Right-sided chest pain at the onset of haemodialysis

(Section Editor: K. Kühn)

Jan T. Kielstein, Faikah Abou-Rebyeh, Carsten Hafer, Hermann Haller and Danilo Fliser

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 1Go). 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.



View larger version (144K):
[in this window]
[in a new window]
 
Fig. 1. Chest X-ray after insertion of a single-lumen dialysis catheter in the left internal jugular vein, showing satisfactory position of the catheter.

 
The patient had no leg edema. At the start of the treatment the patient experienced a sudden onset of severe right-sided chest pain. Immediate physical examination revealed no changes. Because the patient had no sign of cardiovascular instability and sufficient oxygen saturation, as well as high serum potassium, dialysis was continued. To rule out pulmonary embolism and myocardial infarction, an electrocardiogram was performed and showed no signs of acute ischaemia or right ventricular dysfunction. A chest X-ray was performed, revealing a reduced transparency over the right lung that was consistent with fluid accumulation (Figure 2Go). Haemodialysis was discontinued because the patient became diaphoretic and hypotensive. Because of worsening respiratory distress, the patient was transferred to the intensive care unit. Endotracheal intubation was performed and a chest tube was placed through the right chest wall, which drained 1800 ml of fresh blood. After the bleeding had stopped, the patient was transferred to radiology for a thoracic CT in order to check for suspected vascular leaks. The scan showed a perforated brachiocephalic vein with a small extra-luminal extravasation. The patient was then transferred to vascular surgery for thoracotomy, and the perforation was covered with a patch. Several days later, the endotracheal and chest tubes were removed.



View larger version (125K):
[in this window]
[in a new window]
 
Fig. 2. Chest X-ray after the onset of chest pain (13 days after the insertion of the catheter) demonstrating a reduced transparency over the right lung, consistent with fluid accumulation.

 

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

Fresenius Medical Care

Correspondence and offprint requests to: Jan T. Kielstein MD, Department of Nephrology 6840, Medizinische Hochschule, Carl-Neuberg-Straße 1, D-30625 Hannover, Germany. Back

References

  1. Farrell J, Walshe J, Gellens M, Martin KJ. Complications associated with insertion of jugular venous catheters for hemodialysis: the value of postprocedural radiograph. Am J Kidney Dis1997; 30: 690–692[ISI][Medline]
  2. Modi KS, Gross D, Davidman M. The patient developing chest pain at the onset of haemodialysis sessions—it is not always angina pectoris. Nephrol Dial Transplant1999; 14: 221–223[Free Full Text]
  3. Quillen K, Magarace L, Flanagan J, Berkman EM. Vascular erosion caused by a double-lumen central venous catheter during therapeutic plasma exchange. Transfusion1995; 35: 510–512[ISI][Medline]
  4. Vanherweghem JL, Cabolet P. Dhaene M et al. Complications related to subclavian catheters for hemodialysis. Report and review. Am J Nephrol1986; 6: 339–345[ISI][Medline]
  5. Krasna IH, Krause T. Life-threatening fluid extravasation of central venous catheters. J Pediatr Surg1991; 26: 1346–1348[ISI][Medline]
  6. Lin BS, Huang TP, Tang GJ, Tarng DC, Kong CW. Ultrasound-guided cannulation of the internal jugular vein for dialysis vascular access in uremic patients. Nephron1998; 78: 423–428[ISI][Medline]
  7. Lin BS, Kong CW, Tarng DC, Huang TP, Tang GJ. Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: an ultrasonographic survey in uraemic patients. Nephrol Dial Transplant1998; 13: 134–138[Abstract]
  8. Nadig C, Leidig M, Schmiedeke T, Hoffken B. The use of ultrasound for the placement of dialysis catheters. Nephrol Dial Transplant1998; 13: 978–981[Abstract]
  9. Bersten AD, Williams DR, Phillips GD. Central venous catheter stiffness and its relation to vascular perforation. Anaesth Intensive Care1988; 16: 342–351[ISI][Medline]
  10. McIk PS, Pelage J, Boyer J, Legendre C, Lacombe M, Moreau J. Vascular rupture complicating transluminal angioplasty applied on a failed dialysis vascular access in a patient under chronic steroid therapy. Eur Radiol1997; 7: 313–315[ISI][Medline]