Remove or not,that is the question: A case report on carotid artery cannulation during indwelling venous hemodialysis catheter

A 58‐year‐old woman visited the emergency department for acute occlusion of arteriovenous fistula. One session of hemodialysis was scheduled via temporary venous hemodialysis catheter before thrombectomy. Unfortunately, neck arterial cannulation was discovered after complete placement of catheter. The catheter was removed immediately but bleeding could not be stopped. Pseudoaneurysm over the right carotid artery was proved by angiography and repaired by graft stent. Arterial cannulation during venous hemodialysis catheter insertion is a rare but serious complication and there is no standard response recommended. Immediate removal of the misplaced hemodialysis catheter might not be the best choice. We suggest to leave the misplaced catheter in artery until further intervention in consideration of complications and repair access. Every hemodialysis center should standardize responses to arterial cannulation during venous hemodialysis catheter indwelling, especially carotid puncture happens, according to the medical facility.     

Catheter tip malposition after percutaneous placement of tunneled hemodialysis catheters

The percutaneous catheterization of central veins is increasingly used in nephrological practice as a temporary or permanent vascular access. The aim of our study was to present and to analyze episodes of catheter tip malposition during percutaneous tunneled hemodialysis catheter insertion in the large, unselected group of patients. All patients who underwent the procedure of catheter insertion in our department during year 2012 were analyzed retrospectively. One hundred four tunneled hemodialysis catheters were inserted in 101 patients. In 58 patients, the catheter was inserted at the initiation of hemodialysis therapy as the first access and in 46 the catheter was placed because of the failure of the existing one. In 68 patients, the catheter was inserted into the right internal jugular vein and in 20 patients into the left internal jugular vein (LIJV). Subclavian veins were used in five cases and femoral veins in 11 cases. Malposition of the catheter tips occurred in six patients. In all cases, the LIJV was cannulated. In two cases, the catheter tip malposition was in the right innominate vein and in four cases in the azygos vein. Our data demonstrate that with the blind insertion of tunneled hemodialysis catheters, the risk of catheter tip malposition is significantly higher with the left side insertion. As catheter insertion through the LIJV holds very high (30%) risk of the tip malposition, it should always be performed under the fluoroscopic control.     

Hemodialysis catheter insertion using transrenal approach

We report a patient suffering from end‐stage renal disease (ESRD) because of lupus nephritis presented with exhausted vascular access after multiple arteriovenous grafts creation and hemodialysis catheters insertion. A rare percutaneous transrenal approach was finally used for the insertion of dialysis catheter. After 2 years, this hemodialysis catheter was complicated by blockage but was successfully replaced by a new catheter via the same site. Our report shows that the transrenal route of hemodialysis catheter insertion can provide a glimpse of hope for those ESRD patients with exhausted vascular access.     

A dangerous entanglement

Entrapment of guidewires by inferior vena cava filters can occur during the blind insertion of a jugular or a subclavian central venous catheter. Recently, few case reports have been published in the radiology literature. In addition, others have described endovascular techniques aimed at removing entrapped guidewires, avoiding the possibility of vena cava rupture. Given that a temporary hemodialysis venous catheter is frequently used as a first access, the possibility of entrapping the dialysis catheter guidewire should not be neglected.     

One patient,two malpositioned hemodialysis catheters, (hepatic vein and ascending lumbar vein), no fluoroscopy

Cuffed-tunneled hemodialysis catheter (CTHC) application via the femoral vein is a safe and effective alternative when peripheral vascular routes are exhausted for hemodialysis in patients with end-stage renal disease. Also, imaging methods have become more important for the diagnosis or prevention of the possible complications that may develop during or after catheter placements. Here, we present a case of hemodialysis catheter dysfunction due to the insertion of a CTHC tip into the hepatic vein, and into the left ascending lumbar vein at the next attempt. We think that the use of fluoroscopy, whether in the first catheter intervention or catheter change, is extremely important in preventing possible complications that may develop, or detecting them as soon as possible.     

