Mayo Clinic, 1 Department of Internal Medicine and 2 Division of Nephrology, Rochester, MN, USA
Keywords: ash-split cuffed; double-lumen catheter; bacteraemia; haemodialysis
An 83-year-old male with end-stage renal disease fell while climbing a flight of stairs and hit a doorknob with his right upper chest wall. He had a 28-cm ash-split cuffed, double-lumen, tunnelled venous catheter in his right internal jugular vein for chronic haemodialysis (HD), with the access end taped to his right upper chest wall. Two days after the blunt trauma, the area superior to the HD catheter insertion site was swollen, with a mass and ecchymosis in the right supraclavicular region. The patient was afebrile and had stable vital signs. An angiogram (Figure 1) showed a small leak in the venous port, near the apex of the curve of the catheter in the low neck. Over a guide wire, the fractured ash-split catheter was replaced with a new 14F 28-cm ash-split catheter with no complications.
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This case represents an unusual complication of HD catheters, fracture as a result of blunt trauma with secondary bacteraemia. Several cases of spontaneous leak and transection of permanent subclavian catheters have been reported [1,2]. In a study from Israel [1], 4.2% (12 of 268) patients were identified with a partial tear or transection of subcutaneous port venous catheters being used to deliver chemotherapy at the site where the catheter passed over the first rib. The pinch-off sign, a narrowing of the catheter on the chest X-ray as the catheter passes over the first rib and beneath the clavicle was seen in five of 12 patients. It is believed that the problem is due to insertion of the catheter in a medial location, in the clavicular first rib window, which narrows when the patient is upright, causing the catheter to pinch off. Catheter fracture has an overall prevalence from 0.1 to 1% in various studies [3]. Immediate removal of the catheter has been suggested when radiologic signs of pinch-off are noticed, given the risk of subsequent complete or partial fracture. Prior to the use of the site, chest radiography should be performed, and even the slightest irregularity in the catheter should prompt further investigation before the catheter is used. Prophylactic antibiotic therapy following replacement of a catheter might be advisable, especially if the fracture site is in close proximity to the catheter insertion site.
Notes
Correspondence and offprint requests to: K. L. Venkatachalam, Mayo Clinic, Department of Internal Medicine, Rochester, Minnesota, USA. Email: venkat.kl{at}mayo.edu
References