To the editor:
Temporary or permanent central venous catheterization is commonly performed in in hemodialysis patients when an internal vascular access is not available. Internal jugular vein catheterization is nowadays the preferred vascular access because it is associated to lower risks and complications (15% of mechanical, infectious or thrombotic complications). The most frequent mechanical complications are arterial puncture and secondary hematoma. By contrast, hemothorax and pneumothorax incidence is lower than 0,0.2% and it happens immediately after the puncture.2
We present a 72 year-old woman with a history of high blood pressure and CRF secondary to nephroangiosclerosis in on hemodialysis since 2000. The patient had a permanent catheter in within the right jugular vein, which was placed 5 years ago. The catheter was non-functioning, permeation was not possible with the use of urokinase and the catheter had to be removed. Due to the lack of an internal vascular accesses, a temporary catheter, which was shorter than usual (16 cm instead of 19 cm), was placed in the left jugular vein. An X-ray film confirmed that the catheter was appropriately placed. Nineteen days later it was removed because it did not work properly and was changed by means of a metal wire (16 cm). No radiological control was made. During the following hemodialysis sessions the catheter flow was always lower than 200 mL/min, and the catheter was repeatedly manipulated.
The patient came 29 days later to hemodialysis referring dyspnea and pain in on her right scapula. At the beginning of the session clear fluid was obtained through the arterial branch and hematic fluid through the venous branch. A chest X-ray film was made (fig. 1), which showed right pleural effusion. Dialysis was performed without heparin through a right femoral access. Fifteen minutes after the end of hemodialysis the patient referred sudden right chest pain and dyspnea and she suffered cardiopulmonary arrest. On physical exam right pulmonary hypoventilation was evident. A decrease of hemoglobin value was detected on blood analysis, and the right pulmonary field was opaque on chest X-ray. The diagnosis of massive hemothorax was suspected, a drain tube was placed and resuscitation maneuvers were initiated. The patient was referred to the ICU, where she spent 72 hours and after that she was admitted to our Department with no consequences.
Internal jugular vein catheterization is not free from complications. Massive hemothorax is not frequent, occurs immediately after the puncture and commonly after catheterization of the subclavian vein. In the reported case, hemothorax happened 29 days after catheterization of the vascular access. That was due to the removal of the left jugular catheter, that was occluding a fistula created by the impact of the catheter.
Several facts were determinants for perforation into the interpleural space:3 canalization of the left jugular vein instead the right one (that was occupied by a permanent catheter, which had to be removed), the replacement by a short catheter (16 cm) and the various manipulations of the catheter because of the low flow. Massive hemothorax was the consequence of the catheter removal, and perhaps this procedure should have been done with some precautions (removal in the ICU).
The widespread use of catheters for hemodialysis in patients with difficult vascular accesses increases the morbimortality. It is mandatory the referral of the patient to the nephrology department, and the cooperation of vascular surgeons and radiologists to achieve appropriate vascular accesses.
A radiological control should be made after catheterization and replacement of the catheter to assess the correct position and the lack of complications, although some authors do not agree with this measure.4
In summary, when placing temporary catheters the appropriate length, the correct position after placement and replacement should be considered, and manipulations should be avoided.
