Teaching Case

Section

Cardiovascular

Case Type

Clinical Case

Authors

Massimo Della Giustina¹, Marco Sorato²

¹ Istituto Universitario di Radiodiagnostica, Santa Maria della Misericordia University Hospital, Udine, Italy

²Department of Radiology, Santi Giovanni e Paolo Hospital, Venice, Italy

Patient

38 years, male

Categories

No Area of Interest ; Imaging Technique CT ;

Procedure Catheters, Complications ; No Special Focus ;

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Clinical History

A 38-year-old man with a history of polycystic kidney disease (heterozygous mutation of PKD1) on biweekly dialysis, awaiting transplant.

Admitted to our nephrology department for anaemia after having recently undergone a left nephrectomy performed elsewhere for polycystic kidney.

Differential Diagnosis List

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Right-sided heart failure

Biliary atresia

Congenital hepatic fibrosis

Dialysis catheter malposition

Imaging Findings

A CT scan performed on admission demonstrated the presence of blood material retroperitoneally in the left flank and medial to the splenic parenchyma and adjacent to the profile of the left psoas, in planes passing through L5, a hyperdense spot in the arterial phase without increasing in later phases. Subsequent angiography of the hypogastric artery revealed no active spillage.

A CT scan performed at discharge after polytransfusion, negative for active bleeding, showed a migration of the tip of the central venous catheter used for dialysis which had passed through the inferior vena cava wedging at the outlet (flow direction) of the left suprahepatic vein, which appeared completely thrombosed.

Discussion

The incidence of end-stage renal disease (ESRD) in the United States of America has tripled between 1990 and 2018 [1]. Haemodialysis represents the primary form of renal replacement therapy and must be initiated as soon as possible to reduce mortality [2].

Arteriovenous fistulas (AVFs) and grafts provide the optimal long-term central venous access for haemodialysis (HD). However, in the event of failure, alternative sites must be considered. In approximately 15% of patients with ESRD and multiple access failures, tunnelled dialysis catheters (TDCs) provide an alternative access site for HD [3]. In particular, transhepatic venous catheters, although associated with an increased incidence of catheter thrombosis [4], represent a valid access site when no other accessible central venous route is available. TDCs are a popular choice for initial dialysis treatment [11] and could be a suitable alternative to an AVF in complex patients, particularly those with limited life expectancy and vascular access problems [2,4–10] despite the presence of complications such as primarily venous thrombosis/stenosis and infection. However, other complications of significant importance must also be considered, including Horner’s syndrome, pneumothorax and cardiac tamponade. They remain a popular choice for initial dialysis treatment [11].

The incidence of complications (haematoma, infection, malposition) is significantly lower compared to other catheterisations, with a 2–5 times lower rate [12,13]. Furthermore, the occurrence of catheter malposition is rare with this type of catheterisation [14,15]. The occurrence of catheter malposition and the resulting vascular injury/perforation and catheter thrombosis may depend on numerous factors, including methodological inadequacies, anatomical variations and operator experience [16,17].

Budd–Chiari syndrome is defined as an obstruction of the hepatic veins at any level (from the inferior vena cava to the right atrium) caused by a variety of factors, including systemic thrombotic and non-thrombotic conditions. As a consequence of this obstruction, the liver is unable to drain effectively, resulting in increased pressure within the hepatic sinusoids. This leads to portal hypertension and reduced hepatic perfusion. Patients typically present with hepatomegaly, ascites, abdominal swelling and pain.

The mainstay of treatment is the removal of the obstruction, anticoagulant therapy and the management of the underlying disease. Liver transplantation is considered because of the possibility of progression to hepatic fibrosis and cirrhosis [18].

The utilisation of imaging techniques during and subsequent to catheterisation has the potential to prevent significant morbidity and mortality. Nevertheless, catheter malposition represents a relatively uncommon complication.