Temporary vocal cord paralysis following hemodialysis catheter placement

We report a case of temporary right vocal cord paralysis manifesting as hoarseness after hemodialysis, beginning several hours after placement of a non‐cuffed hemodialysis catheter into the right internal jugular vein using prilocaine local anesthesia. Diagnosis of right vocal cord paralysis was confirmed by laryngoscopy. Hoarseness completely resolved that same day, and subsequent laryngoscopy showed normal vocal cord movement, suggesting that the most likely cause of the initial vocal cord paralysis was diffusion of the local anesthetic agent injected during catheter insertion.     

Dilator venotomy technique for placement of hemodialysis catheter following recanalization of occluded central vein

Recanalization of occluded central veins for insertion of hemodialysis catheter is a particular attractive option in patients who are catheter dependent for hemodialysis, as it delays exhaustion of conventional venous accesses. Literature detailing techniques for catheter placement in recanalized veins remain sparse. We hereby describe a safe and economical technique of using dilator venotomy to allow catheter placement following successful recanalization.     

A new titanium fiber mesh-cuffed peritoneal dialysis catheter: An experimental animal study

CAPD catheters are associated with infectious complications. To solve this problem, we developed a new catheter. In our design, sintered titanium fiber mesh material replaced the Dacron cuffs, as used in standard Tenckhoff catheters. The purpose of the current study was to compare the tissue response to new titanium-cuffed vs. Dacron-cuffed catheters. Experimental and standard Tenckhoff catheters were inserted intraperiotoneally in 12 goats, using a so-called two-stage surgical technique. In the first surgical session, the catheters were implanted. However, the percutaneous part of the catheter was buried subcutaneous. After 3-5 weeks, the percutaneous part of the catheter was exteriorized. After 14 weeks of implantation, all implants with surrounding tissue were retrieved and prepared for histological evaluation. Subsequently, we quantified: the characteristics of the fibrous tissue capsule surrounding the cuffs, the tissue inside the cuff porosity, and the epidermal downgrowth. Histologic and histomorphometric evaluation showed that titanium mesh evoked a lesser inflammatory response inside the cuff porosity compared with Dacron cuffs. Besides, the fibrous tissue capsule surrounding the titanium cuffs was significantly thinner. Supported by the obtained results, we conclude that the use of titanium fiber mesh has a great potential for application in percutaneous devices.     

Carotid-jugular arteriovenous fistula and cerebrovascular infarct: a case report of an iatrogenic complication following internal jugular vein catheterization

Central venous catheterization is frequently performed for perioperative management and long-term intravenous access. Although complications associated with central venous catheter insertion have been widely reported, there are few reports of carotid-jugular arteriovenous fistula formation. Endovascular procedures are associated with a risk of immediate and delayed thromboembolic and ischemic complications. We describe a case of a carotid-jugular arteriovenous fistula and a cerebrovascular infarct following the insertion of a double-lumen catheter for hemodialysis access. We provide recommendations for the prevention and the early detection of this iatrogenic complication.     

Urgent hemodialysis with the use of peripheral veins to avoid catheter insertion

Urgent hemodialysis (HD) in patients with uremia is usually performed using a central vein catheter unless an arteriovenous fistula (AVF) was created in the predialysis period. We present a unique approach, in a patient in whom the first two HD sessions were conducted without implantation of a catheter or AVF. The perfectly developed peripheral veins of a professional bodybuilder served as vascular access allowing catheter insertion to be avoided. The aim of this short case report is to recall a forgotten method for performing urgent HD in patients without a fistula, but with suitably enlarged superficial veins.     

Comparison of side hole versus non side hole high flow hemodialysis catheters

Current literature suggests that side holes may be detrimental to dialysis catheter performance. Today, these catheters are primarily available with side holes. The purpose of this study was to compare flow rates, infection rate, and survival of side hole vs. non side hole hemodialysis catheters. Over a 16-month period patients were arbitrarily assigned to either a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter with side holes or a 14.5 F MAHURKAR MAXID cuffed dual lumen tunneled catheter without side holes ("non side hole catheters"). We performed a retrospective analysis of catheter flow rates, patency, catheter survival, and catheter-related infections. Information was gathered for the life of the catheter or up to 28 weeks. A total of 54 patients were enrolled in the study. Thirty-seven of 54 (68%) patients received a catheter with side holes for a total of 3,930 catheter days and 17/54 (32%) received a similar catheter without side holes for a total of 2,188 catheter days. Catheter infection necessitating removal of the catheter occurred in 10/37 catheters with side holes and 1/17 without side holes. Infection rates per 1,000 catheter days were 2.545 with side holes and 0.254 without side holes (p<0.001). Slightly improved catheter survival (p<0.05) was recorded with the non side hole catheters. No insertion complication (e.g., air embolization, bleeding, or kinking) occurred with either catheter. One catheter without side holes had to be repositioned 5 days after insertion because of poor flows. No significant difference was recorded in mean blood flow rates between the catheters. Results indicate reduced catheter infection rate in hemodialysis patients with the use of non side hole dual lumen tunneled cuffed catheters.     

