Superior vena cava injury after cuffed tunneled catheter insertion using a right subclavian approach

Abstract

We report a hemodialysis patient who suffered from superior vena cava perforation after a cuffed tunneled catheter insertion using the right subclavian approach. A 59-year-old lady suffered from end-stage renal failure due to unknown cause and was initiated on peritoneal dialysis. She was switched to hemodialysis via the right A-V fistula as a result of abdominal adhesions. Her right forearm A-V fistula was thrombosed 3 years after creation. The right internal jugular vein was thrombosed and there was a left carotid/jugular fistula as a result of previous traumatic puncture. She was therefore scheduled for a cuffed tunneled catheter insertion using the right subclavian approach. There was difficulty during the negotiation of the peel-away sheath and kinking was noted. The procedure was aborted and CT thorax showed extravasation of contrast in the mediastinum. Perforation of the superior vena cava was diagnosed and DDAVP was given to control the bleeding. The cardiothoracic surgeons suggested for conservative anagement in view of the stable hemodynamics. Repeat CT scan 1 week later showed no further extravasation or hematoma formation. The right subclavian vein was attempted again after 2 weeks with a split catheter using a double guidewire technique (Retrocath) and the procedure was uneventful. Because of the angulation between the right subclavian vein and superior vena cava, cuffed tunneled catheter insertion using the subclavian approach is of higher technical difficulty. Attempts should be made to use the jugular vein for cuffed tunneled catheter insertion if possible. The risk of perforation or vascular injury is increased especially when the catheter is inserted using a peel-away sheath that is nonflexible. We suggested that if the subclavian approach is used, one should attempt with a flexible split catheter using a double guidewire technique to minimize the chance of vascular injury.