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Letters to the Editor
Rare but Life-Threatening Complication: Delayed Common Iliac Vein Perforation by Hemodialysis Catheter Dear Editor, Percutaneous femoral catheterization is considered a quick and an easy access for hemodialysis (HD) (1). However, it could cause severe and fatal late complications such as infection, thrombosis, vessel perforation, and hemorrhage (2). We report a case of the delayed common iliac vein perforation by the catheter tip, diagnosed by computed tomography (CT). This is a rare, unreported, but life-threatening complication. A 72-year-old man with chronic kidney disease stage 5 due to type 2 diabetic nephropathy without permanent vascular access was admitted to introduce HD (day 1). His past medical history was significant for type 2 diabetes requiring insulin for 18 years, diabetic retinopathy, and neuropathy. He suffered from severe azotemia, pleural effusion, and ascites. A non-cuffed double-lumen dialysis catheter (12 Fr, 16 cm, Teleflex, NC, USA) was inserted smoothly in the right femoral vein under ultrasonography guidance using the Seldinger technique by an experienced operator. After insertion, abdominal X-ray photography confirmed that the catheter tip was located in the
a
523
appropriate position. Then, the first HD session was performed without any problem. At the beginning of the second HD session (day 2), it was identified that the venous lumen of the catheter was unable to aspirate blood. The right median cubital vein was used as a venous route instead. He reported slight discomfort around the waist, but his vital signs had been stable during the second HD. After the second HD, a CT was obtained to estimate the pleural effusion and ascites. Surprisingly, the CT revealed that the catheter tip has penetrated the common iliac vein (Fig. 1a,b). The catheter was immediately removed. He underwent successful arteriovenous fistula formation in the left forearm, and was transferred to another dialysis clinic without any complications on day 15. The CT imaging and the functioning of the arterial lumen suggested that the tip of the arterial lumen might have remained in the vein. After the first HD session, the patient became restless and moved his lower limbs violently in his bed late at night. The removed catheter was bent at the tip. Therefore, the possibility remains that the catheter tip had perforated the vein due to his violent movement between the first and second HD session a. Disuse of the venous lumen in the second HD saved him from massive bleeding. Although the patient had no bleeding, retroperitoneal bleeding is a frequent complication of femoral vein catheterization. The similarity of the
b
FIG. 1. A computed tomography scan revealed that the catheter has perforated the right common iliac vein and its route between the psoas muscle and the inferior vena cava at the 5th lumbar vertebra level (arrow). (a) Coronal view, (b) horizontal view. © 2015 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy
Ther Apher Dial, Vol. 19, No. 5, 2015
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524
Letters to the Editor
complication might be the presence of lower back pain and feelings of discomfort (3). The dissimilarity might be the presence of hypotension, tachycardia, and decreasing hematocrit levels. A follow-up CT with or without contrast might be required to check for active bleeding after removal. In conclusion, late onset of common iliac vein perforation by temporal HD catheter is a rare, but lifethreatening complication. Nephrologists inserting temporal catheters in the femoral vein should keep in mind that this complication can happen especially in patients with delirium. Acknowledgments Conflict of interest: None to declare.
Kentaro Wada,1 Motoo Araki,2 and Yuko Wada3 Division of Nephrology and Dialysis, Department of Internal Medicine, Nippon Kokan Fukuyama Hospital, and 3Department of Internal Medicine, Central Hospital, Hiroshima, and 2Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan Email: [email protected]
1
REFERENCES 1. Kukita K, Ohira S, Amano I et al. Guidelines of vascular access construction and repair for chronic hemodialysis. J Jpn Soc Dial Ther 2011;44:855–937. (In Japanese). 2. Oliver MJ. Acute dialysis catheters. Semin Dial 2001;14:432–5. 3. Sirvent AE, Enríquez R, Millán I et al. Severe Hemorrhage because of delayed iliac vein rupture after dialysis catheter placement: is it preventable? Hemodial Int 2012;16:315–9.