Evaluation of the tissue reaction to a percutaneous access device using titanium fibre mesh anchorage in goats

The tissue reaction to a percutaneous access device, applicable as a carrier for an implantable glucose sensor, was evaluated in goats. Titanium fibre mesh structures were used for anchorage of the device in superficial as well as deeper soft-tissue locations. The percutaneous part was subcutaneously anchored with a fibre mesh sheet. The distal part was placed intraperitoneally and anchored in deeper soft-tissue layers using a fibre mesh cuff. All implants showed good healing with the surrounding tissue. Histological evaluation showed that the subcutaneous fibre mesh sheets and peritoneal fibre mesh cuffs were filled with immature connective tissue, generally free of inflammation. Problems concerning disconnection of the silicone catheter from the titanium holding element and filling of part of the peritoneal fibre mesh cuff with silicone glue have to be overcome by more appropriate preclinical testing and improved implant design. Our results demonstrate that titanium fibre mesh structures can be used effectively for soft-tissue anchorage of percutaneous access devices. A sufficient ingrowth of connective tissue was obtained in superficial as well as in deeper soft-tissue layers. The access device could have application as a carrier for an implantable glucose sensor for glucose monitoring in different tissue compartments.     

Accidental extravascular insertion of a subclavian hemodialysis catheter is signaled by nonvisualization of catheter tip

Subclavian hemodialysis (HD) catheter placement under fluoroscopy with perforation of the superior vena cava (SVC) is a rare complication that needs to be recognized and treated appropriately. We report the case of a 47-year-old black woman under treatment for end-stage renal disease secondary to HIV-associated nephropathy who sustained an extravascular insertion of fluoroscopy-guided subclavian catheterization for HD. Subsequent successful removal of the extravascularly placed catheter along with repair of the lacerated SVC were effected by open thoracic surgery.     

Tunneled-cuffed catheter implanted into the accessory hemiazygos vein because of occlusion of the left innominate vein

Hemodialyzed patients are at risk of multiple catheterizations. Nephrologists performing such procedures need to be familiar with congenital and acquired vascular abnormalities. We describe a successful insertion and use of a cuffed-tunneled catheter in a patient with unusual anatomy of the central venous system. Computed tomography angiography revealed thrombosis of the right subclavian vein and bilateral occlusion of innominate veins. The left internal jugular and subclavian veins joined to form a large vessel that drained through the accessory hemiazygos and azygos veins into the superior vena cava. The catheter was implanted through the left internal jugular vein into the accessory hemiazygos vein. The presented case demonstrates that the catheter can be implanted into distended collateral, especially when no other location is possible.     

Development of a new tissue-equivalent material applied to optimizing surgical accuracy

The precision of orientation to target placement during invasive therapy is mainly influenced by tool–tissue interaction. In this study, we aim to investigate a transparent Poly (vinyl alcohol) (PVA) hydrogel as tissue-equivalent material which is used in accurate surgical insertion research. The PVA hydrogel with specified formula was prepared by means of physical and chemical crosslink. The effects of chemical composition and synthesis technique on the biomechanical property, density and micro-structure morphology of PVA materials have been investigated in detail. It can be concluded that when PVA concentration is 8 g/dl, the NaCl concentration is 4 wt.%, with mix water/DMSO solvent, prepared under 7 freeze/thaw cycles, the material has the most similar properties with kidney tissue. Experimental results demonstrate that this tissue-equivalent material could be used in the ex vivo insertion accuracy test for robot-assisted percutaneous intervention and surgical training in minimally invasive surgery (MIS).     

