Introduction
Patients with end-stage kidney failure need hemodialysis. Among 740,000 patients with end-stage kidney failure in the United States more than 460,000 patients received renal replacement therapy with hemodialysis in 2017 [1]. All these patients need permanent vascular access for hemodialysis [2]. Moreover, multiple surgeries for vascular access set up, and catheter insertions followed by thrombosis are not uncommon among them. Vascular access failure for hemodialysis requires alternative techniques such as percutaneous translumbar inferior vena cava cannulation. The cannulation technique is often advantageous than the extra-anatomic bypass due to the accuracy and possibility to do hemodialysis the next day if another vascular access is not available.
Case Presentation
A 39-year-old patient was admitted to hospital due to hemodialysis permanent catheter failure in the left internal jugular vein in February 2019. The patient had chronic kidney disease followed by terminal nephrosclerosis throughout 21 years. She had been receiving hemodialysis three times a week for 19 years.
Many attempts for permanent vascular access for hemodialysis had been made over the past ten years: arteriovenous (AV) fistula in the lower third of the right and left forearms, which had been functioning for 7 and 5 months, respectively. AV fistula in the bend of right elbow worked four months. AV graft between the right brachial artery and vein worked for nine months. AV graft at the right thigh was followed by thrombosis, thrombectomy, pyesis and finally was removed after three months. Also, the internal right and left jugular veins, the right and left subclavian veins and the left common femoral vein were consecutively catheterized for hemodialysis earlier.
The patient received enoxaparin 0.4 ml (4000 IU) once daily. She also received 25 IU/kg of unfractionated heparin at the beginning and 1000 IU per hour during the hemodialysis procedure, with the cancellation of the heparin supply one hour before the end of the procedure.
We performed CT angiography of the lower and upper vena cava territories. It revealed occlusion of the right brachiocephalic vein, internal jugular and subclavian veins. Numerous varicosities veins were found around the heart and along the diaphragm (Fig. 1). The patient also had occlusion of the left brachiocephalic vein so that the catheter in the left internal jugular vein could not provide adequate volumetric blood flow for hemodialysis. At the same time, the patient had occlusion of the inferior vena cava 5 cm below the renal vein. Besides, there were occlusion of both common, external iliac and left common femoral veins.
Fig. 1. CT angiography of superior vena cava and its tributaries.
We performed two attempts of balloon angioplasty of subclavian and brachiocephalic veins with no success. We failed to have catheter guide passed through obstruction area.
Taking into consideration the lack of full venous access for hemodialysis, we decided to install a percutaneous translumbar permanent dialysis catheter in the lower vena cava under CT guidance.
Procedure was performed under local anaesthesia with lidocaine. Firstly, we checked anatomy of the renal veins, arteries and right ureter using contrast-enhanced CT. Contrast was injected through the left jugular vein catheter. Despite the dysfunction of this catheter, the contrast was spreaded by existing collaterals. Then we punctured the inferior vena cava with 21Gx15cm needle with trocar-style (Merit Medical, USA). The needle was inserted 10 cm to the right of the midline at the height of the iliac crest and moved toward the front of L3 right margin under CT guidance (Fig. 2).
Fig. 2. Inferior vena cava catheterization with a 21G needle.
After confirming of successful inferior vena cava puncture by CT, we removed the trocar stylet and got blood flow from the cannula. Then we inserted 0.038” (0.97 mm) x150 cm double ended heavy duty 3 mm J guide wire (Merit Medical, USA) and placed it inside inferior vena cava. The 8 Fx20 cm length dilator and 12 Fx15 cm length dilator and AirGuard® Valved Introducer, Peel-Apart Sheath 15 Fx13 cm length with vessel dilator (Bard Access Systems, USA) were inserted over the wire. Then we introduced 14,5 Frx42 cm EQUISTREAM Long-Term Hemodialysis Catheter (Bard Access Systems, USA) and peeled off the sheath. Under the contrast-enhanced CT we positioned the catheter tip between the right atrium and inferior vena cava. Then, we embedded the catheter through a subcutaneous tunnel and placed the port chamber in the right lower back region for patient comfort (Fig. 3). There was no bleeding from the puncture site.
Fig. 3. Final position of percutaneous translumbar permanent hemodialysis catheter in inferior vena cava.
Follow up. Clinical, lab and ultrasound examinations did not reveal bleeding in the early postoperative period. Next day patient experienced fatigue, dyspnea, bradycardia, hypotension. Severe electrolyte disturbances (hyperkalemia 5.9 mmol/l, hypercreatininemia 1,344 mmol/l, blood urea 34.2 mmol/l) were also detected. Due to that we decided to perform hemodialysis, despite the associated bleeding risk due to anticoagulation. The hemodialysis via a new catheter was successful without any clinical, lab and ultrasound signs of bleeding. Later the patient got routine hemodialysis three times a week.
Control CT on the 7th day demonstrated the proper catheter positioning in the inferior vena cava with the top at the level of the right atrium and absence of any contrast extravasation.
During 30 months follow up, we did not observe quality of life dissatisfaction, infectious or non-infectious complications and problems with hemodialysis handling.
Discussion
The graduated lose of vascular access in patients with long term hemodialysis is a frequent and dramatic situation [3]. J. Al Shakarchi et al. [4] proposed a simple anatomically based classification for end-stage vascular access failure:
1. No upper limb vascular access option.
2. No lower limb vascular access option.
3. No options at any site.
We presented the case undoubtedly related to the third category of the classification. Patients like this are the most difficult to permanent hemodialysis vascular access installation. Percutaneous translumbar insertion of the hemodialysis catheter seems to be a good solution for them. CT guidance plays a key role for technical success of such procedure [5].
