Successful prolonged use of an intracardiac catheter for dialysis

Olivier Chavanon1, Jocelyne Maurizi-Balzan2, Nicolas Chavanis1, Bertrand Morel2 and Dominique Blin1

1 Department of Cardiac Surgery, and 2 Nephrology, Grenoble University Hospital, Grenoble, France

Correspondence and offprint requests to: Dr Olivier Chavanon, Service de Chirurgie Cardiaque, CHU Grenoble, BP 217 Grenoble cedex 9, France.

Keywords: catheter; dialysis; intracardiac



   Introduction
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Vascular access for dialysis in complicated cases may be so difficult that a novel approach may be required. We report such a case of a patient with a progressive lack of central venous access.



   Case
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 Case
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A 43-year-old patient, treated with haemodialysis since the age of 36 for chronic renal failure due to diabetes mellitus, and with a history of uraemic pericarditis for the past 3 years was followed because of progressive constrictive pericarditis. He had recurrent infection of the permanent vascular catheters due to Staphycoccus aureus chronic cutaneous infection. Staphylococcus aureus and Escherichia coli bacteriaemia frequently occurred with thrombosis of the catheters (Table 1Go). Each episode was treated by local and systemic antibiotherapy. The patient was hospitalized to undergo pericardectomy with simultaneous insertion of two Canaud catheters into the right atrium by sternotomy because of the total lack of venous access for dialysis (February, 1996). The superior vena cava was thrombosed and the left iliac vein access was preserved to allow for a kidney transplantation. Four months later, it was necessary to remove the Canaud catheter because of a staphylococcus infection. Dialysis was temporarily performed through a right femoral catheter which then had to be removed because of an extensive external iliac venous thrombosis. Inserting a new intra-cardiac catheter was the only alternative. After a subxiphoidal approach and a careful dissection of the right atrium, the catheter was inserted through an atrial purse-string, then fixed and tunnelled. The catheter blood flow was insufficient during dialysis, it was consequently replaced by a dual-lumen cuff catheter, through a right mini-thoracotomy. This catheter was ruptured (fatigue fracture), and had to be replaced. We inserted the new one using a guidewire inside the former. In the meantime dialysis was carried out through a left femoral access (first Shaldon, then Canaud catheter). Fifteen days later a catheter-related bacteriaemia was treated and led to removal of the catheter. The patient was dialysed through the left femoral access until the kidney transplantation which was carried out on October 4, 1998.


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Table 1. Chronology of vascular access
 


   Comments
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Increasingly difficult vascular access for dialysis poses serious therapeutic problems. The quality of vascular access is related to the increasing age and prevalence of dialysed patients who are often poor candidates for arteriovenous fistula because of cardiovascular comorbidity. Giorcelli reports that in 4 out of 1037 operations, it was impossible to obtain vascular access in the upper limbs [1]. Common alternatives to arteriovenous fistula are peritoneal dialysis or central venous catheter. The latter is affected by many complications [24], including thrombosis and infection which remain frequent and serious, even when the catheter is tunnelled. Salvaging can be attempted with either intraluminal antibiotic and intensive antibiotic therapy, since leaving the catheter in place does not increase the risk of complications [5]. In our patient, those alternatives were ruled out, because of extensive thrombosis of the major central venous vessels and adhesion of the peritoneum. Placement of an intra-cardiac catheter is easy to perform through various approaches (thoracotomy, subxiphoid) depending on the thorax morphology. As far as we know, this technique has never been reported. Furthermore, placement of the catheter tip in the right cardiac cavities provides optimal haemodynamic conditions during dialysis [6]. In our patient, the high risk of catheter infection could lead to endocarditis. Frequent echocardiographic evaluation is thus mandatory, and the catheter may be removed according to the patient's clinical status. Infection usually reduces the use of central venous catheter for short-term dialysis [7]; in this case the intra-cardiac catheter allowed to overcome dialysis-related problems every time, and to save time until kidney transplantation.



   Acknowledgments
 
We wish to thank Dr Pierre-Emmanuel Colle for revision of the manuscript.



   References
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Received for publication: 16. 4.99
Accepted in revised form: 20. 4.99