Mechanical Complications of Long-Term Tesio Catheters

[Endoluminal balloon dilatation of impacted central venous catheter-Case report and literature review]

BACKGROUND

The long-term application of tunneled central venous catheters leads to the development of firm adhesions between the wall of the vein and the catheter, which makes removal of the catheter difficult or impossible. The treatment options in such cases include abandonment of catheter parts or an open surgical approach up to sternotomy. At present, procedural alternatives are available, which include endovascular techniques such as the use of laser energy and endoluminal dilatation.

METHODS

This article describes the successful application of endoluminal dilatation for removal of ingrown central venous catheters in three patients, which had impacted in the superior vena cava and brachiocephalic vein. A 5 Fr (Cordis, Santa Clara, CA, USA) sheath was inserted into one lumen through the severed end of the double lumen catheter. Subsequently, a balloon catheter was inserted into the other lumen to prevent retrograde bleeding or air embolism. Under fluoroscopy a guidewire (0.018, Terumo Medical Corporation, Somerset, New Jersey, USA) was introduced via the sheath to beyond the tip of the hemodialysis catheter into the right atrium. Finally, an angioplasty balloon was inserted (4 × 80 mm) via the guidewire and the complete catheter was sequentially inflated with a pressure of 4 atm. It was then possible to pull out the catheter with no difficulty.

RESULTS

This technique resulted in the removal of the central venous catheters in all three patients, without any relevant complications or resistance.

CONCLUSION

By dissolving adhesions between the catheter and the vein wall, endoluminal balloon dilatation constitutes a reliable and safe technique for the extraction of impacted central venous hemodialysis catheters and may thus help to avoid further invasive surgical procedures.

Intervention of rarely seen catheter loss during permanent tunneled hemodialysis catheterization: A case report

Introduction: In patients with end-stage renal disease (ESRD), permanent hemodialysis catheters are often used by performing percutaneous catheterization to create a permanent vascular access. To the best of our knowledge, no cases with accidental loss of catheter piece during hemodialysis catheter replacement or during its retrieval under scopy has been reported in the literature yet. Case report: It was decided to retrieve the right permanent dialysis catheter of a 54-year-old woman, who had received a temporary dialysis catheter due to the development of catheter site infection in her 3rd permanent catheter (the first two were changed due to thrombosis). Due to excess adhesion in the region, the retrieval of the catheter was complicated, only half of it (proximal piece after cutting into two) was removed, while the distal section slipped and migrated to the right subclavian vein, up to the right atrium. The diagnosis was confirmed by chest radiographs showing that the distal piece of the catheter piece was in the right subclavian vein and right atrium. The catheter piece was retrieved through a minor invasive procedure made possible by scopy without any further complications. Conclusion: Permanent dialysis catheters should ideally be placed under scopy. Also, when the retrieval of a catheter is planned, cutting from any part of the catheter should never be performed.

Multiple complications of a 14-year-old hemodialysis catheter

INTRODUCTION

Vascular access for hemodialysis is a key factor in every patient dependent on this treatment. Maintaining a central venous catheter can be a good choice when all the other options have been exhausted, but unwanted and rare complications may arise from longer catheter dwell time.

CASE REPORT

We describe a case of a 65-year-old woman undergoing hemodialysis treatment since 1986 after a bilateral nephrectomy due to complicated nephrolithiasis. Her last access, two Tesio® tunneled cuffed catheters implanted via the right internal jugular vein functioned correctly for 14 years without complications, and so, was not replaced in the meantime. She was referred to our hospital due to a rupture in a catheter lumen, which was corrected conservatively by creating a more proximal tunnel and excising the affected area. A few weeks later, a new rupture in the same lumen was identified, so the catheter was replaced with angiographic control. The catheter was frail, so upon its removal, the tip fractured and remained in the right ventricle, being swiftly removed by an endovascular snare without complications.

