Massive Hemothorax Secondary to Manipulation of a Kinked Dialysis Catheter

Abstract

INTRODUCTION: For central venous catheter (CVC) replacement, guide-wire exchange is associated with fewer mechanical complications compared to new-site replacement. We describe a case where guide-wire exchange was associated with a fatal outcome. CASE PRESENTATION: A 73 year-old male with congestive heart failure and chronic kidney disease was admitted to the Intensive Care Unit (ICU) for gram-positive bacteremia, oliguric renal failure, severe metabolic acidosis and lactic acidemia (10.2 mmol/l). He was intubated and mechanically ventilated for respiratory compromise. Intravenous heparin was started for a left ventricular thrombus found on echocardiogram. For dialysis initiation, a Niagara catheter was placed in the right internal jugular vein under ultrasound guidance. Post-insertion chest radiograph revealed a kinked distal lumen (Image 1). The kinked catheter was replaced using guide-wire exchange. Repeat imaging revealed the catheter tip in the cavo-atrial junction and interim development of a right pleural effusion (Image 2). Soon after, the patient deteriorated with hemodynamic instability. Hematocrit fell from 31% to 20%. Resuscitation was begun and heparin was discontinued. The replaced Niagara catheter had poor flow despite alteplase infusion. A CVC was then placed in the left internal jugular vein. It was noted that the right hemithorax was asymmetrically elevated. Needle decompression showed return of blood. Urgent tube thoracostomy drainage was performed with massive hemothorax evacuation. Chest radiograph confirmed placement of the left CVC and right chest tube, and demonstrated increased density in the right upper chest with subcutaneous emphysema along the chest wall. He remained hemodynamically unstable despite resuscitation. A thoracotomy was considered. Because of the patientaTMs underlying morbidity and poor prognosis, the family declined further intervention. The patient died shortly thereafter. Autopsy revealed that the Niagara catheter had punctured and exited the right brachiocephalic vein into the pleural space, resulting in massive hemothorax and hemorrhagic shock. DISCUSSION: It is unclear if the penetration into the pleural space occurred at the initial catheter insertion or during catheter replacement using guide-wire exchange. Regardless, guide-wire exchange for replacement of a kinked catheter might be avoided because of the potential for misplacement. That potential benefit must be balanced against the risk of catheter insertion complications associated with choosing a new insertion site. CONCLUSIONS: Manipulation of a kinked hemodialysis catheter can be life threatening and guide-wire exchange might be avoided in such circumstances.