Mediastinal hematoma: a rare complication of subclavian catheterization for hemodialysis

Brachiocephalic Vein Injury Leading to Massive Hemothorax Following the Insertion of a Tunneled Dialysis Catheter Requiring Surgical Intervention for Repair: Report of a Rare Case

Dialysis catheters are commonly used tools for patients requiring hemodialysis. A dilator with a large caliber is used to insert such a catheter, which in turn can result in serious vascular injury leading to rare complications like hemothorax. Common treatment options for such vascular injuries comprise surgical repair by thoracotomy or video-assisted thoracoscopic surgery (VATS) and endovascular repair. We herein report a case of a brachiocephalic vein injury and massive right-sided hemothorax following the insertion of a tunneled dialysis catheter in the right internal jugular vein, treated successfully by our team at Square Hospitals Ltd.

Monitoring of Central Dual-Lumen Catheter Placement in Haemodialysis by Endocavitary Electrocardiography: A Simple and Safe Technique for the Clinical Nephrologist

Complications in the placement of central venous catheter (CVC) may occur in up to 20% of cases. The catheter can be misplaced in the contralateral brachiocephalic vein, the ipsi or controlateral internal jugular vein, and usually a chest X-ray is necessary to evaluate its location. We believe that the best technique, first described by Serafini et al, to establish the position of a CVC is the endocavitary electrocardiography (EC-ECG) and its employment is recommended in all uraemic patients requiring haemodialysis. This technique uses the tip of the CVC as reference lead in a standard electrocardiograph. The best use of this technique has been obtained by echotomographic visualization of the internal jugular vein executed just before transcutaneous puncture of the vessel. From 1991 to December 1999 we have successfully applied this technique in CVC placement in 612 patients requiring haemodialysis. In our opinion, this method is a safe and simple technique that avoids the need for thoracic X-ray controls and time lost waiting for radiographs that prolong the start of the haemodialysis session. According to our experience, we believe that the EC-ECG technique is a method in compliance with Food and Drug Administration guidelines regarding catheter tip location in uraemic patients.

The Placement of Central Venous Catheters in Hemodialysis: Role of the Endocavitary Electrocardiographic Trace. Case Reports and Literature Review

At present, the placement of a central venous catheter is becoming more and more a routine procedure nevertheless it involves different operators in fields such as oncology, nutrition, nephrology, and emergency medicine. It is well known that complications in the placement of CVC may occur in up to 20% of cases. One fifth of the catheters may result to be misplaced either in the internal omolateral jugular vein or in the innominate vein or in the controlateral brachiocephalic veins and usually a chest radiogram is necessary to evaluate its location. On the basis of 10 years of experience including more than 1,000 CVC placements, we now believe that endocavitary electrocardiography EC-ECG, initially studied and applied by Dr. Serafini, constitutes the best technique, more secure and more comfortable for the patient, to verify the position of the tip of a CVC. The technique EC-ECG, very simple and secure, utilizes the CVC as an endocavitary electrode. This is connected to a standard electrocardiograph, the same one to which the patient is connected during the placement of the CVC, and provides, in derivation V1 or D3, an electrocardiographic pattern extremely sensitive to the position of the catheter tip.

From December 1991 to December 2000, this technique has been used successfully in our departments of nephrology and applied to 1,139 patients that needed a CVC for hemodialysis. EC-ECG and a standard chest radiogram controlled the first 100 CVC we placed and in the other 1,039 cases, the control was made by EC-ECG alone. Only in 31 patients (2.7% of all cases), due to arrhythmia, the technique EC-ECG was not utilized. According to our experience, the procedure EC-ECG is an extremely reliable technique, sensitive and specific in 100% of cases, easy for the operator to perform, comfortable for patient. It doesn't need additional time to be performed and eliminates the need of taking a chest radiogram that up to now was considered indispensable in order to verify the position of the catheter tip. In this manner serious complications such as pneumothorax, and haemothorax that can complicate the placement of a CVC can also be avoided.

Based on our experience, we now believe that this technique, that today has a large application in nephrology, oncology, clinical nutrition and in various branches of general medicine whenever the placement of a CVC is required, should be considered as a possible new guide line in controlling the placement of a CVC together with a chest X-ray when it is necessary.

Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion-A Case Report and Review of Relevant Literature

Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early.