Wrong Turn at the Renal Vein: Malposition of a Right Femoral Tunneled Hemodialysis Catheter Into the Left Renal Vein

Tunneled hemodialysis catheters placed through the femoral vein provide an alternative form of vascular access when conventional upper-body access is unavailable or undesirable.However, their extended intravascular course may permit clinically important malposition.We describe a 78-year-old man with severe heart failure and chronic kidney disease who developed oligoanuric acute kidney injury after an outof-hospital cardiac arrest.Hemodialysis was initiated through a temporary left femoral catheter.Because continued dialysis was anticipated and upper-body access was limited by recent cardiac-device procedures, a 44-cm cuffed tunneled dialysis catheter was inserted through the right femoral vein under ultrasound guidance.Both lumens aspirated and flushed normally, and no resistance was encountered during placement.Routine abdominal radiography demonstrated that the catheter ascended the inferior vena cava (IVC) before turning sharply toward the left, with its tip likely terminating in the left renal vein.The catheter was not used and was exchanged over a guidewire for a 42-cm cuffed catheter.Post-exchange radiography demonstrated termination of the replacement catheter in the intrahepatic IVC.The replacement catheter functioned normally during hemodialysis.No hematuria, bleeding, thrombosis, hemoglobin decline, or other catheter-related complication occurred.This case demonstrates that ultrasound-guided venous entry, uncomplicated advancement, and normal aspiration do not confirm appropriate catheter-tip position.Postplacement imaging should be reviewed before a femoral tunneled dialysis catheter is used.