Department of Nephrology, Medical School Hannover, Hannover, Germany
Keywords: chest pain; complications; dialysis catheter; haemodialysis
Introduction
Frequent causes of acute chest pain in patients undergoing haemodialysis include acute myocardial infarction, pericarditis, pleuritis, air embolism, and gastro-oesophageal reflux. Rare causes due to complications after insertion of a central venous catheter, such as pneumothorax, haematothorax, and mediastinal haematoma, can be detected by chest X-ray. This case report illustrates a rare late complication that occurred 13 days after insertion of an internal jugular-vein catheter.
Case
A 62-year-old Caucasian male suffered from chronic renal insufficiency due to suspected cyclosporin toxicity following a liver transplantation performed 3 years previously. His past medical history was significant for liver cirrhosis and subsequent development of a hepatocellular carcinoma caused by a chronic hepatitis C infection. The current immunosuppressive regimen consisted of tacrolimus and steroids. The patient also suffered from arterial hypertension, insulin-dependent diabetes mellitus, psoriasis, prostate hyperplasia, and kidney stones.
He was admitted to the hospital for treatment of ascites and chronic renal failure. A central line was placed in the right internal jugular vein for monitoring of central venous pressure. Because conservative treatment failed to stabilize renal function, the patient was given a left internal jugular single-lumen catheter for temporary dialysis access. Dialysis treatment was initiated. A routine chest X-ray revealed the satisfactory position of the catheter (Figure 1). The patient then underwent six haemodialysis sessions without further problems. During the seventh dialysis session, a new native Cimino fistula was used for the arterial blood line and the jugular catheter was used for the venous blood line. Routine physical examination of the immobilized patient before haemodialysis revealed reduced nutritional status, generalized jaundice, ascites, and tachycardia. Blood pressure was 161/102 mmHg. Auscultation of the lung revealed a slight decrease of breathing sounds bilaterally.
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Comment
In haemodialysis units, chest radiographs are routinely performed after insertion of internal jugular catheters for venous access in order to verify correct catheter placement and to ensure that no procedural complications have occurred. However, a study by Farrell et al. [1], analysing the placement of 460 internal jugular dialysis catheters, showed that routine chest radiographs rarely contribute to the diagnosis of procedural complications and are of little value after internal jugular access placement, especially when clinical signs of complication are lacking. Perforation of the vessel can rarely be detected using chest X-ray [2]. Furthermore, a total of 19.6% clinical complications were reported, all of which occurred at the time of insertion. These complications consisted of carotid-artery puncture (7.6%) and local haematoma (12%) [1]. The case reported here illustrates a complication associated with an internal jugular-vein catheter insertion that was rare because of the late onset of the problem. Such a late onset complication has not previously been reported [3,4]. The symptoms were at first misleading, because the chest pain did not subside after discontinuation of the haemodialysis treatment. In addition, a routine chest radiograph failed to detect the perforation of the vessel wall.
We conclude that success of central venous line insertion and placement may be documented using a chest X-ray; however, a continual reappraisal of both function and location of the line is necessary, as has been reported for different catheter types [5]. The use of ultrasound-guided catheter insertion can significantly lower the rate of complications [68]. The rare delayed venous perforation observed here was probably related to the catheter stiffness, since dialysis catheters have been shown to be up to five times as stiff as central venous catheters [9]. It is unknown whether the use of steroids may have increased the risk of perforation of the venous wall in our patient, as was reported previously in a case report [10].
Teaching point
Complications from dialysis catheters can occur late after their insertion.
Routine X-ray after insertion of a temporary dialysis catheter may fail to detect perforation of the vessel.
Conscientious physical examination together with good clinical acumen and judgement in evaluating patients should guide clinical decisions.
Notes
Supported by an educational grant from
Correspondence and offprint requests to: Jan T. Kielstein MD, Department of Nephrology 6840, Medizinische Hochschule, Carl-Neuberg-Straße 1, D-30625 Hannover, Germany.
References