Removal of Dialysis Catheter from the Mediastinum with Sequential Stenting of the Left Brachiocephalic Vein

Purpose: To present a case of a removal of a dialysis catheter from the mediastinum and sequential stenting of the left brachiocephalic vein to prevent further extravasation

Materials and Methods: An 88-year-old female patient with a past medical history of diabetes mellitus type 2, coronary artery disease, and end-stage renal disease on hemodialysis was referred from the US Virgin Islands because of incorrect placement of a dialysis catheter in the region of the left subclavian vein after failure of the patient’s fistula. There was concern that the catheter was actually in the subclavian artery, and the facility lacked appropriate resources in case of emergent arterial bleed. Further imaging at our facility proved the catheter was in the anterior mediastinum and appeared to pierce through the left brachiocephalic vein.

Results: The patient had a temporary right common femoral dialysis catheter previously placed, which was removed over a wire, and a combination of glide wire and catheter were advanced through the access into the left axillary vein. Central venogram was performed with no active extravasation visualized. With the wire in place, the malpositioned left tunnel dialysis catheter was removed. Repeat central venogram was obtained showing active extravasation at the level of the left brachiocephalic vein. Balloon tamponade was immediately performed using 10-mm balloon, which did not resolve extravasation. Thereafter, a 10- ´ 40-mm Fluency covered stent was deployed across the left brachiocephalic vein. Hemostasis was achieved, and a tunneled right dialysis catheter was placed for further dialysis.

Conclusions: Multiple complications can be associated with the placement of dialysis catheters, including malposition, extravasation, and arterial access. It is important to ensure proper venous access using ultrasound and fluoroscopy during the procedure. If improper placement is suspected, it is important to further characterize with further imaging and determine the vascular structures involved. When removing these catheters, it is important to have vascular access at another location to treat complications such as extravasation and vascular injury.