Perforation of the internal jugular vein during cannulation for haemodialysis
*Jacek Wadełek1, Dominik Drobiński1, Piotr Szewczyk1, Fouad Abbas1, Marzena Franczyk1, Monika Niewińska1, Franciszek Majstrak2, Zbigniew Gałązka3, Andrzej Kański1
1II Department of Anaesthesiology and Intensive Therapy, Warsaw Medical University
2Department of Cardiac Surgery, Warsaw Medical University
3Department of Vascular Surgery, Warsaw Medical University
- Fig. 1. Thoracic computed topography scan showing shadowing of the catheter inserted from the left hand side jugular access, running outside the vessel lumen and entering the mediastinum. The distal part of the catheter – below the clavicle
- Fig. 2. Spatial reconstruction based on the thoracic CT scan showing the site where the catheter punctured the internal jugular vein and its route in the mediastinum
Background. Reliable temporary vascular access is necessary for haemodialysis when the establishment of permanent access is not possible. Double-lumen catheters are favoured in most cases. These catheters are commonly inserted percutaneously using anatomic landmarks, but the technique is far from being perfect and serious complications may occur during the procedure. We describe a serious and potentially lethal complication of internal jugular venous cannulation.
Case report. A 50-year-old woman was transferred from another hospital because of misplacement of a tunnelled permanent haemodialysis catheter and internal bleeding. A computed tomographic angiogram of the chest revealed that the catheter had migrated to the mediastinum. Emergency surgery with cardiopulmonary bypass was performed, the catheter removed, and the damaged left internal jugular and right subclavian veins were reconstructed.
Conclusion. Migration of a dialysis catheter outside the vascular bed is a potentially lethal complication. Removal of a misplaced catheter may lead to massive uncontrolled bleeding and should be managed surgically.
Haemodialysis can be administered once proper vascular access has been provided. In chronically dialysed patients, arteriovenous fistulas are created. In acute renal failure, however, the treatment of choice is cannulation of big veins. In such cases, catheters of wider diameters are used, often firmer than those applied during central vascular line procedures. The risk of complications accompanying such procedures is markedly higher.
We report a case of perforation of the internal jugular vein with the dialysis catheter and haemorrhage to the mediastinum and pleural cavities.
A 50-year-old woman was referred to our department from another primary care hospital due to suspected haemorrhaging to the mediastinum. Since 2001, the patient has been dialysed for end-stage renal failure in the course of lupus nephropathy.
The patient had three arteriovenous fistulas created (in 2002, 2004 and 2006), which occluded due to vascular thrombosis. Further attempts to carry out the procedures on the arm or forearm failed.
In this situation, the decision was made to insert the catheter through the left internal jugular vein. The circumstances of catheter insertion were unknown as the description of them found in medical records was extremely laconic stating that the procedure was carried out with great difficulties; dyspnoea and thoracic pain developed. Therefore, thoracic CT was performed which showed great amounts of fluid in the mediastinum and the dialysis catheter dislocated to the mediastinum after puncturing the left internal jugular vein. The catheter ran between the right innominate artery and the left common carotid artery, anterior to the trachea, passing to the right mediastinum and reaching below the tracheal bifurcation (Fig. 1 and 2). The right brachiocephalic vein was narrow with the slit-like lumen. The pericardial sac was filled with fluid.
Due to the suspected iatrogenic injury to big vessels, the patient was transferred to the department of vascular surgery. The repeated thoracic CT confirmed that the cannula approximated the left jugular vein, punctured it and ran to the right and downwards passing anteriorly to the left common carotid artery between the innominate artery and trachea superiorly to the initial part of the right subclavian artery. One of the distal arms of the catheter turned back at the right side of the trachea and rested on the aortic arch wall (without symptoms of its injury). The other arm ran medially downwards and intersected with the first arm inferiorly to the aorta bifurcation. The fluid body, 25 mm in diameter, formed between the distal ends of the catheter, half filled with blood with contrast, limited posteriorly by the trachea. Compared to the previous scan, enlarged haemomediastinum was found as well as substantial amounts of blood in both pleural cavities and atelectasis of lower lobes of both lungs (earlier invisible).
