JVA ISSN 1129-7298
J Vasc Access 2016; 00 (00): 000-000 DOI: 10.5301/jva.5000566
Case report
Dialysis catheter placement via the left internal jugular vein: risk of brachiocephalic vein perforation Michiel B. Winkes1, Maarten J. Loos1, Marc R. Scheltinga1, Joep A. Teijink2 1 2
Department of Vascular Surgery, Máxima Medical Center, Veldhoven - The Netherlands Cardiovascular Center, Catharina Hospital, Eindhoven - The Netherlands
Abstract Purpose: We discuss a case of a brachiocephalic vein (BCV) perforation after Tesio® central venous catheter insertion. Method and results: An 80-year-old patient underwent an ultrasound-guided hemodialysis (HD) catheter placement via his left internal jugular vein (IJV). One day postoperatively, the patient became hemodynamically unstable immediately after HD initiation. As a vascular event was feared, an emergency CT scan was performed demonstrating a BCV perforation. The patient underwent a sternotomy, the lines were removed and the venous laceration was closed. The patient recovered well. Conclusions: In spite of ultrasound guidance, fluoroscopy for guidewire and sheath advancement, venous blood aspiration and a normal appearing postoperative x-ray, traumatic central venous catheter placement is still possible. Tenting of the BCV wall during catheter advancement possibly caused the venous perforation. A ‘how-to’ for correct catheter placement via the IJV is provided and potential pitfalls during each procedural step are discussed. Keywords: Brachiocephalic vein, Central venous catheter insertion, Internal jugular vein, Perforation, Tesio® catheters
Background Brachiocephalic vein (BCV) or superior vena cava perforation is a rare but serious complication after central venous catheter placement. Because of anatomic differences, almost all perforations occur after left-sided internal jugular vein insertion. Several precautions such as ultrasound guidance, fluoroscopy, and venous blood aspiration may be taken to minimize perforation risk. We present a case of a BCV perforation despite the use of these precautions, possibly because of unnoticed tenting of the BCV wall during advancement of the catheter.
Case presentation An 80-year-old man with end-stage renal disease awaiting right-sided arteriovenous (AV) fistula surgery required HD catheter placement via his left internal jugular vein (IJV). A
Accepted: March 28, 2016 Published online: Corresponding author: Michiel B. Winkes De Run 4600 PO Box 7777 5500MB Veldhoven, The Netherlands
[email protected]
© 2016 Wichtig Publishing
Tesio® catheter system (Bio-flex® Tesio® Cath, Medical Components Inc.) containing two tunneled free floating catheters was chosen. With the patient in Trendelenburg position, ultrasound-guided left IJV punctures using a Seldinger technique were performed under local anesthesia with hemodynamic monitoring. A smooth introduction and positioning of guidewires in the inferior caval vein (ICV) under direct fluoroscopy to a level just below the diaphragm followed. A ‘vascu-sheath’ (peel-away sheath with inserted dilator) was advanced over each guidewire. After dilator and guidewire removal, catheters were introduced followed by removal of the peel-away sheaths. Tips of the catheters were positioned just cephalad to the right atrium. Venous blood was easily aspirated. After flushing and addition of a heparin lock, both lines were tunneled subcutaneously. A postoperative posteroanterior chest x-ray confirmed correct position of both catheter tips 1 and 4 cm above the right atrium, respectively (Fig. 1). No hemodynamic alterations were detected perioperatively. One day later while initiating HD, the patient experienced an abrupt chest pain and developed hypotension suggesting a vascular event. An emergency CT-angiography showed ventral perforation of both catheters through the brachiocephalic vein (BCV) along with massive pleural effusion (Fig. 2). Patient was stabilized and transferred to a nearby cardiothoracic center. After sternotomy and hematoma evacuation, both catheter tips were found to perforate the anterior wall of the BCV (Fig. 3). The lines were removed and the lacerated vein was closed. Both pleural spaces were partially opened, evacuating 3 L of serosanguinolent fluid. A Hemoglide dialysis line
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Fig. 1 - Postoperative chest x-ray suggesting correct positioning of two Tesio® catheter tips 1 and 4 cm above the right atrium, respectively.
BCV perforation due to dialysis catheter placement
Fig. 3 - Intra-operative view of a sternotomy procedure reveals two white colored central catheters perforating the brachiocephalic vein, ending in the anterior mediastinum.
Fig. 2 - Axial and sagittal slides of a CT-angiography showing the course of two internal jugular vein inserted central catheters (marked yellow), perforating the ventral wall of the brachiocephalic vein.
(HemoGlide® dialysis catheter, Bard Access Systems Inc.) was placed via the right IJV. The patient recovered uneventfully.
