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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 786-789
Mediastinal malposition of a left jugular tunneled hemodialysis catheter with bilateral hemothorax and pneumo-hemo-mediastinum


1 Hemodialysis and Renal Unit, Centre Hospitalier Jacques Lacarin, Vichy, France
2 Radiology Department, Centre Hospitalier Jacques Lacarin, Vichy, France

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Date of Web Publication8-Jul-2015
 

How to cite this article:
Kosmadakis G, Correia ED, Carceles O, Somda F, Bros C, Aguilera D. Mediastinal malposition of a left jugular tunneled hemodialysis catheter with bilateral hemothorax and pneumo-hemo-mediastinum. Saudi J Kidney Dis Transpl 2015;26:786-9

How to cite this URL:
Kosmadakis G, Correia ED, Carceles O, Somda F, Bros C, Aguilera D. Mediastinal malposition of a left jugular tunneled hemodialysis catheter with bilateral hemothorax and pneumo-hemo-mediastinum. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Oct 18];26:786-9. Available from: http://www.sjkdt.org/text.asp?2015/26/4/786/160217
To the Editor,

Central venous catheter (CVC) placement is a standardized procedure in clinical practice since at least 50 years. [1] The advances made in medicine have increased the demand for a reliable central access in order to perform a wide range of medical therapeutic procedures, including hemodialysis (HD). More than five million CVCs are placed each year in the United States, with an associated complication rate that varies between 6.3% and over 15%. [2],[3] The most common complications are arterial puncture (10.6-13%) and hematoma formation (4-8.4%). [3],[4]

In HD, despite the development of diagnostic and surgical techniques that have facilitated the arteriovenous fistula doctrine, there are still a very large number of patients who are being dialyzed from tunneled CVCs.

A 74-year-old male HD patient with a primary diagnosis of multiple myeloma was admitted for the addition of a second tunneled branch on his single CVC in order to improve the adequacy of HD. Twenty-five months before the event, he had a right jugular nontunneled catheter followed by a single-branch left tunneled catheter that was replaced one year later. The patient had received various chemotherapeutic medications for his myeloma and his condition was considered relatively frail.

On the day of the intervention, the patient was placed in the procedure room and, under local anesthesia, two guide wires were passed through the single-lumen catheter and the old catheter was removed. The first guide wire was successfully catheterized but the second catheter could not be passed even after using a dilator. The second guide wire was then removed and the jugular vein was accessed at a distance of 1 cm from the existing branch. The access to the left jugular vein was successful and event free in the first attempt itself. Another guide wire was easily passed through and, with the use of a dilator, a second silicon branch was placed. On function control, both branches were operational in aspiration and injection modes. During the last part of the procedure, the patient complained of bilateral shoulder and back aches that were attributed to the prolonged stay in a non-physiological position.

Directly after the procedure, a control front chest X-ray showed the two branches in physiological position and the hemoglobin levels were stable at 9.9 g/dL. The day after, the patient was put on HD and, at the time of connection, it was found that one of the two branches was functioning properly on aspiration and the other branch on injection only. During the dialysis session, the patient complained of shoulder aches, the intensity of which varied with the speed of the dialysis pump. The patient developed two hypotensive episodes during that session that had to be terminated earlier than scheduled. On auscultation, the breath sounds were reduced bilaterally and more so on the right side. The hemoglobin levels on that day had fallen to 7.7 g/dL without any external signs of blood loss.

A thoracic computed tomography (CT) scan was urgently performed after the interrupteddialysis session; it showed bilateral pleural effusion, predominantly on the right side. This was associated with a right upper mediastinal effusion bearing the characteristics of a hematoma with pneumo-mediastinum extending at the front of the pericardium [Figure 1]. One of the two catheter tips was well within the superior vena cava but the second catheter tip appeared outside the venous structure in front of the aortic arch and directly in contact with the mediastinal hematoma [Figure 2]. A right pleural puncture drained 800 mL of hemorrhagic effluent.
Figure 1: Mediastinal effusion with features suggestive of hematoma and pneumo-mediastinum at the pericardial area.

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Figure 2: Computed tomography 3D image reconstruction showing the left arterial catheter tip medially and slightly reversed while the venous tip is obviously displaced from the vascular structure into the mediastinal area.

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The day after, the patient was febrile with leukocytosis and a rise of C-reactive protein (CRP) levels. Mediastinitis was suspected and a triple intravenous antibiotic regimen was initiated consisting of vancomycin, gentamycin in doses based on drug levels and ceftriaxone 2 g every second day. The displaced catheter tip was ablated.

A thoracic CT scan four days after the event showed minimal pleural effusion with a significant reduction of the collection of blood and air in the mediastinum.

Complications of CVC placement can be broadly divided into two groups: (a) malposition of the catheter and (b) complications associated with perforation and/or injury to nearby vascular structures. The most common locations for malposition of CVC while attempting to cannulate the internal jugular vein include the internal mammary vein and the pericardiophrenic vein. The frequency of occurrence of catheter tip malposition is estimated to be 14%, with the tip most commonly located in the right atrium (55%), followed by the left brachiocephalic vein (14%), the inferior vena cava and the right pulmonary artery. [5]

Catheterization through the left internal jugular vein is associated with more malpositions and vascular perforations than a catheter placed from the right internal jugular vein. This is due to the fairly straight course of the right internal jugular vein passing into the right brachiocephalic vein, while the left internal jugular vein forms a greater bend when it becomes the left brachiocephalic vein.