DISCUSSION

This case reports two rare complications associated with catheter handling and identifies a possible technique for conservative resolution of a lumen rupture.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

The Removal of a Stuck Catheter: An Alternative to Hong's Technique

The use of the tunneled central venous catheter (CVC) is steadily increasing worldwide as a means of vascular access for hemodialysis. The increased use of these devices, which often outlive the patients, and the extended time they are used are associated with more frequent complications. Among these, one of the emerging complications is that of the “embedded” or stuck catheter. This term refers to when the catheter cannot be removed after detaching the retention cuff. In medical literature, experiences with the removal of stuck catheters are described with the use of several different methods. Currently the most commonly used technique also considered the safest is “endoluminal dilation” also known as Hong's Technique, recently modified by Quaretti and Galli. Below, a new technique using a Vollmar ring is described for removing a stuck catheter as an alternative to Hong's technique, or after a failed attempt at using Hong's technique.

A stuck haemodialysis central venous catheter: not quite open and shut!

Removal of tunnelled central venous catheters can become complex if left in situ for a prolonged period. We report a challenging case of a stuck tunnelled haemodialysis catheter, which required sternotomy with cardio-pulmonary bypass for retrieval. A 47-year-old female had failed attempts to remove the venous limb of a Tessio line on the ward. A cut down on the internal jugular vein and division of the fibrin sheath failed to release it. Synchronous traction was applied via a snare inserted through a femoral approach. On table trans-oesophageal echocardiogram showed the tip of the catheter traversing the tricuspid valve. At sternotomy with cardio-pulmonary bypass, the tip of the catheter was found attached to the septal leaflet of the tricuspid valve requiring release and repair. The management of stuck line has potential serious complications. Prophylactic catheter exchange should be considered to avoid complications.

Successful retrieval of an irretrievable jugular tesio catheter using a fogarty arterial embolectomy catheter

Long life expectancy and wide development of therapies have increased the number of patients under artificial treatment for lost kidney function or dialysis. Different options for vascular access are suitable for receiving this therapy. The use of tunneled catheters has consequently increased complications related to its use. A difficult retrieval of catheters caused by a hard fibrin sheath along its trajectory is a common drawback. Herein, we report a woman with suspicion of hemodialysis catheter infection and an irretrievable Tesio catheter. A novel technique using a Fogarty arterial catheter allowed a successful retrieval and avoided an aggressive management.

Challenges of caring for an advanced chronic kidney disease patient with severe thrombocytopenia

An autogenous arteriovenous fistula has been considered to be the optimal form of vascular access for hemodialysis (HD) in the field of nephrology. Nevertheless, the decision regarding the type of access, whether it be an arteriovenous fistula, an arteriovenous graft, or a central venous catheter, must still be individualized. In the present report, we describe the case of a female patient with advanced chronic kidney disease (CKD) associated with a hemostatic disorder. Despite the exhausted peripheral vasculature, she required recurrent platelet transfusions for severe thrombocytopenia due to aplastic anemia. The goal of care for this patient was to optimize the dialysis treatment without increasing the bleeding risk. Various concerns regarding the therapeutic conundrums encountered in the case are also discussed.

A Refinement of Hong's Technique for the Removal of Stuck Dialysis Catheters: An Easy Solution to a Complex Problem

Aim

A long-term tunneled hemodialysis catheter can be difficult or impossible to pull out if a fibrin sleeve has attached it to the venous wall. We report the outcome of a refinement of Hong's technique for removing incarcerated catheters aimed at improving its feasibility and safety.

Methods

We applied a modification of Hong's technique in four patients (two males, age ranging from 51 to 68 years) with jugular twin hemodialysis catheters (five of eight lines incarcerated). Hong pioneered the technique of endoballooning to expand a stuck central venous catheter, thus freeing it from adhesions. In our technical refinement, we cut the catheter close to its venous entry point in order to facilitate pullout and inserted a valved introducer as access for guide wires as well as for inflations of the catheter balloon. A stiff guide wire was placed in the inferior vena cava to avoid potential damage to heart cavities. Dilation was monitored under fluoroscopy with constrictions showing points where the catheter was incarcerated. If adhesions persisted through the same introducer, endoluminal dilations were repeated with a larger diameter balloon until the catheter was released. New catheters can be positioned using the stiff guide wire already in place. All removals were carried out under local anesthesia in an angiographic room by interventional radiologists.

Results

All catheters were successfully removed without complications. Average fluoroscopy time for removal was 12 minutes. In the case of a Tesio catheter removed after 12 years because of infection, a computed tomography scan 2 months later revealed persistence of a calcified fibrin sleeve in the vessel.

