Catheter fracture—an underrecognized and serious condition in haemodialysis

Albert H. Verhage and Eric F.H. van Bommel

Albert Schweitzer Hospital, Department of Internal Medicine, Location Amstelwijck, Dordrecht, The Netherlands

Keywords: catheter fracture; pulmonary infiltrate; subcutaneous blood leakage; Wegener's granulomatosis

Case report

Patients with systemic vasculitis may present with sometimes complex X-ray aspects of pulmonary involvement, due to the underlying disease and subsequent infectious complications. We describe here our difficulties with the interpretation of a series of chest X-rays in a 76-year-old patient with end-stage renal disease (ESRD) due to Wegener's granulomatosis (WG), who received chronic haemodialysis treatment in our centre since 1996. Initial vascular access at presentation with acute renal failure had been obtained by cannulation of the right femoral vein with a double-lumen dialysis catheter. Immunosuppressive treatment with corticosteroids and cyclophosphamide had resulted in impressive clinical improvement albeit with persistent renal failure.

Three weeks after presentation, a tunnelled double-lumen silicone dialysis catheter (Ulldal, 16 F, L 28 cm; Cook Incorporated, Bloomington, USA) was placed surgically in the right internal jugular vein. After 4 days, dialysis procedures were complicated by a diminished blood flow over the catheter. A chest X-ray was performed to check the catheter position, which showed that the tip of the catheter was just above the junction between the left and right brachiocephalic veins and in the right internal jugular vein. The catheter was repositioned surgically with the tip of the catheter now in the superior caval vein. Again, a dysfunctioning catheter was observed, now with difficulties withdrawing blood from the catheter. A repeat chest X-ray showed the tip of the catheter in the orifice of the caval vein in the right atrium. The catheter was repositioned again in a correct position by the surgeon.

Two months later the patient complained about right thoracic pain. No other pulmonary symptoms or signs were present. A chest X-ray suggested an ‘infiltrative’ lesion in the right lung top. There were no signs or symptoms of active WG. Indeed, dialysis frequency had been reduced to once a week because of improvement of his renal function. In addition, c-ANCA test at that time was negative. Other relevant laboratory results included= ESR 87 mm/h and white blood cell count 8.8x109/l with 81% granulocytes. Because of suspected bacterial origin of the lesion, the patient was treated with amoxicillin and clavulanic acid orally (625 mg three times daily). After 1 week of antibiotic treatment a contrast radiograph was performed of the jugular catheter because of persistent malfunctioning. Immediately after injection through the catheter, contrast extravasation was seen at the level of the kinking catheter (Figure 1Go). In addition, enhancement of the pre-existent ill-defined opacification of the right upper lung field was seen (Figure 2Go). The suspected infiltrative lesions in the right upper lung were, thus, the result of overprojection of blood in the subcutaneous tissue due to leakage through the fractured jugular catheter. Subsequently, the jugular catheter was removed and a new catheter was positioned using the same tunnel but with a new exit. When the removed catheter was explored carefully with coloured dye, leakage could be confirmed.



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Fig. 1. During contrast injection extravasation of blood was seen at the level of the kinking catheter.

 


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Fig. 2. Chest X-ray, performed immediately after contrast injection through the tunnelled jugular catheter, showing ill-defined opacification of the right lung field. Retrospectively, this opacification had probably been the result of leakage of blood (and contrast) in subcutaneous space suggesting an infiltrate in the right lung top.

 

Discussion

In this patient we had distinct problems with the interpretation of a series of chest X-rays. Radiologically, there was suspicion of a pulmonary infiltrate in the right lung top. The differential diagnosis included renewed activity of WG, banal bacterial infection or atypical pneumonia. We considered the patient to be severely immunocompromised as a result of 1-year immunosuppressive treatment with cyclophosphamide and prednisone and as a result of ESRD with chronic dialysis treatment. After ample consideration, we decided not to re-introduce immunosuppressive treatment but to start a trial of antibiotics. Eventually, the probable cause was revealed, i.e. blood extravasation in the subcutaneous tissue through a catheter fracture mimicking a pulmonary infiltrate.

In the present case, specific signs and symptoms of catheter malfunctioning were present. Dialysis procedures were complicated by a diminished blood flow, difficulties withdrawing blood from, and resistance to infusion of fluids through the catheter. In addition, a chest X-ray showed a fixed sharp angle of the catheter in the neck region. As such, it bares great similarity with the so-called ‘pinch-off’ syndrome [1]. This refers to the intermittent compression of a tunnelled subclavian vein catheter between the first rib and clavicle, leading to the same symptoms as described with radiographic signs of luminal narrowing in the shoulder. Although increasingly recognized, the ‘pinch-off’ syndrome is still an often misdiagnosed complication of tunnelled subclavian vein catheters [2–4]. In our case, causative factors may have been the repeated tearing and traction of the catheter during insertion and repositioning and the fixed sharp angle of the catheter. Importantly, it shows that the risk of developing a fracture in a tunnelled catheter is not restricted to the subclavian route (i.e. the classical ‘pinch-off syndrome’) but may occur also with a tunnelled jugular vein catheter.

Hazardous complications could have developed in this patient when we had decided to re-introduce immunosuppressive treatment or when the fracture had been complete, which carries the risk of embolization. Indeed, embolization of a distal catheter fragment through the heart or large vessels — sometimes with fatal outcome — has been reported [5–6].

Leakage of intravenous infusion of fluids or blood, usually in the subcutaneous tissue, has been described [7,8]. One patient is described with a Port-a-cath system and a painless subcutaneous swelling, fluoroscopy confirming leakage below the right clavicle [7]. Another patient complained 16 months after implantation of an infusion port about pain in his left clavicular region. This was found to be due to the leakage of infusion fluid resulting from partial fracture of the catheter at the level where the catheter passed between the first rib and clavicle [8].

It has been suggested that a chest X-ray (anterior–posterior and lateral view) should be examined routinely 3 weeks after catheter implantation to check for, or rule out, extravasation of fluid [9]. Some suggest immediate removal of the catheter when radiologic signs of ‘pinch-off’ is noticed, due to a significant risk of subsequent partial or complete fracture [10].

With the increasing use of tunnelled central venous catheters, this complication may become more prevalent. Therefore, recognition of the distinct risk of developing a catheter fracture as a result of prolonged catheter malfunctioning, especially in the case of evident (intermittent) compression or in the case of repeated tearing or traction of the catheter, may prevent hazardous complications like catheter embolization and, as illustrated in the present case, potential mistreatment.

Notes

Correspondence and offprint requests to: Dr A. H. Verhage, Albert Schweitzer Hospital, location Amstelwijck, Dept of Internal Medicine, Room D-200, PO Box 444, NL-3300 AK Dordrecht, The Netherlands. Back

References

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