In a recent Swedish study, the incidence of radiographic catheter tip malposition, both extra-thoracic and ventricular positioning, was 3.3%. Cannulation through the right subclavian vein carried the highest risk of malposition of 9.1% compared with 1.4% while using the right internal jugular vein; no case of malposition had associated vascular perforation, local venous thrombosis or cerebral symptoms. [6] The main risk factors for acute adverse events during cannulation of vascular access without ultrasound guidance are the body mass index, operator experience, coagulopathy and history of prior cannulation. [7]

Accidental puncture and perforation of blood vessels, which is associated with more adverse outcomes, is not uncommon. Earlier reports have indicated left mediastinal central line malposition after cannulation of the pulmonary artery or during a temporary venous pacemaker placement with negative outcomes and a fatal cardiac tamponade. [8],[9]

It should be remembered that successful aspiration of a small amount of blood from the catheter lumen after placement of the catheter does not necessarily confirm an in situ catheter. As in the case reported here, it is possible that the blood was aspirated from a local hematoma created after perforation of the internal jugular vein.

We strongly recommend taking a chest X-ray following the placement of any CVC. If there are suspicious radiographic findings, a CT scan or a venography should be performed. The use of ultrasound guidance during the procedure is unlikely to have prevented the above-mentioned complication, because the internal jugular vein was cannulated without difficulty on the first attempt by using anatomical landmarks. There are reports of ipsilateral pleural effusions due to displaced CVCs, [10],[11] but not with a simultaneous mediastinal hematoma or this set of symptomatology during the HD session.

In a case similar to the one described, the confluence of the right innominate vein and the superior vena cava was perforated during the placement of a right tunneled jugular CVC. [12] The particular event had a favorable outcome, although this is not always the rule. [13] In our case, we simply pulled the misplaced tip out of the mediastinum 24 h after the placement and there were no unfavorable events. Other proposed solutions for a central vein puncture include thoracotomy and correc-tion of the injury, [14] or the use of an endo-prosthesis to occlude the perforation site. [15]

In conclusion, we report a very rare case of central vascular puncture during a tunneled central catheter placement for HD resulting in pneumo-hemo-mediastinum and important bilateral hemorrhagic pleural effusions that had a favorable outcome. It is important to take into consideration the slightest changes in clinical parameters of a patient during a CVC placement. A CT scan should be performed in every suspected clinically important catheter displacement.

Conflict of Interest

No conflicts of interest exist for any of the authors. The results presented in this paper have not been published previously in whole or in part.

 
   References Top

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Treleaven RB, Copestake GG. Experiences with Seldinger catheterization. J Can Assoc Radiol 1962;13:58-64.  Back to cited text no. 1
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2.
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 2
    
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Martin MJ, Husain FA, Piesman M, et al. Is routine ultrasound guidance for central line placement beneficial? A prospective analysis. Curr Surg 2004;61:71-4.  Back to cited text no. 3
    
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Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterization of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Crit Care 2006;10:R162.  Back to cited text no. 4
    
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Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE. Cannulation of the internal jugular vein: Is postprocedural chest radiography always necessary? Crit Care Med 1999;27:1819-23.  Back to cited text no. 5
    
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Pikwer A, Bååth L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: A prospective cohort study in 1619 patients. Anaesth Intensive Care 2008;36:30-7.  Back to cited text no. 6
    
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Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735-8.  Back to cited text no. 7
    
8.
Moskal TL, Ray CE Jr. Left mediastinal central line malposition - A case report. Angiology 1999;50:349-53.  Back to cited text no. 8
    
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Albertson TE, Fisher CJ Jr, Vera Z. Accidental mediastinal entry via left internal jugular vein cannulation. Intensive Care Med 1985;11:154-7.  Back to cited text no. 9
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10.
Campagnutta E, Segatto A, Maesano A, Sopracordevole F, Visentin MC, Scarabelli C. Bilateral hydrothorax with hydromediastinum after cannulation of the left internal jugular vein. Minerva Ginecol 1989;41:479-83.  Back to cited text no. 10
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11.
Simmons TC, Henderson DR. Bilateral pleural and pericardial effusions because of mediastinal placement of a central venous catheter. JPEN J Parenter Enteral Nutr 1991;15:676-9.  Back to cited text no. 11
    
12.
Kuzniec S, Natal SR, Werebe Ede C, Wolosker N. Videothoracoscopic-guided management of a central vein perforation during hemodialysis catheter placement. J Vasc Surg 2010;52:1354-6.  Back to cited text no. 12
    
13.
Jankovic Z, Boon A, Prasad R. Fatal haemothorax following large-bore percutaneous cannulation before liver transplantation. Br J Anaesth 2005;95:472-6.  Back to cited text no. 13
    
14.
Wang CY, Liu K, Chia YY, Chen CH. Bedside ultrasonic detection of massive hemothorax due to superior vena cava perforation after hemodialysis catheter insertion. Acta Anaesthesiol Taiwan 2009;47:95-8.  Back to cited text no. 14
    
15.
Anaya-Ayala JE, Charlton-Ouw KM, Kaiser CL, Peden EK. Successful emergency endovascular treatment for superior vena cava injury. Ann Vasc Surg 2009;23:139-41.  Back to cited text no. 15
    

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Correspondence Address:
Dr. Georgios Kosmadakis
Hemodialysis and Renal Unit, Centre Hospitalier Jacques Lacarin, Vichy
France
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DOI: 10.4103/1319-2442.160217

PMID: 26178558

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