalic vein (it wasn't visible in the venogram and we were unable to pass the wire through the subclavian catheter), the blood from the left axillary vein had to follow other paths in order to drain into the right atria. The result of this was the expansion of the veins that received more blood, such as the veins of the front thoracic wall and the internal thoracic vein. This was probably the reason for the incorrect and uneventful placement of the catheter in the internal thoracic vein. From the above we conclude that it is possible to correctly place a central vein hemodialysis catheter even in vascular branches smaller than these most commonly chosen, and that a routine chest X-ray is necessary after the placement of a hemodialysis catheter.