Abstract
Dear Editor,
The conversion from nontunneled to tunneled cuffed catheter (TCC) via the right internal jugular vein (IJ) without fluoroscopic assistance was concluded as “may be a safe” practice by Motta Elias et al (1) (Rosilene Motta Elias, MD, Sao Paulo, Brazil). It was also suggested that the ideal time to do this procedure is within less than 2 weeks of existing nontunneled catheter. As is known, well-implemented central venous catheter (CVC) has a vital role to manage the dialysis process in patients with complete renal failure. IJ cannulation comprises the first step in the majority of cases and the effectiveness of imaging modalities mostly including ultrasound (US) to provide an optimal IJ puncture was quested by previous studies (2). Increased success rates with real-time US guidance when compared by anatomical landmark technique were also reported (3, 4). However, limited studies were aimed to investigate the cost-effectiveness of fluoroscopically guided versus traditional placement of TCCs. Yevzlin et al declared that nonfluoroscopic technique as the preferred initial procedure has no disadvantages of complication rates when compared with fluoroscopic guidance technique; besides, decreased consumption rates can be achieved (5). In our institution, we prefer the fluoroscopy guidance when implementing CVC in complicated patients such as with the anamnesis of past thrombotic events or multiple catheterizations. We also utilize fluoroscopy while converting from nontunneled to TCC in cases unless if initial CVC (temporary) placement by a nephrologist was accomplished with adversities such as the necessity of multiple attempts or slightly hardened guide-wire advancement due to a potential stenosis. Despite our conservative approach, we experienced a catastrophic complication when performing the procedure without fluoroscopic assistance: In a 60 year-old female patient, arcus aorta perforation with 12.5F, 24 cm TCC occurred when converting from nontunneled to TCC via left JV. The left JV was preferred due to the established thrombosis in the right side. Initial CVC placement was performed by an interventional radiologist; the confirmation of the catheter location within the superior vena cava was achieved by a computed tomography (CT) examination with else indication (Fig. 1). Conversion for TCC was decided and performed by nephrologists within a 2-week period. In this procedure, after the construction of the subcutaneous tunnel, a 0.35 inch J-guidewire was advanced through the temporary CVC and the catheter was removed. TCC was advanced over the guidewire but a slight impediment was felt, and an 8F dilator was used to overcome the issue. Finally TCC was placed but the squirt of high-pressure arterial blood was observed from both spouts. The penetration of arcus aorta was revealed by control CT (Fig. 2). In the surgery room, the patient was monitored, the preparation for an urgent intervention was made and the catheter was withdrawn gently under the surveillance of the surgeon and the anesthesiologist. The patient was monitored in the ICU for the following 24 hours and no additional complication was observed. In our opinion, although the negligence of fluoroscopic guidance while initial placement of CVC or conversion to TCC may be tolerated especially when performing the procedure via right IJ (because of its short and straight route), the necessity of fluoroscopic assistance should be kept in mind even when simply converting the CVC to TCC in left-sided approaches.
CT confirmation of CVC location after initial placement. Coronal reformatted CT images demonstrated the CVC catheter in (A) left jugular vein and (B) superior vena cava (SVC). CVC location within central venous system can also be confirmed in axial and sagittal reformatted images. (C) CVC can be detected in SVC in axial plane and (D) in left brachiocephalic vein in sagittal reformatted images (white arrows). CT = computed tomography, CVC = central venous catheter.
CT demonstration of TCC located in arcus aorta. Noncontrast axial CT images revealed the TCC in the lumen of (A) arcus and (B) ascendant aortic segments (white arrows). The penetration of the aortic dome can be seen in (C) coronal reformatted images. CT = computed tomography, TCC = tunneled cuffed catheter.