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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 3  |  Page : 560-563
The stuck dialysis catheter: A nasty astonishment


1 Department of Vascular Surgery, "Iasò General" Hospital of Athens; Department of Pharmacology, Medical School, University of Athens, Athens, Greece
2 Department of Vascular Surgery, "Iasò General" Hospital of Athens, Athens, Greece

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Date of Web Publication20-May-2015
 

   Abstract 

Removal of a tunneled cuffed central venous catheter can be challenging and risky. In some cases, the catheter firmly adheres to the surrounding tissues, becoming an integrated part of the vessel wall. We present the case of an adult female hemodialysis (HD) patient with a dysfunctioning HD tunneled cuffed catheter. The catheter removal procedure proved mazy. After several attempts, the catheter was removed together with the peri-catheter fibrin sheath. However, the post-procedure period was uneventful.

How to cite this article:
Galanopoulos G, Lambidis C. The stuck dialysis catheter: A nasty astonishment. Saudi J Kidney Dis Transpl 2015;26:560-3

How to cite this URL:
Galanopoulos G, Lambidis C. The stuck dialysis catheter: A nasty astonishment. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jun 23];26:560-3. Available from: https://www.sjkdt.org/text.asp?2015/26/3/560/157366

   Introduction Top


Tunneled central venous catheters play an important role in the hemodialysis (HD) patients, providing an important means of a longterm vascular access. Complications associated with their use (dysfunction, infection) may mandate their removal. Although the presence of a pericatheter sheath is common, removal of catheters does not present any inconvenience in the large majority of patients.

In this report, we present a case of a young woman, whose catheter was firmly adherent to the vessel wall, resisting any kind of withdrawal maneuver.


   Case Repor Top


A 39-year-old female patient with end-stage renal disease (ESRD) secondary to polycystic kidney disease had a cuffed tunneled HD catheter implanted in the right internal jugular vein 24 months ago. Because of reduced catheter flow during the last two months, the patient was referred to us for catheter removal and substitution.

From a technical point of view, we usually prefer to make an incision at the entry point of the catheter in the neck, at the vertex of the triangle formed between the two heads of insertion of the sternocleidomastoid muscle. At that point, the catheter is captured and cut. The distal part of the catheter is removed after making a second incision over the cuff. The cuff is detached, and this part of the catheter is pulled out. Through one of the lumens of the remnant (proximal) part of the catheter, a 0.038 inch guide wire is passed under fluoroscopic guidance in order to reuse the same passage for inserting a new catheter in the same site.

In the present case, under local anesthesia, the guide wire was passed through the catheter without any problem, but the catheter retrieval encountered significant resistance. Any attempt to pull out the catheter was accompanied with severe pain in the neck and the chest of the patient. Dissection all the way to the venotomy site failed to release the catheter. Intravenous sedation was administered to the patient and we decided to proceed with traction and gentle torsion of the catheter around its axis, maintaining the guide wire within the lumen. After numerous attempts, the catheter was removed, without any procedure-related complications. The surrounding fibrous tissue was also removed along with the catheter. That tissue encircled the entire length of the catheter from the entry point to the jugular vein to the tip, causing severe dysfunction and firm adhesion to the wall of the vein.


   Discussion Top


HD tunneled catheters are wide-spread among patients with ESRD. In the USA, approximately 25% of HD patients use tunneled dialysis catheters, while the corresponding percentage is up to 39% in Canada. [1]

Catheter removal can become mandatory when several complications occur, such as dysfunction, infection or thrombosis. These catheters can stay in place for years, and this fact favors the development of firm adhesion of the catheter to the wall of the vein, rendering removal extremely problematic. A fibrin sheath is formed around the catheter. It is believed that these sheaths derive from thrombus formations around the catheter that organize into a fibrous connective tissue. [2] This fibrous tissue can invade the lateral holes and the distal end tubes of the catheter causing severe dysfunction or even thrombosis of the access. The fibrous tissue seems to be calcified in nature. Wilson et al [3] reported their histopathological findings in children with stuck catheters. The pericatheter tissue was the result of reactive fibrosis. It was calcified with a lamellar structure, suggestive of metaplastic bone formation. Disturbances in calcium homeostasis in HD patients may, hypothetically, accelerate the formation of the calcified tissue around the catheter, causing a firm adhesion with it. A firmly adherent catheter to the wall of the vein can fracture during forced traction for catheter removal. Migration and infection of the retained fragment have been described. [4] It is obvious that a firmly adherent retained piece of the catheter is not likely to migrate to the heart or to the pulmonary circulation, [5] but can primarily serve as a nidus for infection. In the literature, cases of stuck catheters have been described, where these catheters were fixed at the point of entry to the vein. [5] Dissection or venotomy may be required in order to remove them.

Some authors have found that adhesion to the fibrous tissue formed around the catheter is more intense and, as a consequence, retention became more frequent when polyurethane catheters were used. [3],[5] For that reason, the use of silicone catheters has been recommended, especially in pediatric patients and if indwelling time of more than 18 months is expected. [3] There are no consistent data demonstrating a clear correlation between retention and material of the catheter. In our practice, we use almost exclusively catheters made by polyurethane, and this is the first case of problematic removal. Furthermore, in our experience, there were patients whose long-standing catheters, after many years, were removed without any difficulty. To clarify the role of the parameter "indwelling period," further studies are needed.

