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Fragment of a Hemodialysis Catheter in the Vena Cava—A Complication of Guidewire Exchange
International Journal of Gerontology 4 (2010) 205–206
Contents lists available at ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Letter to the Editor
Fragment of a Hemodialysis Catheter in the Vena CavadA Complication of Guidewire Exchangeq We read with interest the case report on distal guidewire migration during central venous catheterization by Huang et al.1 Indeed, advanced surgical skills and meticulous attention are required for central venous catheterization. A limited number of sites are available for inserting a central venous catheter, not to mention a hemodialysis catheter. Therefore, in some cases, malfunctioning or infected catheters may have to be replaced by exchanging them over a guidewire.2–4 Here, we report a case involving a rare complication of guidewire exchange. A 75-year-old man was admitted with septic shock and respiratory failure. He received continuous venovenous hemodialysis for the treatment of anuric acute kidney injury with metabolic acidosis. Thrombosis of the femoral double-lumen catheter was noted a few hours after starting dialysis, and guidewire exchange was performed. The catheter was cut with sterile scissors at a point about 1.5 cm distal to the catheter port. While threading and advancing the guidewire,
the residual catheter fragment slipped and migrated beneath the skin. The follow-up radiograph (Fig. 1) revealed that this fragment was located across the inferior and superior vena cava. No arrhythmia was noted. Angiographic removal of the fragment was not performed because the patient died of profound shock few hours later. Although such catheter fragments may not completely migrate into the vena cava during cutting, the operator should prevent this migration by holding the catheter tightly while the new guidewire is being passed. Clamping the catheter fragment with a hemostat may be required to prevent the complications observed in this case. Furthermore, cutting the catheter at the points proximal to the catheter port may ultimately prevent this complication. References 1. Huang CC, Chan CM, Chen JH, et al. Emergency femoral central venous catheterization in an elderly patient complicated by distal guidewire migration. IJGE 2008;2:133–135. 2. Cunningham JM. Aseptic technique for performing central venous catheter exchange using a guidewire. Available at: http://www.surgicalroundsonline. com/issues/articles/2008-01_05.asp; 2008 [Date accessed: 28 January 2010]. 3. Casey J, Davies J, Balshaw-Greer A, et al. Inserting tunnelled hemodialysis catheters using elective guidewire exchange from nontunnelled catheters: is there a greater risk of infection when compared with new-site replacement? Hemodial Int 2008;12:52–54. 4. Hou SM, Chou PC, Huang CH, et al. Is guidewire exchange a better approach for subclavian vein re-catheterization for chronic hemodialysis patients? Thromb Res 2006;118:439–445.
Ming-Ju Tsai, Po-Ju Wei Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Shu-Hui Chuang Department of Nursing, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Huang-Chi Chen* Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Fig. 1. Chest radiograph showing the fragment of a hemodialysis catheter (arrows); the fragment was located across the inferior vena cava, right atrium, and superior vena cava.
q All contributing authors declare no conflict of interest.
Jhi-Jhu Hwang Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
1873-9598/$ – see front matter Copyright Ó 2010, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.ijge.2010.11.010
206
Letter to the Editor
Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Ming-Shyan Huang Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC *Correspondence to: Huang-Chi Chen, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, 482 Shan-Ming Road, Hsiao-Kang District, 812, Kaohsiung, Taiwan, ROC. E-mail address: [email protected]
28 January 2010
Contents lists available at ScienceDirect
International Journal of Gerontology journal homepage: www.ijge-online.com
Letter to the Editor
Fragment of a Hemodialysis Catheter in the Vena CavadA Complication of Guidewire Exchangeq We read with interest the case report on distal guidewire migration during central venous catheterization by Huang et al.1 Indeed, advanced surgical skills and meticulous attention are required for central venous catheterization. A limited number of sites are available for inserting a central venous catheter, not to mention a hemodialysis catheter. Therefore, in some cases, malfunctioning or infected catheters may have to be replaced by exchanging them over a guidewire.2–4 Here, we report a case involving a rare complication of guidewire exchange. A 75-year-old man was admitted with septic shock and respiratory failure. He received continuous venovenous hemodialysis for the treatment of anuric acute kidney injury with metabolic acidosis. Thrombosis of the femoral double-lumen catheter was noted a few hours after starting dialysis, and guidewire exchange was performed. The catheter was cut with sterile scissors at a point about 1.5 cm distal to the catheter port. While threading and advancing the guidewire,
the residual catheter fragment slipped and migrated beneath the skin. The follow-up radiograph (Fig. 1) revealed that this fragment was located across the inferior and superior vena cava. No arrhythmia was noted. Angiographic removal of the fragment was not performed because the patient died of profound shock few hours later. Although such catheter fragments may not completely migrate into the vena cava during cutting, the operator should prevent this migration by holding the catheter tightly while the new guidewire is being passed. Clamping the catheter fragment with a hemostat may be required to prevent the complications observed in this case. Furthermore, cutting the catheter at the points proximal to the catheter port may ultimately prevent this complication. References 1. Huang CC, Chan CM, Chen JH, et al. Emergency femoral central venous catheterization in an elderly patient complicated by distal guidewire migration. IJGE 2008;2:133–135. 2. Cunningham JM. Aseptic technique for performing central venous catheter exchange using a guidewire. Available at: http://www.surgicalroundsonline. com/issues/articles/2008-01_05.asp; 2008 [Date accessed: 28 January 2010]. 3. Casey J, Davies J, Balshaw-Greer A, et al. Inserting tunnelled hemodialysis catheters using elective guidewire exchange from nontunnelled catheters: is there a greater risk of infection when compared with new-site replacement? Hemodial Int 2008;12:52–54. 4. Hou SM, Chou PC, Huang CH, et al. Is guidewire exchange a better approach for subclavian vein re-catheterization for chronic hemodialysis patients? Thromb Res 2006;118:439–445.
Ming-Ju Tsai, Po-Ju Wei Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Shu-Hui Chuang Department of Nursing, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Huang-Chi Chen* Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Fig. 1. Chest radiograph showing the fragment of a hemodialysis catheter (arrows); the fragment was located across the inferior vena cava, right atrium, and superior vena cava.
q All contributing authors declare no conflict of interest.
Jhi-Jhu Hwang Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
1873-9598/$ – see front matter Copyright Ó 2010, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.ijge.2010.11.010
206
Letter to the Editor
Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC Ming-Shyan Huang Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC *Correspondence to: Huang-Chi Chen, Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, 482 Shan-Ming Road, Hsiao-Kang District, 812, Kaohsiung, Taiwan, ROC. E-mail address: [email protected]
28 January 2010