Title: A Rare Complication of Catheter Insertion. Hemodialysis catheter insertion causing hemopericardium
Author(s): Marlena Lesniowska, MD; Timothy Barreiro, DO; Stanley Ozogbo, MD
Email: MLesniowska@mercy.com
Introduction: Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. This is a case of an 80-year-old female that developed hemopericardium form perforation of hemodialysis catheter.
Case Report: An 80-year-old female with a past medical history of AAA s/p endograft repair, chronic atrial fibrillation on Eliquis, HFrEF (EF 45-50%), chronic hypercapnic and hypoxic respiratory failure from COPD on supplemental oxygen, diabetes, CKD with a baseline Cr of 2.5 mg/dL, hypertension, was transferred from Select (LTAC) Hospital after cardiac arrest. The patient was in the long-term care hospital after a protracted complicated hospital course which started with respiratory failure from Covid pneumonia complicated by a left pneumothorax requiring chest tube, ventilator-associated pneumonia, from Pseudomonas. She also developed ATN from shock leading to worsening renal function requiring the initiation of hemodialysis. A temporary HD catheter was placed. (where) Bleeding around her hemodialysis catheter resulted in transfusion requirements of three units. Due to failure to liberate form the ventilator she underwent tracheostomy and PEG tube placement. She was then discharged to LTAC after a new tunneled hemodialysis catheter was placed by IR three days prior. Her Eliquis was resume for her atrial fibrillation. Chest radiograph reported central venous catheter with tip in the left atrium.
A code blue was called when the patient was found to be unresponsive with the cardiac analysis of PEA arrest and asystole. She had return to spontaneous circulation after 30 minutes of ACLS. Femoral access only was placed during the code. She was transferred to St. Elizabeth medical intensive care. She required vasopressors to maintain vital signs. CTA pulmonary with contrast that showed a moderately sized pericardial effusion including dense contrast in the lower pericardial space posteriorly. (Image 1, 2 & 3) The findings were consistent with an acute hemorrhagic effusion related to active hemorrhage near the junction of the right atrium and inferior vena cava. She continued to deteriorate. Cardiothoracic assessment and pericardiocentesis was requested but after arrival of her family, the decision was made for terminal support and expired.
Discussion: Cardiac perforations associated with a THC remain a very rare (incidence from 0.0001% to 1.4%) but life-threatening complication with reported mortality ranging from 65% to 100%, mostly occurring during or early after catheter implantation.[1] The acute periprocedural complications that occur during HDC placement include arterial punctures, venous laceration, bleeding, hematoma (hemothorax, hemopericardium, hemomediastinum), pneumothorax, pneumopericardium, cardiac arrhythmias, and air embolisms. Risk factors for perforation include trauma during insertion and contact-induced chemical erosion leading to injury of the myocardial wall over time [1]. Catheter-type, line top position and angle, anatomic variations as well as prolonged use may be other associated factors [1]. The right atrium, right ventricle, and SVC are the most common perforation sites, with incidence rates of 43%, 27%, and 4%, respectively. [2]
Despite the efforts to decrease its use, HDC remains the main dialysis vascular access utilized in the ESRD population. These catheters are associated with significant morbidity and mortality related to their mechanical and infectious complications. These complications are responsible for high economic burden encountered in this sick population.