On admission, the patient was conscious and complained of moderate dyspnoea. SAP/DAP was 160/90 mm Hg and HR 100 min-1. The patient was qualified for emergency thoracotomy; since the range of mediastinal injury was unknown and the risk of massive haemorrhage high, it was decided to perform the procedure using extracorporeal circulation without cardioplegia.
Combined general anaesthesia was routinely performed after obtaining the femoral vein access. The thoracic cavity was opened by sternotomy and a big haematoma of the mediastinum and haematomas in both pleural cavities were found. The procedure and anaesthesia were uneventful until the time of catheter removal when massive haemorrhage of the injured jugular vein and the right subclavian vein started. The injured vessels were sutured. After surgery the patient was sent to the post-operative care unit; her condition was satisfactory, she was conscious, with efficient respiration and circulation. Several days later, the patient was transferred to the department of nephrology with the dialysis catheter inserted into the femoral vein.
Cannulation of big veins always involves the risk of complications. The commonest of them include pneumothorax and haemothorax, injuries to blood vessels, gas embolism, injuries to the lymph duct, nerves, perforation of the heart and myocardial sac tamponade. The risk is particularly high when the dialysis catheters of large diameters are used [1, 2, 3, 4, 5]. In the last decade, the incidence of such complications was reduced due to new generation catheters and visualization methods used (ultrasonography and fluoroscopy) [6, 7].
Ultrasound-guided cannulation of venous vessels increases the safety of procedures reducing the frequency of failures , shortens the procedure duration and, most importantly, reduces the incidence of complications . Routine ultrasonography may disclose the anatomical variations of jugular veins , therefore, it is superior to the conventional method based on identification of anatomical landmarks. The additional use of fluoroscopy enables precise insertion of the catheter to the desirable depth.
Unfortunately, not all dialysis centres have access to such methods. In many cases, the final success of cannulation depends on the knowledge of anatomy [11, 12]. Generally, cannulation of internal jugular veins does not give rise to any difficulties. The majority of centres prefer the right jugular vein access; if such an access is unfeasible, the procedure is attempted on the left side. The catheter insertion through the left internal jugular vein is more difficult; the catheter route is much more winding (the internal jugular vein joins the brachiocephalic vein almost at the right angle; a similar angle is found between the brachiocephalic and the main superior vein) .
Difficulties during cannulation are greater in chronically dialysed patients as the repeated procedures result in thrombi in big venous vessels, which may narrow or completely occlude their lumen, which happened in the case described; the right brachiocephalic vein in our patient was “narrow with the slit-like lumen”.
Some modern catheters are made of silicon and cause fewer adverse vascular reactions with long-term use. However, such catheters are soft and should be introduced to the vein using the Seldinger method with a firm dilator for tissue tunnelization. It is highly likely that in the case reported both walls of the jugular vein were punctured with the dilator.
How should the venous injuries be managed? In small injuries and once anatomical conditions permit, local compression is recommended. In bigger injuries, however, compression is insufficient. In our case, considering the extent of injury, no attempt was made to remove the catheter, which blocked the holes in both walls of the internal jugular vein. The catheter was removed during surgery after visualizing the site of perforation. In spite of this, massive bleeding developed which was eventually controlled yet the attempt to remove the catheter outside the operating room could have had tragic consequences.
Cannulation of big veins is always accompanied by the risk of complications, which is particularly high during dialysis catheter placements. If the vessel is injured, imaging diagnostic procedures should be used. The management depends on the extent of injuries, general status of a patient and efficiency of the clotting system. It should be remembered that the removal of the offending catheter could result in massive haemorrhage requiring surgical intervention.
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