Determinants of C-reactive protein in chronic hemodialysis patients: relevance of dialysis catheter utilization

Biomarkers of inflammation, especially C-reactive protein (CRP), have been consistently shown to predict poor outcomes in chronic hemodialysis (CHD) patients. However, the determinants of CRP and the value of its monitoring in CHD patients have not been well defined. We conducted a retrospective cohort study to evaluate possible determinants of the inflammatory response in CHD patients with a focus on dialysis catheter utilization. Monthly CRP were measured in 128 prevalent CHD patients (mean age 56.6 years [range 19-90], 68% African Americans, 39% diabetics [DM]) over a mean follow-up of 12 months (range 2-26 months). There were a total of 2405 CRP measurements (median 5.7 mg/L; interquartile range [IQR] 2.4-16.6 mg/L). The presence of a dialysis catheter (p<0.002), cardiovascular disease (p=0.01), male gender (p=0.005), higher white blood cell count (p<0.0001), elevated phosphorus (p=0.03), and lower cholesterol (p=0.02) and albumin (p<0.0001) concentrations were independent predictors of elevated CRP in the multivariate analysis. Additionally, CRP levels were significantly associated with the presence of a catheter, when comparing the levels before and after catheter insertion (p=0.002) as well as before and after catheter removal (p=0.009). Our results indicate that the presence of a hemodialysis catheter is an independent determinant of an exaggerated inflammatory response in CHD patients representing a potentially modifiable risk factor.     

Inserting tunnelled hemodialysis catheters using elective guidewire exchange from nontunnelled catheters: Is there a greater risk of infection when compared with new‐site replacement?

The objective is to evaluate bacteremia outcomes and survival rates when using guidewire exchange to place tunnelled hemodialysis catheter (THDC) compared with a new-site replacement. Retrospectively, all patients were identified who received a THDC between January 1, 2000 and January 1, 2007. Any THDC having received antibiotic line locks or tunnel-to-tunnel exchange were excluded. This left 408 THDC placed in 329 patients: 46 guidewire exchange, 362 new-site replacement. Bacteremia rate from the new-site insertion group was 3.0 per 1000 catheter days, the guidewire exchange group demonstrated a rate of 2.8 per 1000 catheter days. Local infection rates did not differ between the groups at 1.2 per 1000 catheters days. The actuarial catheter survival rates using Kaplan-Meier survival analysis demonstrated no difference between the 2 groups. The placing of tunnelled cuffed hemodialysis catheters to replace temporary catheters using a guidewire exchange did not contribute to further episodes of sepsis and has the advantage of preserving venous access and minimizing invasive procedures for the patient.     

Estimation of doses to personnel and patients during endovascular brachytherapy applications

In the last few years coronary endovascular brachytherapy using gamma- and beta-emitting radionuclides has been established as a standard treatment procedure to prevent restenosis after percutaneous coronary interventions. Direct measurements and calculations were made to determine personnel doses and organ doses of patients due to gamma rays of 192Ir and beta rays of 90Sr/90Y and 32P sources. In general, our results show that the dose levels are low compared with the X-ray exposure from angiography. The dose rate from bremsstrahlung at 1 m distance from a device containing a 90Sr/90Y source of 2.3 GBq is 4 micro Sv h(-1). The skin dose from beta rays during source transfer into and from the patient was estimated with the directional dose equivalent H'(0.07) of 10 micro Sv at 1 m distance from the catheter. By maintaining safe distances, the dose levels can be kept well within annual dose limits.     

Successful tunneled catheter placement in a hemodialysis patient with idiopathic multiple central venous stenoses

Central venous stenosis (CVS) in hemodialysis patients could be secondary to central venous catheterization, high flow arteriovenous fistula, as well as extrinsic compression. However, we report a senile hemodialysis patient of left internal jugular vein stenosis and right innominate vein occlusion unrelated to any known risk factors. Aided by computed tomography and digital subtraction angiography, we managed to dilate the stenosis by percutaneous balloon angioplasty, followed by successful tunneled catheter placement. Nephrologists should be aware of idiopathic CVS and its impact on the creation and preservation of vascular access. When confronted with difficulties in catheter placement, practitioners need to consider the possibilities of idiopathic CVS and refer to radiological tests.