Septic Pulmonary Embolism Caused by Internal Shunt Infection Dear Editor, We report a case of septic pulmonary embolism (SPE) caused by internal shunt infection. Infections and infectious complications of vascular access remain a major cause of morbidity and mortality in HD patients. Metastatic infections complicate 22% of hemodialysis patients with bacteremia (1). SPE is a relatively rare disease caused by infective embolus from septicemia or generalized focus of infection, often resulting in occlusion of pulmonary artery. A female patient in her 50s was first diagnosed with hyperpiesia and renal dysfunction in 1990. TreatTher Apher Dial, Vol. 19, No. 5, 2015
ment with oral medication was started but renal dysfunction progressed. The surgery of internal shunt, a native arteriovenous fistula, was done and hemodialysis was introduced in 1993. She had no past history of diabetic mellitus and her cause of renal dysfunction was thought to be benign nephrosclerosis. In September 2008, red flare at the internal shunt puncture site, swelling, and fever above 40°C were observed. Gram-negative bacilli were detected on blood culture. A diagnosis of shunt infection and septicemia was made, and treatment with 0.5 g/day of meropenem (MEPM) was started. Productive cough appeared, and chest X-ray and computed tomography (CT) showed multiple nodular shadows, and she was referred to our hospital for detailed examination and treatment. Leukocyte count was 9250/μL (3300–8800/μL) with markedly amplified percent of neutrophils (93%). C-reactive protein (CRP) level was also high at 19.7 mg/dL (
Letters to the Editor
Rare but Life-Threatening Complication: Delayed Common Iliac Vein Perforation by Hemodialysis Catheter Dear Editor, Percutaneous femoral catheterization is considered a quick and an easy access for hemodialysis (HD) (1). However, it could cause severe and fatal late complications such as infection, thrombosis, vessel perforation, and hemorrhage (2). We report a case of the delayed common iliac vein perforation by the catheter tip, diagnosed by computed tomography (CT). This is a rare, unreported, but life-threatening complication. A 72-year-old man with chronic kidney disease stage 5 due to type 2 diabetic nephropathy without permanent vascular access was admitted to introduce HD (day 1). His past medical history was significant for type 2 diabetes requiring insulin for 18 years, diabetic retinopathy, and neuropathy. He suffered from severe azotemia, pleural effusion, and ascites. A non-cuffed double-lumen dialysis catheter (12 Fr, 16 cm, Teleflex, NC, USA) was inserted smoothly in the right femoral vein under ultrasonography guidance using the Seldinger technique by an experienced operator. After insertion, abdominal X-ray photography confirmed that the catheter tip was located in the
a
523
appropriate position. Then, the first HD session was performed without any problem. At the beginning of the second HD session (day 2), it was identified that the venous lumen of the catheter was unable to aspirate blood. The right median cubital vein was used as a venous route instead. He reported slight discomfort around the waist, but his vital signs had been stable during the second HD. After the second HD, a CT was obtained to estimate the pleural effusion and ascites. Surprisingly, the CT revealed that the catheter tip has penetrated the common iliac vein (Fig. 1a,b). The catheter was immediately removed. He underwent successful arteriovenous fistula formation in the left forearm, and was transferred to another dialysis clinic without any complications on day 15. The CT imaging and the functioning of the arterial lumen suggested that the tip of the arterial lumen might have remained in the vein. After the first HD session, the patient became restless and moved his lower limbs violently in his bed late at night. The removed catheter was bent at the tip. Therefore, the possibility remains that the catheter tip had perforated the vein due to his violent movement between the first and second HD session a. Disuse of the venous lumen in the second HD saved him from massive bleeding. Although the patient had no bleeding, retroperitoneal bleeding is a frequent complication of femoral vein catheterization. The similarity of the
b
FIG. 1. A computed tomography scan revealed that the catheter has perforated the right common iliac vein and its route between the psoas muscle and the inferior vena cava at the 5th lumbar vertebra level (arrow). (a) Coronal view, (b) horizontal view. © 2015 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy
Ther Apher Dial, Vol. 19, No. 5, 2015
bs_bs_banner
524
Letters to the Editor
complication might be the presence of lower back pain and feelings of discomfort (3). The dissimilarity might be the presence of hypotension, tachycardia, and decreasing hematocrit levels. A follow-up CT with or without contrast might be required to check for active bleeding after removal. In conclusion, late onset of common iliac vein perforation by temporal HD catheter is a rare, but lifethreatening complication. Nephrologists inserting temporal catheters in the femoral vein should keep in mind that this complication can happen especially in patients with delirium. Acknowledgments Conflict of interest: None to declare.
Kentaro Wada,1 Motoo Araki,2 and Yuko Wada3 Division of Nephrology and Dialysis, Department of Internal Medicine, Nippon Kokan Fukuyama Hospital, and 3Department of Internal Medicine, Central Hospital, Hiroshima, and 2Department of Urology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan Email: [email protected]
1
REFERENCES 1. Kukita K, Ohira S, Amano I et al. Guidelines of vascular access construction and repair for chronic hemodialysis. J Jpn Soc Dial Ther 2011;44:855–937. (In Japanese). 2. Oliver MJ. Acute dialysis catheters. Semin Dial 2001;14:432–5. 3. Sirvent AE, Enríquez R, Millán I et al. Severe Hemorrhage because of delayed iliac vein rupture after dialysis catheter placement: is it preventable? Hemodial Int 2012;16:315–9.
Septic Pulmonary Embolism Caused by Internal Shunt Infection Dear Editor, We report a case of septic pulmonary embolism (SPE) caused by internal shunt infection. Infections and infectious complications of vascular access remain a major cause of morbidity and mortality in HD patients. Metastatic infections complicate 22% of hemodialysis patients with bacteremia (1). SPE is a relatively rare disease caused by infective embolus from septicemia or generalized focus of infection, often resulting in occlusion of pulmonary artery. A female patient in her 50s was first diagnosed with hyperpiesia and renal dysfunction in 1990. TreatTher Apher Dial, Vol. 19, No. 5, 2015
ment with oral medication was started but renal dysfunction progressed. The surgery of internal shunt, a native arteriovenous fistula, was done and hemodialysis was introduced in 1993. She had no past history of diabetic mellitus and her cause of renal dysfunction was thought to be benign nephrosclerosis. In September 2008, red flare at the internal shunt puncture site, swelling, and fever above 40°C were observed. Gram-negative bacilli were detected on blood culture. A diagnosis of shunt infection and septicemia was made, and treatment with 0.5 g/day of meropenem (MEPM) was started. Productive cough appeared, and chest X-ray and computed tomography (CT) showed multiple nodular shadows, and she was referred to our hospital for detailed examination and treatment. Leukocyte count was 9250/μL (3300–8800/μL) with markedly amplified percent of neutrophils (93%). C-reactive protein (CRP) level was also high at 19.7 mg/dL (
