|Year : 2019 | Volume
| Issue : 3 | Page : 215-217
Tunneled hemodialysis catheter placement in persistent left superior vena cava: A rare but potential hemodialysis vascular access
Himanshu Verma1, Prem Mohan Jha1, Namrita Sachdev2, Rashi Verma3
1 Department of Nephrology, PGIMER and Dr Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Radiodiagnosis, PGIMER and Dr Ram Manohar Lohia Hospital, New Delhi, India
3 Department of Gynecology and Obstetrics, Sir Gangaram Hospital, New Delhi, India
|Date of Web Publication||29-Aug-2019|
Dr. Himanshu Verma
Department of Nephrology, PGIMER and Dr Ram Manohar Lohia Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Persistent left superior vena cava (PLSVC) is a common congenital thoracic venous anomaly. Asymptomatic cases are often diagnosed incidentally during invasive cardiovascular procedures such as the placement of central venous access catheters. It is important for the physicians to be aware of clinical implications that may occur during catheter placement. We describe our experience with PLSVC during the placement of a tunneled hemodialysis (HD) catheter (permcath) through the left internal jugular venous route. The diagnosis was confirmed by contrast-enhanced computed tomography. PLSVC can be a potential site for HD catheter placement.
Keywords: Congenital variant, internal jugular vein, permcath, superior vena cava, tunneled catheter
|How to cite this article:|
Verma H, Jha PM, Sachdev N, Verma R. Tunneled hemodialysis catheter placement in persistent left superior vena cava: A rare but potential hemodialysis vascular access. Indian J Vasc Endovasc Surg 2019;6:215-7
|How to cite this URL:|
Verma H, Jha PM, Sachdev N, Verma R. Tunneled hemodialysis catheter placement in persistent left superior vena cava: A rare but potential hemodialysis vascular access. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Feb 19];6:215-7. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/215/265783
| Introduction|| |
In general, nephrologists use tunneled or nontunneled dialysis catheters, to gain vascular access for immediate hemodialysis (HD) therapy. The HD vascular access catheters are widely used in end-stage renal disease (ESRD) patients and are required for maintaining HD, especially in case of immediate vascular access. Initially, the catheter should be always be inserted through a right internal jugular vein (IJV), because of the relative direct way to superior vena cava (SVC) and right atrium, and comparatively low chances of central vein stenosis. The left IJV is used only when a temporary HD catheter is to be placed or in case of anatomical or pathological problem in the right IJV. Alternatively, the subclavian or femoral vein can also be used. However, the catheter placement through a subclavian vein may increase the risk of stenosis and thrombosis, while femoral vein is recommended as a last option.
Here, we report a case of successful insertion and use of tunneled HD (permcath) catheter into the persistent left superior vena cava (PLSVC).
| Case Report|| |
This is a case report of a 26-year-old female with ESRD (basic disease unknown) who was on maintenance HD for the last 3 months and was admitted to our hospital for vascular access. She was being dialyzed through dual-lumen dialysis catheter in the right IJV. The right IJV got thrombosed which was confirmed by Doppler ultrasonography. Three weeks before left radial arteriovenous (AV) fistula was constructed, it failed primarily because of poor peripheral veins. As the patient was a prospective renal transplant recipient, femoral placement of a temporary dialysis catheter was avoided. Therefore, we planned for permanent vascular access using tunneled dialysis catheter (permcath) in the left IJV till the time she underwent renal transplant.
During insertion of permcath in the left IJV, no major complications were encountered, except mild resistance during guidewire insertion. On aspiration of the catheter ports, a brisk dark (venous) blood return was observed. Immediately, before insertion of the guidewire, a continuous dark red blood return was recorded. However, routine postprocedure X-ray chest showed the dialysis catheter through a left paramediastinal course from the left neck [Figure 1] and a brisk dark red blood return which was referred for blood gas analysis. The blood gas analysis performed using sample drawn from dialysis catheter and femoral vein was indistinguishable (pH 7.3, PCO2 60 mmHg, PO2 38 mmHg, and cHCO3 28 mmol/L), but was different from femoral artery sample (pH 7.45; PCO2 40 mmHg; PO2 99 mmHg; cHCO3 27 mmol/L).