Discussion BCV perforation is an uncommon complication of central catheter placement (1-8). Almost all perforations occur after a left sided IJV introduction. Compared with a nearly straight vertical course of the right BCV, the left BCV curves with an unfavorable oblique course into the superior caval vein. The left IJV is therefore not preferred as the optimal route for introduction. In this case, the left IJV was chosen since possible thrombotic or stenotic complications after
right-sided central catheter placement occasionally have detrimental effects on maturation of the planned rightsided AV fistula. In order to minimize complication rates of a tunneled left BCV catheter placement, adherence to a number of procedural steps is crucial. First, the left BCV should only be used if there is an absolute contra-indication for right-sided placement (9). Second, placing the patient in Trendelenburg position may increase the IJV diameter, allowing for easier puncturing. In awake and capable patients, an additional Valsalva maneuver may increase dilatation. Third, vein puncturing should be performed using ultrasound guidance. This monitoring technique reduces the chance of a faulty route, possibly leading to a © 2016 Wichtig Publishing
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pneumothorax or carotid artery puncture (6). The IJV should be entered only a few centimeters above the clavicle, which will prevent kinking of the catheters. Fourth, fluoroscopy should guide guidewire insertion and advancement of sheaths and catheters. After vein puncture, a J-tipped guidewire is positioned at a level below the diaphragm. This location rules out an inadvertent arterial guidewire insertion as intra-arterial wires never present below the diaphragm (10). Sheath advancement over the guidewire should always occur smoothly under fluoroscopic control. If in doubt, lateral images should be obtained. It must be appreciated that the dilator is rather stiff and a potentially harmful device. Despite a correctly positioned infradiaphragmally advanced guidewire, a stiff dilator may still cause a venous perforation by pushing the guidewire through the vessel wall. Too much resistance while advancing the sheath or kinking of the guidewire upon advancement should raise awareness of a false route (11). After guidewire removal, a check for kinks is standard. Smooth advancement of the vascu-sheath over the guidewire still does not guarantee a safe intravascular placement of the catheter. Pre-bending the vascu-sheath potentially facilitates a smoother sheath insertion through a curved BCV. However, the Tesio® manufacturer discourages pre-bending as damage to the sheath can possibly occur (http://www. medcompnet.com/products/long_term/bio-flex_tesio. html#ifu). Fifth, after insertion of the vascu-sheath, the dilator and guidewire are removed followed by a fluoroscopic-guided insertion of a saline filled central catheter. In the Tesio® system, this line is clamped to prevent air embolism and blood loss. The peel-away sheath is now removed by splitting it extracorporeally without tearing open the vessel. Correct catheter tip position is fluoroscopically checked. The anticipated catheter exit site is determined by an estimate location of the cuff. Subsequently, the line is cut to a preferred length, mounted onto a trocar and tunneled subcutaneously to a point below the clavicle leaving the cuff buried subcutaneously. After mounting luer lock adapters onto the line, venous blood should be easily aspirated and the line is flushed and filled with a 1000 IE/mL 1.8 mL heparin lock. For the second catheter, all abovementioned steps are repeated. Before using the catheters, a postoperative x-ray control confirms proper catheter positioning and rules out a pneumothorax. What caused BCV perforation in the present case? A number of possibilities may have contributed to this untoward complication. The vascu-sheath was not pre-bended prior to introduction. Possibly, after removing the dilator and guidewire, this sheath may have stretched out against the outer curvature of the BCV. Subsequent insertion of the catheter may have caused tenting of the outer curve vessel wall leading to perforation. Tesio® catheters are supplied with a stiff stylet permitting easier insertion. However, we removed this stylet as we intended to flush the line with saline. Moreover, we seldom use this stylet as advancing the catheter through the sheath almost always occurs very smoothly, whereas a stiffened catheter tip possibly contributes to perforation. Furthermore, use of this stylet is not advised in the manufacturer’s instructions for use. During sternotomy, both catheters were found to be © 2016 Wichtig Publishing
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perforating through the same laceration in the vein. Therefore, it is hypothesized that after perforation of the first catheter, the second followed the same route. Several aspects influencing intravenous placement of the catheters should be discussed. First, complication rates are related to experience. Less experienced surgeons may be more prone to ignore subtle resistance during advancement of guidewires, vascu-sheaths or catheters. This procedure was performed by a general surgery resident who previously performed >50 central venous catheterizations and was qualified to a D level according to the Dutch surgical resident competence level system (range A to E, D = “resident is able to perform a procedure independently”). Despite adhering to all safety precautions, a seemingly perfectly inserted catheter resulted in a vascular emergency. Second, pre- and postoperative x-ray verification of tip position is not a 100% guarantee. A ventrally or dorsally positioned catheter may be projected over the BCV suggesting a perfectly normal appearance. Moreover, aspiration of dark venous blood apparently also does not confirm correct placement. Aspiration of a fresh unclotted hematoma may have mimicked optimal intravascular positioning. Once a BCV perforation is likely, a number of strategies may be followed. Hemodynamic stability, available expertise and position of perforating catheter all determine treatment strategy. Successful conservative treatment with close surveillance is described in clinically stable cases with no signs of ongoing bleeding and a left upper anterior mediastinal hematoma
