Fatal outcome of haemodialysis catheter malposition into the hepatic vein causing Budd-Chiari Syndrome

Dear Editor,

Malposition of tunnelled central venous catheters (CVCs) is a recognized complication and often needs repositioning or replacement. We report a fatal case of malpositioning of the CVC catheter into the hepatic vein resulting in Budd-Chiari syndrome (BCS).

A 30-year-old female with history of end-stage renal failure (ESRF) secondary to long-standing type 1 diabetes mellitus had a tunnelled CVC (HemoStar, Bard, New Jersey, USA) insertion for haemodialysis through the right internal jugular vein (IJV) with its tip in the right atrium. After 4 months of the insertion of the right CVC, she had a negative CT pulmonary angiogram to investigate her pleuritic chest pain, which also showed that the tip of the right CVC had migrated just below the right atrium (Fig. 1). No action was taken at this point to retrieve the CVC tip within the right atrium. The patient continued on haemodialysis for 8 months after the insertion without any problem. She then presented in the emergency department (ED) with 3-day history of worsening right upper quadrant pain, abdominal distension, malaise and confusion associated with deranged liver function. A CT scan demonstrated BCS features secondary to malposition of the tip of the CVC into the middle hepatic vein associated with thrombus within the hepatic veins and the inferior vena cava (IVC) (Fig. 2). This rapidly progressed into hepatic encephalopathy and liver failure resulting in death of the patient.

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Fig. 1

Maximum intensity projection (MIP) of coronal CT scan done 4 months after the insertion of the right internal jugular vein (IJV) haemodialysis catheter shows the tip below the right atrium, in the inferior vena cava (IVC) (arrow).

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Fig. 2

Maximum intensity projection (MIP) of coronal CT scan done after 8 months of insertion of right internal jugular vein (IJV) haemodialysis catheter showing the migration of the tip of the haemodialysis catheter into the hepatic vein (arrow) with large volume of ascites (star).

BCS is characterized by venous outflow obstruction that can be at the level of hepatic venules, hepatic veins, the IVC or at the right atrium (1). The treatment of BCS is based on its cause, consisting of anticoagulation therapy, thrombolytic therapy in conjunction with interventional radiological procedures such as venoplasty, stenting or transjugular intrahepatic portosystemic shunts. Surgical options include decompression, surgical shunts and liver transplantation if the liver is irreparably damaged.

Patients with ESRF have increased risk for thromboembolic episodes due to increased levels of fibrinogen that directly contribute to a hypercoagulable state (2). Our patient was a case of ESRF undergoing haemodialysis for the last 3 years.

The cuffed tunnelled catheters are made of silicon or polyurethane material. These materials reduce thrombogenicity and endothelial damage (3). It should be inserted under fluoroscopic guidance with its tip within the right atrium to prevent recirculation and catheter migration associated with postural change (4). In our patient, the initial placement of the catheter tip was in the right atrium. However, the fluoroscopic image was obtained in supine position and during inspiration. This may have given false assurance to the operator about the tip of the CVC in the right atrium. CVC migration or dislocation occurs due to change in intrathoracic pressure during deep breathing, cough, change in central venous pressure and formation of fibrin sheath around the tip. The incidence of migration can be minimized by placing the line in atriocaval position, which is most accurately located approximately two vertebral body units below the carina (5). Meticulous planning and creation of a smooth arc in the tunnel avoid kinks and migration, thereby reducing complications.

In conclusion, malposition of a CVC into the hepatic vein should be corrected to avoid complications.