Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2021  |  Volume : 32  |  Issue : 1  |  Page : 232--235

Inadvertent Placement of Tunneled Hemodialysis Catheter in Persistent Left Superior Vena Cava


Sameer V Vyahalkar1, Swati A Pawar2,  
1 Kimaya Kidney Care, Thane, Maharashtra, India
2 Shree Imaging Center, Thane, Maharashtra, India

Correspondence Address:
Sameer V Vyahalkar
Kimaya Kidney Care, Khopat, Thane (W), Maharashtra
India

Abstract

Persistent left superior vena cava (PLSVC) is the most common congenital intrathoracic venous anomaly with significant clinical relevance. In the vast majority of cases, it is asymptomatic and diagnosed after noticing an abnormal course of central venous access device on a routine post-procedure roentgenogram. It may also be accidentally discovered after facing difficulty in accessing the right side of the heart from a left internal jugular vein or left subclavian vein approach, a common site of access while placing cardiac pacemaker and Swan-Ganz catheter, or after a complication associated with hemodialysis (HD) catheter insertion. HD through a catheter in PLSVC has its own set of pitfalls and should be reserved for short-term dialysis at the best. In this case report, we present a scenario where PLSVC was discovered after the placement of a tunneled HD catheter.



How to cite this article:
Vyahalkar SV, Pawar SA. Inadvertent Placement of Tunneled Hemodialysis Catheter in Persistent Left Superior Vena Cava.Saudi J Kidney Dis Transpl 2021;32:232-235


How to cite this URL:
Vyahalkar SV, Pawar SA. Inadvertent Placement of Tunneled Hemodialysis Catheter in Persistent Left Superior Vena Cava. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jan 28 ];32:232-235
Available from: https://www.sjkdt.org/text.asp?2021/32/1/232/318530


Full Text



 Introduction



With improving survival on dialysis, procedures of tunneled-cuffed catheter (TCC) insertion for hemodialysis (HD) are increasingly done. Although Kidney Disease Outcomes Quality Initiative (KDOQI) recommends the use of fluoroscopy or an equivalent imaging modality for placement of tunneled HD catheters,[1] “blind” TCC insertions without fluoroscopy guidance are sometimes carried out in resource-limited settings. The right internal jugular vein (IJV) is the first choice for insertion of TCC; however, placement of the catheter in left IJV is usually the next step if there is failed attempt from the right side due to stenosis of the vein from prior interventions. Nephrologists who perform these procedures should be aware of the existence of an anatomical variation, the persistent left superior vena cava (PLSVC), to avoid alarming misinterpretation of the routine postprocedure chest radiographs[2] and to carry out appropriate clinical evaluation so that the risks of continuing HD through PLSVC can be weighed against the possibility of utilizing it as a potential site of vascular access.

 Case Report



A 35-year-old lady receiving HD therapy for 18 months through a right IJV (TCC) presented with catheter dysfunction for one month. Her native kidney disease was chronic tubulointerstitial disease. A radiocephalic arteriovenous fistula (AVF) at the wrist had primarily failed and autologous AVF was deemed not possible due to inadequacy of superficial veins of both upper extremities. For one-month, reduced blood flow was observed from both ports of TCC, which had transiently improved with urokinase instillation in the catheter before complete no flow was observed. With a high degree of suspicion for intraluminal thrombosis, an over-the-guidewire exchange of the catheter was planned. Since fluoroscopy was not available at the center, digital X-ray imaging was used for guidance. The previous TCC was a 28 cm Palindrome™ (Covidien™) catheter with its tip at the SVC – right atrium (RA) junction. With due patient preparation, a 70 cm 0.035”' stainless steel J-tip guidewire was passed through the TCC after dissection of cuff; however, the guidewire could not be advanced beyond the right IJV, suggesting venous stenosis. Therefore, left IJV was selected for catheterization. With 18 G introducer needle, left IJV was entered from a lower anterior approach, brisk nonpulsatile blood flow having respiratory phasicity was observed and the same guidewire was passed smoothly without resistance and without any arrhythmia on cardiac monitor. With the anatomical landmark technique, length and exit site of the TCC were selected. A 23 cm symmetrical tip-design 14 Fr catheter (Glidepath,® Bard Inc.) was then introduced after completing subcutaneous tunneling and sequential dilatation and insertion of Peel-Away dilator sheath over guidewire in a smooth fashion. Good backflow was confirmed from both ports of TCC at the end, and the patient’s vital parameters were confirmed to be normal. A postprocedure chest X-ray showed left paramediastinal course of the catheter with its tip at the caudal-most end of the right border of the heart [Figure 1]. Possibilities that should be considered when such a course is seen on X-ray include the presence of the catheter in the aorta, mediastinum, PLSVC, accessory hemiazygos vein, or superior intercoastal vein.[3],[4] Blood drawn from the catheter confirmed its venous origin on blood gas analysis. Next, a CT venography was done that revealed a PLSVC draining into a dilated coronary sinus (CS) along the posterior atrioventricular groove [Figure 2]. The right innominate vein and part of the right SVC showed stenosis and chronic thrombosis [Figure 3]. There was no communication between the two SVCs, suggesting type IIIb PLSVC according to Schummer’s classification.[5] The catheter coursed along the left IJV, PLSVC, CS, RA, and intrathoracic inferior vena cava with its tip in the middle hepatic vein. On echocardiography, there was no evidence of intracardiac AV shunt, congenital heart disease, or pericardial effusion. It was decided to use the catheter for HD since no arrhythmia or cardiac conduction defect was seen, the blood flow from both ports was adequate and the patient was in need of urgent dialysis due to inadequate dialysis for past many days. During the dialysis too, no hemodynamic instability or cardiac arrhythmia was observed and blood flow of 300 mL/min was obtained. In our patient, the length of the TCC was overestimated by the anatomical landmark technique, as the TCC took a shorter course through PLSVC. The immediate option was to exchange the catheter with a TCC of shorter length so that the tip of the TCC lay above the CS-PLSVC junction. However, since the risk of precipitating SVC syndrome was high if the catheter continued in PLSVC in presence of a stenotic right SVC, removal of the TCC was planned after securing another access. Furthermore, digital subtraction angiography was planned to confirm the venous anatomy and at the same time attempt for right innominate venoplasty and TCC insertion through the right IJV or external jugular vein. Other options of renal replacement therapy and vascular access sites were also discussed with the patient.{Figure 1}{Figure 2}{Figure 3}

