Inadvertent Dialysis Catheter—An Interventional Bailout!

Here is a 38-year-old male patient who presented in the emergency with complaints of severe abdominal pain, vomiting since 4 days, and breathlessness since 2 days. On clinical examination, the patient was drowsy, with dyspnea and moderate dehydration. Blood evaluation showed elevated lipase (63,365 U/L), amylase (2,457 U/L), and total count (17,000 cells/µL of blood). Imaging was suggestive of acute necrotizing pancreatitis. The patient developed secondary renal and respiratory failure for which the patient was shifted to the intensive care unit (ICU) for ventilatory support. Because of rising serum creatinine levels, central venous access was planned for hemodialysis.

Right internal jugular access was planned by the ICU intensivist. The procedure was performed by Seldinger technique using 16G needle without any ultrasound guidance. After the initial backflow, the needle was blindly advanced further, and a wire was introduced, following which a 6F central vein catheter was placed. No free backflow was observed, and the radiologist was called to perform a Doppler scan.

Check radiography was acquired, which showed the catheter to be positioned slightly off center ([Fig. 1]). Because of the patient's condition, contrast-enhanced computed tomographic (CT) angiography was performed, which revealed the central venous catheter to be malpositioned with the catheter traversing the right subclavian artery (first part of subclavian artery distal to the origin of the thyrocervical trunk) and surrounded by a localized hematoma. The catheter tip was in the posterior pleural cavity with associated lung contusion and hemothorax ([Figs. 2], [3]).

Fig. 1 Scanogram showing laterally placed central vein catheter.

Fig. 2 Contrast-enhanced CT. (A) Axial section and (B, C) reformatted coronal and sagittal sections show the central vein catheter (yellow arrow head) traversing the right subclavian artery with surroundings hematoma and right hemothorax.

Fig. 3 Volume-rendered image showing the malpositioned catheter placement.

The patient was referred to the interventional radiology team to evaluate the condition and take the appropriate interventional step required to bail out the patient from this situation. Both options of covered stent and balloon occlusion were explained to the patient, and covered stent placement was considered over balloon occlusion as balloon occlusion is a temporary technique that can be associated with a risk of re-bleed or increase in the rent size.

The patient was taken up for angiography. Right femoral access using a 5F sheath (Cordis) under ultrasound guidance was achieved. Right innominate artery angiogram was performed using a 100-cm Cobra catheter, which revealed that the central venous catheter had traversed the subclavian artery. However, there was no contrast leak across the puncture site that was likely due to the tamponade effect between the arterial wall and the catheter. Next, a wire was placed across the innominate artery, and the focus was shifted to the central vein catheter. A small volume of contrast was injected as the catheter was withdrawn, and a subclavian angiogram was seen once the side holes of the catheter were within the intraluminal portion of the artery ([Fig. 4]). It was decided to place a stent graft across the through and through puncture site. However, as the site was in proximity to the right vertebral artery (origin is 2.8 cm away), a decision of sacrifice of the right vertebral artery was made after evaluating the patency and caliber of the left vertebral artery. The 5F sheath was replaced by a 6F sheath, and a 40- × 8-mm stent graft (iCAST; Atrium Medical) was placed and deployed across the puncture site after pulling out the central vein catheter. Check angiogram images were acquired, which was suggestive of an excellent hemodynamic outcome ([Fig. 5]). Dual-antiplatelet (aspirin 75 mg and clopidogrel 150 mg) medication was initiated on day 2. The patient showed improvement in his condition during the postprocedure period.

Fig. 4 Angiography images. (A) Anteroposterior projection. (B) Oblique projection showing a filling defect within the right subclavian artery.

Fig. 5 Angiographic images. Anteroposterior projection. (A) Subclavian artery angiogram from pulled back catheter. (B) Stent graft placed across the subclavian artery rent.

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