References

[1] U.S. Department of Health and Human Services. Kidney disease statistics for the United States (Update May 2023). In: National Institute of Diabetes and Digestive and Kidney Diseases [Internet]. Accessed 13 May 2024. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

[2] Koyuncu S, Herdem N, Uysal C, Kahriman G, Kocyigit I, Sipahioğlu M, Tokgoz B, Oymak O (2020) A rare complication following internal jugular vein catheterization to malposition: acute Budd Chiari syndrome. BMC Nephrol 21(1):525. doi: 10.1186/s12882-020-02182-0. (PMID: 33272229)

[3] Malviya PB, Andrews R, Ghodke A, Patel B, Reddy A (2020) Percutaneous Transhepatic Vein Permcath: A Case Report. Indian J Nephrol 30(6):430-2. doi: 10.4103/ijn.IJN_47_20. (PMID: 33840966)

[4] Pereira K, Osiason A, Salsamendi J (2015) Vascular Access for Placement of Tunneled Dialysis Catheters for Hemodialysis: A Systematic Approach and Clinical Practice Algorithm. J Clin Imaging Sci 5:31. doi: 10.4103/2156-7514.157858. (PMID: 26167389)

[5] Parikh RK (1972) Horner's syndrome. A complication of percutaneous catheterisation of internal jugular vein. Anaesthesia 27(3):327-9. doi: 10.1111/j.1365-2044.1972.tb08227.x. (PMID: 5041078)

[6] Galbert MW, Kay JE (1971) Perforation of the right innominate vein by central venous polyethylene catheter. Br J Anaesth 43(7):713-4. doi: 10.1093/bja/43.7.713. (PMID: 4935410)

[7] Arnold S, Feathers RS, Gibbs E (1973) Bilateral pneumothoraces and subcutaneous emphysema: a complication of internal jugular venepuncture. Br Med J 1(5847):211-2. doi: 10.1136/bmj.1.5847.211. (PMID: 4686558)

[8] Merrill RH, Raab SO (1982) Dialysis catheter-induced pericardial tamponade. Arch Intern Med 142(9):1751-3. (PMID: 7114996)

[9] Wilson B, Harwood L, Oudshoorn A, Thompson B (2010) The culture of vascular access cannulation among nurses in a chronic hemodialysis unit. CANNT J 20(3):35-42. (PMID: 21038828)

[10] Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP; National Kidney Foundation (2020) KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001. Erratum in: Am J Kidney Dis 77(4):551. doi: 10.1053/j.ajkd.2021.02.002. (PMID: 32778223)

[11] Foley RN, Collins AJ (2013) The USRDS: what you need to know about what it can and can't tell us about ESRD. Clin J Am Soc Nephrol 8(5):845-51. doi: 10.2215/CJN.06840712. (PMID: 23124788)

[12] Hyder SMS, Iqbal J, Lutfi IA, Shazlee MK, Hamid K, Rashid S (2019) Complications Associated with Permanent Internal Jugular Hemodialysis Catheter: A Retrospective Study. Cureus 11(4):e4521. doi: 10.7759/cureus.4521. (PMID: 31259130)

[13] Pikwer A, Bååth L, Davidson B, Perstoft I, Akeson J (2008) The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients. Anaesth Intensive Care 36(1):30-7. doi: 10.1177/0310057X0803600106. (PMID: 18326129)

[14] Sitzmann JV, Townsend TR, Siler MC, Bartlett JG (1985) Septic and technical complications of central venous catheterization. A prospective study of 200 consecutive patients. Ann Surg 202(6):766-70. doi: 10.1097/00000658-198512000-00017. (PMID: 3935062)

[15] Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM (1994) Complications and failures of subclavian-vein catheterization. N Engl J Med 331(26):1735-8. doi: 10.1056/NEJM199412293312602. (PMID: 7984193)

[16] Aslamy Z, Dewald CL, Heffner JE (1998) MRI of central venous anatomy: implications for central venous catheter insertion. Chest 114(3):820-6. doi: 10.1378/chest.114.3.820. (PMID: 9743173)

[17] Bahcebasi S, Kocyigit I, Akyol L, Unal A, Sipahioğlu MH, Oymak O, Utas C (2011) Carotid-jugular arteriovenous fistula and cerebrovascular infarct: a case report of an iatrogenic complication following internal jugular vein catheterization. Hemodial Int 15(2):284-7. doi: 10.1111/j.1542-4758.2010.00525.x. (PMID: 21231999)

[18] Brancatelli G, Vilgrain V, Federle MP, Hakime A, Lagalla R, Iannaccone R, Valla D (2007) Budd-Chiari syndrome: spectrum of imaging findings. AJR Am J Roentgenol 188(2):W168-76. doi: 10.2214/AJR.05.0168. (PMID: 17242224)

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