 Discussion



A PLSVC represents persistence of the left common cardinal vein, which normally involutes during embryogenesis and is seen as a remnant (ligament of Marshall) later on.[4] PLSVC is a rare anomaly seen in 0.1%–0.5% of the general population, it is associated with congenital heart disease in 10%.[5] In most of the the cases (92%), PLSVC drains into a dilated CS and further to the RA; in 8%, it drains partially or completely into the left atrium (LA) either directly or via venous channels from the CS or via pulmonary veins.[5] In most of the cases, PLSVC is asymptomatic and not diagnosed until a central venous access device is either found to have coursed abnormally on imaging or presents with a procedure associated complication.[4],[5] The major subtypes of PLSVC identified include (a) absence of a right SVC and drainage of venous blood from both upper extremities and head completely through PLSVC, seen in 10%–20%, (b) presence of both SVCs without any communicating vein in-between, as in our case, seen in up to 65%, and (c) presence of both SVCs connected by a left innominate vein in the remaining.[6],[7],[8] The main concerns regarding HD through a PLSVC include (1) poor blood flow, thrombosis, and increased risk of vascular erosion by the catheter in case of inadequate size of PLSVC and CS,[9] (2) hemodynamic alterations in the CS during dialysis may precipitate cardiac conduction defects and sinus arrest,[4] (3) the possibility of precipitating SVC syndrome if there is no communication between left and right SVCs and the right SVC is stenosed,[4] as seen in our patient, (4) systemic thromboembolism, if the PLSVC communicates with LA,[5] and (5) precipitation of life-threatening CS thrombosis.[3],[10] Although PLSVC is a potential site for short-term HD catheter insertion, placement of a TCC in PLSVC for long-term HD is controversial.[4],[5] Absence of communication from PLSVC to LA, presence of adequate diameter of PLSVC and CS to accommodate the catheter, absence of cardiac arrhythmia, and a patent left innominate vein that communicates both SVCs are considered as essential prerequisites for TCC insertion in PLSVC for long-term dialysis.[4],[5] In these situations, the TCC should be either advanced into the right-sided SVC via the patent communicating left innominate vein or its tip should be positioned above the junction of PLSVC and CS.[5],[10] Diagnosis of PLSVC should be actively sought in patients in whom vascular access from left subclavian or jugular veins is planned. Clinical signs indicating a PLSVC include disproportionate left jugular vein distension and abnormal left jugular venous waveforms, and chest radiography may reveal subtle but inconsistent signs like widening of aortic shadow and a paramedical bulge along the left heart border.[10] Transthoracic echocardiography with agitated saline injection is a safe and sensitive test to detect PLSVC, which is flagged by the finding of prompt filling of the dilated CS with microbubble contrast on intravenous injection of the saline.[7],[10]

This case highlights the importance of availability of fluoroscopy guidance for TCC insertion as recommended by KDOQI so that anatomical variations in the venous drainage are detected instantaneously and appropriate positioning of TCC may be decided upon. Furthermore, “blind” TCC insertion without fluoroscopy should be avoided or limited, at the most, to over-the-guidewire conversion from nontunneled right IJV catheter to right IJV TCC within less than two weeks of the existing nontunneled catheter.[11]

Conflict of interest: None declared.

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