Path less Traveled: Unusual Complication of Hemodialysis Catheter Insertion

A 20-year-old woman with end-stage kidney disease was to be initiated on hemodialysis and required hemodialysis catheter insertion. Patency of the right internal jugular vein (IJV) was confirmed on ultrasonography (USG). After taking informed consent and under USG guidance, right IJV was penetrated and guidewire was inserted. During the first two attempts, some resistance was felt in passing the guidewire and hence it was withdrawn. On the third attempt, guidewire passed without any resistance. There were ventricular premature complexes (VPCs) on the cardiac monitor after wire insertion; therefore, guidewire was withdrawn a bit till the VPCs settled and serial dilatation was done without any extra efforts followed by insertion of a double lumen temporary curved hemodialysis catheter. However, there was no flow in either port of the catheter. Immediate chest X-ray showed that the catheter was crossing the para-tracheal stripe, indicating that it was not in alignment with suprior vena cave (SVC) and probable malpositioning was suspected. [Figure 1a]. Contrast computed tomography (CT) thorax was done that was suggestive of the catheter tip in the esophagus [Figure 1b-d]. A consult was sought with interventional radiology and a controlled removal of the catheter was planned under fluoroscopy guidance. Right femoral vein was accessed under USG guidance and a long sheath was advanced up to the SVC. The terminal guide wire was advanced and parked in the right IJV for control [Figure 2a]. A reliant-compliant balloon was inserted over the guidewire and inflated across the segment where the catheter was crossing the right IJV. The catheter was removed under fluoroscopic guidance. Balloon tamponade at the level of IJV rent was applied with the reliant balloon for 10 min [Figure 2b]. After the successful tamponade, there was no oozing as demonstrated on subsequent venogram. A new femoral catheter was inserted over the stiff wire. Immediate upper gastrointestinal endoscopy was done to look for esophageal perforation but no rent was obvious. Endoscopy-guided Ryle’s tube was placed by the gastroenterology team and the patient was kept nil by mouth to prevent mediastinitis. Follow-up CT chest was done with oral contrast revealing no leak or stricture.Figure 1: (a) The chest X-ray of the patient showed that the catheter was crossing the paratracheal stripe, indicating that it is not in alignment with suprior vena cave (SVC) and probable malpositioning. (b and c) are of contrast computed tomography thorax of the patient. (d) suggestive of the catheter tip in the esophagusFigure 2: (a) The terminal guide wire advanced and parked in the right internal jugular vein (IJV). (b) Balloon tapenade being applied at the level of IJV rentAlthough the procedure was done with utmost precaution, possible reasons for this complication could be the usage of pressure while dilating and the dilators crossing the guidewire causing a venous rent. Esophageal rent was not visualized on endoscopy probably because it was very minute and presumably sealed off by the muscles of the esophageal wall. The patient continues to do well 6 months postcomplication. We conclude that the dilator should be inserted gently into the skin down to the depth of the vein as it is meant to dilate the skin and subcutaneous tract only. Guidewire and dilators should not be put forcefully if any resistance is encountered during the procedure. Multiple attempts for inserting the catheter are associated with more mechanical complications, the incidence of which increases up to six times with more than three attempts as compared to a single attempt.[1] 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 initials 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.