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La utilización de catéteres venosos centrales como acceso vascular de larga duración es cada vez más frecuente. Entre las complicaciones más habituales asociadas a su uso están las relacionadas con su implantación1.
To the editor: The use of central venous catheters for long-term vascular access is an increasingly common practice. The most frequent complications associated with the use of such catheters include aspects relating to their insertion.1
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To the editor: The use of central venous catheters for long-term vascular access is an increasingly common practice. The most frequent complications associated with the use of such catheters include aspects relating to their insertion.1
We report two complications of tunneled catheter placement. In both cases the catheter was successfully removed
in the operating room.
CASE 1
A 58-year-old male presented with chronic kidney failure secondary to diabetic nephropathy, subjected to hemodialysis since April 2006 through a tunneled catheter inserted in the right innominate vein. The patient was admitted to our Service on December 20, 2006, due to sepsis probably related with the catheter. Despite antibiotic treatment, the fever failed to subside, and the catheter was therefore removed. Following clinical improvement of the patient, an attempt was made to tunnel a new catheter to the right innominate vein. The vein was punctured, and after drawing blood of venous appearance, the catheter was positioned. The catheter failed to function, however, and chest X-rays revealed an extravascular position of the tip, with a right pneumothorax. Withdrawal in the operating room was decided jointly with the Services of Chest Surgery and Vascular Surgery.
Following contrast administration via the axillary vein, the catheter was seen to traverse the subclavian vein (fig. 1a). Removal of the former was then carried out under imaging control. The postwithdrawal radiological control revealed linear contrast leakage tracing the catheter trajectory and accumulating within the pleural cavity (fig. 1b). A right infraclavicular incision was made for direct compression of the subclavian vein and the application of hemostatic material. The vein leakage was seen to disappear, and a right pleural drain was placed - followed by a favorable clinical and radiological course.
CASE 2
A 19-year-old male presented with chronic renal failure secondary to acute renal failure in the context of meningococcemia. A left radiocephalic fistula was prepared on March 27, 2007, with poor venous development. In view of the need to start dialysis, tunneled catheter placement was programmed for May 18, 2007. Following vein puncture and the drawing of blood of venous appearance, the catheter was positioned but was found to function poorly. The chest X-rays showed the catheter tip to be located in a right paravertebral position, with no firm evidence of pneumothorax (fig. 1c). Emergency surgical removal was carried out, with no evidence of leakage at phlebographic control.
Since 1996, we access the right internal jugular vein as described by Apsner et al.2 for the placement of tunneled catheters, since localization is easy and the procedure has few complications. Puncture is carried out at the confluence between the right internal jugular vein and the subclavian vein, at the so-called right innominate vein. We use fluoroscopic control only in those cases presenting insertion difficulties. In the 10 years during which we have applied this technique, there have been few complications ¿ the above two cases being the only examples
of extravascular positioning registered in our experience.
In our review of the subject, we have found few cases of extravascular placement of central venous catheters for hemodialysis. 3 Complications of this kind could be avoided by using ultrasound or fluoroscopic control on a systematic basis.
We report two complications of tunneled catheter placement. In both cases the catheter was successfully removed
in the operating room.
CASE 1
A 58-year-old male presented with chronic kidney failure secondary to diabetic nephropathy, subjected to hemodialysis since April 2006 through a tunneled catheter inserted in the right innominate vein. The patient was admitted to our Service on December 20, 2006, due to sepsis probably related with the catheter. Despite antibiotic treatment, the fever failed to subside, and the catheter was therefore removed. Following clinical improvement of the patient, an attempt was made to tunnel a new catheter to the right innominate vein. The vein was punctured, and after drawing blood of venous appearance, the catheter was positioned. The catheter failed to function, however, and chest X-rays revealed an extravascular position of the tip, with a right pneumothorax. Withdrawal in the operating room was decided jointly with the Services of Chest Surgery and Vascular Surgery.
Following contrast administration via the axillary vein, the catheter was seen to traverse the subclavian vein (fig. 1a). Removal of the former was then carried out under imaging control. The postwithdrawal radiological control revealed linear contrast leakage tracing the catheter trajectory and accumulating within the pleural cavity (fig. 1b). A right infraclavicular incision was made for direct compression of the subclavian vein and the application of hemostatic material. The vein leakage was seen to disappear, and a right pleural drain was placed - followed by a favorable clinical and radiological course.
CASE 2
A 19-year-old male presented with chronic renal failure secondary to acute renal failure in the context of meningococcemia. A left radiocephalic fistula was prepared on March 27, 2007, with poor venous development. In view of the need to start dialysis, tunneled catheter placement was programmed for May 18, 2007. Following vein puncture and the drawing of blood of venous appearance, the catheter was positioned but was found to function poorly. The chest X-rays showed the catheter tip to be located in a right paravertebral position, with no firm evidence of pneumothorax (fig. 1c). Emergency surgical removal was carried out, with no evidence of leakage at phlebographic control.
Since 1996, we access the right internal jugular vein as described by Apsner et al.2 for the placement of tunneled catheters, since localization is easy and the procedure has few complications. Puncture is carried out at the confluence between the right internal jugular vein and the subclavian vein, at the so-called right innominate vein. We use fluoroscopic control only in those cases presenting insertion difficulties. In the 10 years during which we have applied this technique, there have been few complications ¿ the above two cases being the only examples
of extravascular positioning registered in our experience.
In our review of the subject, we have found few cases of extravascular placement of central venous catheters for hemodialysis. 3 Complications of this kind could be avoided by using ultrasound or fluoroscopic control on a systematic basis.
Bibliography
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