We searched PubMed, Elibrary and GoogleScholar databases for the keywords «hemodialysis catheter» and «translumbar». 69 sources were found of which only 13 described 320 cases of translumbar installation of a hemodialysis catheter in total (Table).
Table. Complications of translumbar catheterization of the inferior vena cava
|
Author, publication year |
Number of procedures |
Complications, absolute value and % from the number of procedures |
||||
|
in total |
hematoma* |
infection** |
thrombosis |
transposition |
||
|
F. Moura et al., 2018 [6] |
12 |
5 (41.6%) |
0 |
5 (41.6%) |
0 |
0 |
|
G. Nadolski et al., 2013 [7] |
92 |
64 (82%) |
0 |
39 (50%) |
10 (12.8%) |
15 (19.2%) |
|
A. Power et al., 2009 [8] |
39 |
61 (156.4%) |
2 (8.2%) |
45.1 (15.4%) |
10 (25.6%) |
4 (10.4%) |
|
R. Biswal et al., 2000 [9] |
23 |
6 (20%) |
1 (4.3%) |
0 |
1 (4.3%) |
3 (13%) |
|
J. Rodriguez Mori et al., 2018 [10] |
26 |
5 (19.2%) |
0 |
2 (7.7%) |
1 (3.8%) |
2 (7.7%) |
|
F. Liu et al., 2015 [11] |
84 |
67 (79.7%) |
0 |
28 (35.9%) |
24 (30.8%) |
15 (19.2%) |
|
G. Kade et al., 2013 [12] |
16 |
16 (100%) |
0 |
9 (56.2%) |
5 (31.2%) |
2 (12.5%) |
|
G. Herscu et al., 2013 [13] |
3 |
1 (33%) |
0 |
1 (33%) |
0 |
0 |
|
F. Wacker et al., 2005 [14] |
3 |
1 (33%) |
0 |
0 |
1 (33%) |
0 |
|
D. Markowitz et al., 1998 [15] |
5 |
2 (40%) |
1 (20%) |
1 (20%) |
0 |
0 |
|
G. Lund et al., 1995 [16] |
17 |
13 (76.5%) |
0 |
6 (35.3%) |
7 (41.2%) |
0 |
Note. *Retroperitoneal hematoma was unrelated to the inferior vena cava bleeding; **this refers to exit-site infection, and/or bacteremia, and/or sepsis.
Fernando Moura et al. conducted a retrospective analysis of translumbar hemodialysis catheter in 22 patients in 2019. During the procedure, one patient had severe bleeding, and one patient had extubation failure. The average catheter functioning was 315.5 days (65 to 631 days) with only two cases of patency lost. They observed catheter-related infection in 41.6% of patients [6].
G.J. Nadolski et al. (2013) described 92 translumbar hemodialysis catheters in 33 patients (33 primary catheterization and 59 replacements) from 2002 to 2011. The technical success of the procedure was achived in 100% for both initial insertion and catheter exchanges. The most common causes for catheter replacement or removal (n=78) were catheter-associated infection (n=39; 50.0%), malposition (n=15; 19.2%), catheter malfunction secondary to occlusion (n=10; 12.8%), mature permanent vascular access (n=7; 9.0%) [7].
Albert Power et al. [8] monitored 26 patients with 39 episodes of translumbar catheter placement in the inferior vena cava for nine years. They reported preserved catheter function during the first year in 73% of cases. The majority of the complications were infectious (n=45; 115.4%) with 32 episodes of local infection and 13 episodes of catheter-associated bacteremia. Non-infectious complications (n=16; 41%) included 4 cases of the distal catheter end transposition and 10 cases of catheter thrombosis followed by replacement, as well as 2 cases of a retroperitoneal hematoma. Thus, even well-performed installation of the translumbar hemodialysis catheter in the inferior vena cava, as any long-term catheterization, has a high risk of catheter-associated infection.
Table presents the structure of complications during translumbar catheterization of the inferior vena cava according to different authors.
Before the introduction of the CT navigation into clinical practice, the X-ray phlebography was mandatory for the translumbar installation of the hemodialysis catheter in the inferior vena cava. According to Rajiv Biswal et al., the technical success of 10 procedures performed by the authors was 100% [9]. The only complication of the procedure was retroperitoneal bleeding from the inferior vena cava after catheter installation that required blood transfusion. The authors also described one episode of catheter thrombosis on the day of implantation. Thrombus was lysed by injection of 100,000 units of urokinase into each port. The catheter had been functioning for 580 days subsequently after that.
Conclusions
Translumbar percutaneous catheterization of the inferior vena cava in hemodialysis patients remains a kind of desperate operation when all other possibilities come to the end of a tether. However, this procedure is safe, easy to perform and less traumatic than extra-anatomical shunts. Also, translumbar percutaneous catheterization of the inferior vena cava does not require general anaesthesia, and the hemodialysis can be done the next day.
Authors' participation:
Conception and design: K.V. Mazayshvili
Analysis and interpretation: E.N. Nikolaev, A.A. Kabanov, D.S. Lobanov
Data collection: E.N. Nikolaev, A.A. Kabanov, D.S. Lobanov , K.V. Mazayshvili
Writing the article: E.N. Nikolaev
Critical revision of the article: K.V. Mazayshvili
Final approval of the article: K.V. Mazayshvili
Statistical analysis: E.N. Nikolaev
Obtained funding: no
Overall responsibility: K.V. Mazayshvili
The authors declare no conflict of interest.