|Figure 1: Chest radiograph showing the permcath passing through a persistent left superior vena cava (arrow)|
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A two-dimensional transthoracic echocardiogram with saline coronary sinus microbubble contrast showed the dialysis catheter with its tip lying above the draining to the right atrium, in PLSVC. The coronary sinus appeared as dilated, large, echo-free space posteriorly in the atrioventricular groove between the left atrium and ventricle. Contrast-enhanced computed tomography (CT) of the chest [Figure 2] revealed the presence of a PLSVC. CT scan showed a central catheter with contrast, laterally to the aortic arch and anteriorly to the left hilum. It crosses the posterior wall of the left atrium, through the coronary sinus, and drains into the right atrium. Subsequent digital subtraction angiography (venogram) [Figure 3] confirmed that the catheter was placed in PLSVC, draining in the right atrium. The catheter was effectively used for HD treatments.
|Figure 2: Coronal reformatted computed tomography image showing the course of the permcath in a case of persistent left superior vena cava (arrow)|
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|Figure 3: Digital subtraction angiographic image showing the permcath lying in persistent left superior vena cava draining into the right atrium through the coronary sinus (arrow)|
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The HD sessions were easily performed with a blood flow rate of 250 ml/min. We planned to leave the catheter in place for HD, as the patient did not have any complaint and no other accessible site for HD. During the first and subsequent HD, her vitals were maintained and there was no evidence of impaired venous drainage of the left upper limb. The electrocardiogram showed no evidence of any arrhythmia or ischemia. No catheter-related complications were observed. The catheter was then used uneventfully with careful and continuous monitoring.
| Discussion|| |
PLSVC is a rare vascular anomaly, but the most common congenital abnormality of thoracic venous return. PLSVC has an incidence of 0.3%–5% in healthy individuals and around 4% in patients with congenital heart disease. Most of the dialysis catheters are inserted through the right IJV, however, PLSVC occurs in ≥80% of patients with catheters inserted through SVC.
The tunneled HD catheter has several advantages including immediate use after placement, no repeated venipuncture or hemodynamic effects, and no help of vascular surgeon during placement. However, there are also chances of infection, hospitalization, cardiovascular events, and long-term risk of mortality as compared to other options of vascular access.
In the present case, tunneled HD (permcath) catheter was successfully used into PLSVC. In a previous case, a 35-year-old male patient diagnosed with chronic kidney disease 2 years back was admitted due to thrombus in the right IJV, and the procedure was conducted through the left IJV. PLSVC was subsequently confirmed following venogram. Balasubramanian et al. reported a 57-year-old male admitted with acute kidney injury and major upper gastrointestinal bleeding. The temporary dialysis catheter was inserted through the left IJV. The venogram showed PLSVC and the patient was on HD. Following HD, complications such as breathlessness and cardiomegaly were noted, and the presence of pericardial effusion was thus confirmed by echocardiography. The accurate noninvasive diagnosis of PLSVC can be done by echocardiography. In many studies, during the placement of HD catheters, PLSVC is detected incidentally causing complications such as vascular thrombosis, supraventricular arrhythmia, cardiac arrest, and vascular erosion.,,, Guerrot et al. reported a case of 45-year-old female with ESRD due to diabetic nephropathy. After a successful placement of a catheter through right IJV, an unusual curve toward the left was seen radiographically. A CO2-phlebocavography confirmed a rare type II PLSVC. The PLSVC probably causes difficulties with the insertion of the catheter into the right heart through left subclavian but does not prohibit the insertion.
| Conclusion|| |
We report a case of ESRD patient who displayed a PLSVC after placement of tunneled HD catheter (permcath) through left IJV. An initial attempt at left internal jugular catheter placement in a patient with PLSVC can mimic an accidental arterial puncture to the unwary proceduralist. Therefore, real-time ultrasonography access of IJV is mandatory. Tunneled central venous catheter should always be placed under fluoroscopy guidance. Whenever an unusual track of guidewire is noted, venogram should be performed before placing the catheter blindly. PLSVC can be used as an optional vascular access, if no other central veins are available. Considering the small caliber of PLSVC, a symmetric tip design tunneled catheter would have been preferred. Nephrologists who place HD catheters in the left jugular or subclavian vein should be aware of the existence, diagnosis, and complications of PLSVC to prevent misinterpretation of routine postprocedure X-ray chest and unnecessary removal of dialysis catheters.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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