ENDOVASCULAR MANAGEMENT OF IATROGENIC CENTRAL VEIN PERFORATION

Introduction:

Iatrogenic central vein perforation is a relatively rare but serious complication, with reported incidence ranging from 0.1% to 2.7%. An arteriovenous fistula is the gold standard for vascular access, but circumstances often require using a central venous catheter (CVC) in clinical practice. Although these CVCs offer prompt access to hemodialysis, they may be associated with various complications. We present two cases with iatrogenic central vein perforation.

Methods:

CASE 1

A 55-year-old woman with T2DM, HTN, and CKDVD was on a right internal jugular venous (IJV) hemodialysis (HD) catheter for 3 months. Because of the infection, the catheter was removed, and a left IJV HD catheter was inserted. One week after insertion, she developed worsening dyspnea and hypotension with dialysis. She was found to have left hydrothorax, which was bloody on aspiration. A possibility of CVC-induced perforation was suspected. Because of morbid conditions and the high risk of mortality, she was unwilling to undergo surgery. The right femoral catheter was inserted, and HD was done. Later, she was taken up for a venogram. A guiding catheter was passed through the right femoral catheter, and a venogram showed brachiocephalic vein perforation with thrombus and tip in the left pleural cavity. A 12x10mm balloon was passed over the wire up to the perforation site. The IJV catheter was removed, and simultaneously, the balloon was inflated and kept for 20 minutes. A check angio done later showed the absence of a leak (Figure 1). She was continued on maintenance HD with the resolution of the left hydrothorax. 

CASE 2

A 48-year-old man with CKDVD, Multiple myeloma, was evaluated for non-functioning right IJV tunneled central venous catheter (TCC). CT chest showed the catheter perforating the posterior wall of IJV in the upper part of the chest with a tip in the mediastinum. The perforated site was not accessible for manual compression. Because of co-morbid conditions, endovascular management was planned. Ultrasound guided right IJV puncture was done slightly above the previous catheter, and guidewire passed to the inferior vena cava. Check angiogram showed perforation high in the chest. A balloon (14x10mm) was passed over the wire and kept adjacent to the perforation site. The misplaced catheter was removed, and balloon dilation and tamponade were done for 20 minutes. Later, a new tunneled catheter was inserted from the same venotomy site. The patient was continued on MHD.

Results:

Conclusions:

Iatrogenic central vein perforation poses significant risks like hemorrhage and Infection. Early detection and timely intervention are critical to reduce morbidity and mortality. Surgical interventions were previously the only approach for their management. However, novel endovascular techniques can help in successfully managing these patients without much morbidity.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.