Conclusions

Hong's technique was confirmed to be a simple, safe and highly effective way to remove incarcerated long-term central venous catheters. The refinements we adopted made the procedure more flexible and possibly less prone to complications. By properly using ordinary tools available anywhere, Hong's technique could be considered Columbus’ egg in this previously risky field.

Retained central venous lines (CVLs) after attempted removal: an 11-year series and literature review

BACKGROUND

Central venous lines (CVLs) are frequently used in the management of many neonatal and pediatric conditions. Failure to remove the luminal part of the line (retained CVL) is rare. Consequently, there is lack of experience and consensus in its optimal management.

AIM

To document the incidence and management of retained CVLs in a tertiary pediatric surgical centre with access to interventional cardiology services. To review the literature and report efficacy/morbidity of attempted extraction of retained CVLs.

METHODS

Children with retained CVLs were identified from departmental morbidity and mortality records over an 11-year period. A literature search was performed in PubMed and Scopus to identify studies reporting retained CVLs (earliest date to 1 January 2012). This was supplemented by scanning bibliographies of retrieved articles.

RESULTS

The 11-year incidence of retained CVL was 0.3% (n=10; median duration in-situ 66.5 {range 47-146} months). The underlying pathology in 8 was cystic fibrosis. Antegrade transfemoral snare retrieval was successful in 6 of 7 attempts. In the remaining 3, a conservative approach was adopted following consultation with the family. None of the 4 with retained CVL developed complications (median follow-up 7.5 {range 1-53} months). The literature describes 38 pediatric index cases (including 10 from the current series). Seventeen (49%) were managed conservatively either intentionally or by default after failed endovascular removal attempt (n=4). No complications directly attributed to retained CVLs have been reported (median follow-up 40 {range 1-120} months). Reported morbidity associated with endovascular retrieval includes: procedural failure 30%, line embolization 8%, and intra-operative thrombo-embolism 8%.

CONCLUSION

Literature regarding management of retained CVLs is anecdotal. Although uncommon, the complication should feature in consent for removal of CVLs. Conservative management carries long-term risks of infection, thrombosis, and even migration, albeit unquantified over a child's lifetime. Endovascular retrieval is feasible with appropriate expertise.

Imaging and management of complications of central venous catheters

Central venous catheters (CVCs) provide valuable vascular access. Complications associated with the insertion and maintenance of CVCs includes pneumothorax, arterial puncture, arrhythmias, line fracture, malposition, migration, infection, thrombosis, and fibrin sheath formation. Image-guided CVC placement is now standard practice and reduces the risk of complications compared to the blind landmark insertion technique. This review demonstrates the imaging of a range of complications associated with CVCs and discusses their management with catheter salvage techniques.

A Breakthrough Technique for the Removal of a Hemodialysis Catheter Stuck in the Central Vein: Endoluminal Balloon Dilatation of the Stuck Catheter

Background

Hemodialysis (HD) catheters can get stuck in the central vein after long-term use and their removal might become difficult especially in patients with fibrosed or occluded central veins. Herein, a breakthrough technique is reported for the easy removal of a stuck HD catheter from the central vein.

Case Report

Attempts were made to remove a tunneled double-lumen HD catheter from the central vein of a 74-year-old woman, only to find that the catheter was stuck. The patient was transferred to the operating room and a skin incision was made in the neck and the subcutaneous portion of the HD catheter was retrieved from the tunnel. Under fluoroscopy, a guide wire was inserted into one lumen of the HD catheter and advanced into the right atrium beyond the catheter tip. A 5 mm × 4 cm balloon angioplasty catheter was then inserted into the HD catheter lumen over the guide wire and advanced into the jugular vein junction of the HD catheter around the thoracic inlet. The balloon was inflated to its maximum dimension and pressure. This endoluminal dilatation of the HD catheter was continued by deflating the balloon and then pushing the angioplasty catheter 4 cm at a time towards the tip of the HD catheter in the right atrium. After a second balloon angioplasty catheter of 6 mm × 4 cm was used to expand the entire segment of the other lumen, the HD catheter was pulled out easily from the central vein without any resistance.

Comments

The endoluminal balloon dilatation of the HD catheter not only separates the stuck HD catheter from the adherent vein by breaking the adhesions between them, but also expands the vein simultaneously, thus enabling easy removal of the HD catheter.