Dealing with a stuck catheter may become complicated and risky. Several complications may arise during removal, such as vascular damage, rupture and retention of catheter fragments. [6],[7] Forced withdrawal of the catheter can cause extreme stretching and finally breaking of it, with subsequent retention of a fragment. It is not to underestimate the elevated possibility of vessel injury, because retrieval force pulls out the catheter and the vessel en block. This is the reason why most authors advise against applying tension. Various methods have been described, including slow gentle traction (up to 36 h), [8] cutaneous cut-down with distal venotomy, [9] rotation of the catheter, introduction of a guide wire and bidirectional motion of the catheter or introduction of a stiff guide wire and push-in the catheter to detach it from the vein. [10] Balloon dilation in order to rupture the pericatheter sheath has also been described. [11] Over-the-wire introduction and inflation of an angioplasty balloon inside the lumen along the entire length up to the entry point may be effective in detaching the catheter from the sheath. [11] Laser sheath technique has also been described. [12] In this way, all the adhesions can be transected all the way down to the catheter tip under fluoroscopic control. Surgical exploration and remotion is used as a last choice because of the invasiveness and morbidity accompanying this method.

In our case, we decided to proceed with gentle traction and rotation of the catheter in both directions. Although the catheter seemed completely integrated in the vein wall and impossible to remove, we made numerous attempts, trying to break bridges, pedicles and generally all the adhesions between the catheter and the vessel by tracting and rotating it. At the end, the catheter came out with the pericatheter tissue that encircled all the intravascular tract, keeping in contact the two, otherwise free-floating lumens of the split catheter [Figure 1]A and B. Thrombosis developed inside and between the two, attached by the sheath, lumens [Figure 2]A. It is noteworthy that, after removal, we tried to dissect and separate the catheter from the surrounding tissue. We met significant resistance during these maneuvers, suggesting the calcified nature of this tissue as reported by others [Figure 2]B.
Figure 1: The pericatheter sheath surrounds the two lumens (A) keeping them in firm contact (B).

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Figure 2: Thrombus formation is visible within the catheter tip and between the lumens (A). The resistant sheath is clearly evident (B).

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   References Top

1.
Ethier J, Mendelssohn D, Elder S, et al. Vascular access use and outcomes: An international perspective from the dialysis outcomes and practice patterns study. Nephrol Dial Transplant 2008;23:3219-26.  Back to cited text no. 1
    
2.
Santilli J. Fibrin sheaths and central venous catheter occlusions: Diagnosis and management. Tech Vasc Interv Radiol 2002;5:89-94.  Back to cited text no. 2
    
3.
Wilson G, van Noesel M, Hop W, van de Ven C. The catheter is stuck: Complications experienced during removal of a totally implantable venous access device. A single-center study in 200 children. J Pediatr Surg 2006;41:1694-8.  Back to cited text no. 3
    
4.
Hassan A, Khaffa M, Al-Akira M, Lord R, Davenport A. Six cases of retained central venous haemodialysis access catheters. Nephrol Dial Transplant 2006;21:2005-8.  Back to cited text no. 4
    
5.
Jones SA, Giacomantonio M. A complication associated with central line removal in the pediatric population: Retained fixed catheter fragments. J Pediatr Surg 2003;38:594-6.  Back to cited text no. 5
    
6.
Thein H, Ratanjee SK. Tethered hemodialysis catheter with retained portions in central vein and right atrium on attempted removal. Am J Kidney Dis 2005;46:E35-9.  Back to cited text no. 6
    
7.
Ndzengue A, Kessaris N, Dosani T, Mustafa N, Papalois V, Hakim NS. Mechanical complications of long-term Tesio catheters. J Vasc Access 2009;10:50-4.  Back to cited text no. 7
    
8.
Gladman G, Sinha S, Sims DG, Chiswick ML. Staphylococcus epidermidis and retention of neonatal percutaneous venous catheters. Arch Dis Child 1990;65:234-5.  Back to cited text no. 8
    
9.
Ng PK, Ault MJ, Fishbein MC. The stuck catheter: A case report. Mt Sinai J Med 1997;64:350-2.  Back to cited text no. 9
    
10.
Huang SC, Tsai MS, Lai HS. A new technique to remove a "stuck" totally implantable venous access catheter. J Pediatr Surg 2009;44:1465-7.  Back to cited text no. 10
    
11.
Farooq A, Jones V, Agarwal S. Balloon dilatation: A helpful technique for removal of a stuck dialysis line. Cardiovasc Intervent Radiol 2012;35:1528-30.  Back to cited text no. 11
    
12.
Carrillo R, Garisto J, Salman L, Merrill D, Asif A. A novel technique for tethered dialysis catheter removal using the laser sheath. Semin Dial 2009;22:688-91.  Back to cited text no. 12
    

Top
Correspondence Address:
Dr. Georgios Galanopoulos
Department of Vascular Surgery, "Iasò General" Hospital of Athens; Department of Pharmacology, Medical School, University of Athens, Athens
Greece
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DOI: 10.4103/1319-2442.157366

PMID: 26022028

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