Introduction
Vascular exhaustion is a key concern for hemodialysis patients who are able to live longer than expected. Some patients with left arteriovenous fistula (AVF) dysfunction and cuffed tunneled catheter (CUFF), as well as stenosis and occlusion of the veins in the upper hemothorax underwent direct cannulation of the superior vena cava through anterior thoracotomy and subsequently exhibited severe hemothorax complications [
1,
2]. Our group has published the first case of catheterization via direct cannulation of the superior vena cava for hemodialysis [
3]. However, localization might be the most difficult step for the other groups to follow. In the present study, we reported a case on a new way of localization for direct catheterization of tunneled cuffed dialysis catheter via the superior vena cava in patients with vascular access exhaustion, who had an original dysfunctional catheter on the left internal jugular vein.
Presentation of case
A 50-year-old female patient was hospitalized because of a dysfunction in her left CUFF. She experienced blood flow lower than 200 ml/min 2 weeks prior to her admission. The patient was obese and suffering primarily from glomerular nephritis. She had been undergoing chronic hemodialysis for 7 years. After being subjected to left AVF for 5 years and right AVF for 1 year, she was subjected to CUFF via the left internal jugular vein, because she had thromboses in her AVF and right internal jugular vein. Previous nontunneled catheter on the right internal jugular vein had been used for 2 months at the initial hemodialysis session, and catheters on both sides of the femoral veins were used during the following transition periods. Upon her admission, occlusion in her right innominate vein and thromboses in the left innominate, right internal jugular, and right subclavian veins were documented through multidetector computed tomography venography (MDCTV).
Except for the previous findings, thrombosis was also observed in her right femoral vein. Given that this patient has been working as a farmer, she was hesitant to undergo graft or CUFF on her left femoral vein. For doctors, using the femoral vein as an access for temporary use is necessary. Direct puncture via the superior vena cava under fluoroscopic visualization was attempted, because no other vessel was suitable for the puncture.
Intervention was applied via the left femoral vein as the approach site for canalization. The arrangement of the vessels were observed through MDCTV, which was used to design the path for canalization in order to avoid entry into the thoracic cavity and damage to the nearby vessels. The distal end of the superior vena cava was localized clearly by the original CUFF and guidewire in the left internal jugular vein under DSA (Fig. 1). Directed to the distal end of the superior vena cava, the secondary puncture was successfully applied 0.5 cm below the lateral head of the sternocleidomastoid muscle, which was designated as “Point CUI for superior vena cava,” via the right neck area [
3]. The depth of needle was guided by DSA. Dark red blood indicated the success of the puncture. On the horizontal position of the DSA, localization was verified by the overlap between the inserting needle and section of the left CUFF in the superior vena cava (Fig. 2). After the successful placement of the guidewire and CUFF into the superior vena cava, the CUFF on the left side was removed. The blood flow for hemodialysis via the newly inserted CUFF on the right side was good (Fig. 3). Furthermore, the new CUFF was currently permeable after being used for 1.5 years.
Discussion
Vascular exhaustion is a key concern of hemodialysis patients who lived longer than expected [
4–
6]. In the present study, the history of nontunneled and tunneled catheterizations and high risk caused by central vein stenosis and occlusion in an obese patient were studied. The patient had dysfunctional AVFs on both sides of her wrists and on CUFF on her left internal jugular vein, classic vessels (internal jugular and subclavian), and nonclassic vessels (innominate) in her upper hemothorax. The use of graft on the left femoral vein had been rejected by the patient because of her working condition. Direct puncture via the superior vena cava under fluoroscopic visualization appeared to be the only convenient resort. As such, the left femoral vein can be used as an access for temporary entry in the future.
Reports regarding direct catheterization of tunneled cuffed dialysis catheter via the superior vena cava in hemodialysis patients with vascular access exhaustion have been published. In these reports, the patients underwent anterior thoracotomy. However, they developed severe hemothorax complications [
1,
2]. This side effect limited the application of anterior thoracotomy in clinical practice. In the present study, a new method of catheterization via direct cannulation of superior vena cava for hemodialysis was developed [
3]. This method presented few side effects. Given the risks of several complications, such as pneumothorax, hemothorax, hemopneumothorax, and damage of vessels, nerves, and adjacent organs, performing direct puncture via the superior vena cava under fluoroscopic visualization must be thoroughly performed by interventionists who are experts in CT imaging and local anatomy. In addition, the patient must be willing to undergo such technique, which must be applied carefully and must not be misused. In this technique, using MDCTV is strongly recommended to visualize the arrangement of vessels and thus prevent needle entry into the thoracic cavity. Contrasting and real-time DSA are key elements for the location of the distal end of the superior vena cava. In the present case, the original CUFF and guidewire on the left internal jugular vein facilitated the location of this area by showing the overlap between the inserting needle and section of left CUFF in the superior vena cava, as well as the withdrawn dark red blood. The depth of the needle was guided by DSA. Therefore, direct puncture to the superior vena cava was successful in one section of the intervention operation. Compared with our first published case [
3], the proposed technique, assisted by the original left catheter, exhibited less puncture times, because of the new localization indicated by the overlap between the inserting needle and section of the left CUFF in the superior vena cava under fluoroscopic visualization. Nevertheless, these patients must be extensively monitored. Furthermore, the transitional period for the use of the left side of the catheter must not be extremely long. Otherwise, occlusion in the left innominate vein may occur. With the assistance of the original left CUFF, selecting the appropriate location for the puncture site is easier, and puncture times are reduced (2 vs. 5 in the first case) [
3]. We believe that the presentation of this case will encourage other researchers to explore this new technique with the help of left CUFF.
Catheterization via direct cannulation of the superior vena cava is not only convenient and safe but also important for the conservation of other vessel resources and prolonging the catheter life. An international working guideline [
5] stated that “the preferred insertion site for tunneled cuffed venous dialysis catheters or port catheter systems is the right internal jugular vein. Other options include the right external jugular vein, left internal and external jugular veins, subclavian veins, femoral veins, and translumbar and transhepatic access to the IVC. Subclavian access should be used only when no other upper-extremity or chest-wall options are available.” However, the patency rates of CUFF in the left upper side and lower femoral are limited. Thus, this case might provide alternative for patients with similar conditions (dysfunction of left CUFF on the neck and occlusion in the right innominate vein). The presence of the original left CUFF can facilitate the location of the puncture site [
3].
Conclusions
The present study is one of the few reports on direct catheterization of tunneled cuffed dialysis catheter via the superior vena cava in a patient with vascular access exhaustion and CUFF dysfunction in the left internal jugular vein. Furthermore, this study suggested a new alternative for the placement of the central venous catheter into hemodialysis patients. Nevertheless, the long-term effects of this technique require further investigation, particularly through close follow-ups.
Higher Education Press and Springer-Verlag Berlin Heidelberg
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