Successful hemodialysis catheter placement into a stenosed femoral vein using balloon dilation for central venous access

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Successful hemodialysis catheter placement into a stenosed femoral vein using balloon dilation for central venous access

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Co-author 1

Koichi Saiki k.saiki1996@gmail.com Takamatsu Red Cross Hospital Nephrology Takamatsu Japan *

Co-author 2

Haruka Ikegami m08035hk@jichi.ac.jp Takamatsu Red Cross HospitalTakamatsu Red Cross Hospital Nephrology Takamatsu Japan -

Co-author 3

Takuro Fujita fujita.t1979@gmail.com Takamatsu Red Cross Hospital Nephrology Takamatsu Japan -

Co-author 4

Tomoko Yokoyama tomokoyoko@hotmail.co.jp Takamatsu Red Cross Hospital Nephrology Takamatsu Japan -

Co-author 5

Yoshihiro Toyama toyama1712@gmail.com Takamatsu Red Cross Hospital Radiology Takamatsu Japan -

Co-author 6

Masahito Yamanaka ymasahito21@gmail.com Takamatsu Red Cross Hospital Urology Takamatsu Japan -

Co-author 7

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Co-author 10

Co-author 11

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Introduction

Vascular access must be secured for hemodialysis (HD). Repeated vascular access complications necessitate the use of a central venous catheter (CVC), but vascular stenosis makes even that difficult. Regarding superior vena cava stenosis, several case reports have described balloon dilatation; however, balloon dilatation for IVC (inferior vena cava) stenosis has been reported only rarely. This time, balloon dilation was performed for inferior vena cava stenosis following femoral CVC placement, enabling reinsertion of the CVC. We report on this procedure as well.

Methods

A 67-year-old woman has undergone hemodialysis for 20 years due to end-stage renal failure caused by IgA nephropathy. The arteriovenous fistula (AVF) and arteriovenous graft (AVG) were already occluded, and the patient was dependent on CVC dialysis. Due to vascular access troubles, CVCs have been replaced 13 times. The CVC in the right femoral vein was removed due to catheter-related infection. Vascular assessment was performed after CVC removal. Contrast-enhanced CT and intraoperative contrast revealed stenosis of the right external iliac vein and thrombus formation in the intrahepatic IVC. Both internal jugular veins and subclavian veins were already severely stenosed and unusable for catheter placement. The left femoral vein was severely narrowed, making puncture impossible, so we had no choice but to opt for reinsertion of the catheter via the right femoral vein. The indwelling catheter was a 14.5Fr, 42cm GlidePath (Bard Medical, Georgia, USA). Outer diameter was 4.8mm. The right external iliac vein was dilated using a Mustang 5.0 mm catheter (Boston Scientific, Marlborough, Massachusetts, USA). IVC showed diffuse stenosis, and the wire was advanced to the right atrium using a TEMPO 4 catheter (Cordis, California, USA).

The patient was transported to CT for confirmation, which confirmed that the pathway passed through the IVC. The entire IVC was dilated using a Mustang 7.0 mm. No obvious stenosis was observed, and the CVC was placed just before the right atrium under wire guidance. The patient has been able to continue dialysis without difficulty for one year postoperatively with good blood draw.

Results

Previous reports indicated that the purpose was to place a stent after balloon dilatation of the IVC, with a maximum balloon diameter of 12 mm being used. In this case, collateral circulation was also sufficiently developed. Considering the risk of vascular injury during balloon dilatation, it was determined that a diameter just large enough to accommodate the catheter's outer diameter would be sufficient. Transhepatic and translumbar catheters may also be considered, but based on past reports, they become obstructed within approximately two months and are limited to short-term use.

Conclusion

With an aging population and prolonged dialysis duration, the number of patients with CVCs in the femoral vein is expected to increase.

In cases of venous stenosis resulting from repeated CVC placement, balloon dilatation combined with CVC reinsertion may facilitate this procedure.

We submitted this paper to Radiology Case Reports.

Kewords