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Patanè D, Morale W, Bonomo S, Failla G, Santonocito S, Camerano F, Arcerito F, Coniglio G, Calcara G, Malfa P, Stefano A. Complex central venous catheter for dialysis: interventional radiology experience in insertion and management of their complications. J Vasc Access 2024; 25:149-157. [PMID: 35674099 DOI: 10.1177/11297298221103209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND CVCs are defined 'complex' when they are inserted through non-conventional accesses or positioned in non-usual sites or substituted by IR endovascular procedures. We report our experience in using diagnostic and interventional radiology techniques for complex CVC insertion and management; we recommend some precautions and techniques that could lead to long-term availability of central venous access and to avoid non-conventional sites CVC insertion. METHODS We retrospectively evaluated 617 patients, between January 2010 and December 2019, (mean age 71 ± 13; male 448/617), treated in our department for insertion of tunnelled CVC for haemodialysis. RESULTS Among 617 patients, 241 cases (39%) are considered 'complex' because they required either a PTA with or without stenting to restore/maintain venous access or had an unusual positioning site or required unconventional access. A direct correlation between CT angiography and PTA (r = 0.95; p-value <0.001) and an inverse correlation between CT angiography and unconventional 'rescue' access (r = -0.92; p-value <0.001) were found. CONCLUSIONS Precise pre-operative planning of treatment in a multidisciplinary setting and diagnostic and interventional radiology procedures knowledge allows reducing complex catheterisms in haemodialysis patient.
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Affiliation(s)
- Domenico Patanè
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Walter Morale
- Department of Nephrology, Ospedale Maggiore, Modica, Via Aldo Moro, Italy
| | - Stefania Bonomo
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Giovanni Failla
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Serafino Santonocito
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Francesco Camerano
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Flavio Arcerito
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Giovanni Coniglio
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Giacomo Calcara
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Pierantonio Malfa
- Department of Diagnostic and Interventional Radiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Alessandro Stefano
- Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), Cefalù, Italy
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金 骊, 王 慧, 崔 天, 廖 若. [Catheter Replacement Methods in Hemodialysis Patients With Dysfunctional Tunneled-Cuffed Catheters With Fibrin Sheaths]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:1283-1287. [PMID: 38162080 PMCID: PMC10752794 DOI: 10.12182/20231160201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Indexed: 01/03/2024]
Abstract
Objective Tunneled-cuffed catheters (TCCs) are frequently used for establishing hemodialysis access for maintenance hemodialysis in older patients with exhausted resources of peripheral vessels. Fibrin sheath formation around the catheter is one of the most common complications of long-term use of indwelling catheter, which may cause the malfunction of the catheter. In this study, we intend to compare the prognosis of two catheter replacement methods, in situ replacement and replacement through a fibrin sheath crevice, with both being assisted by balloon dilation, and to explore the optimal catheter replacement process. Methods A retrospective study was conducted with 52 patients who underwent a replacement of their TCCs. Among them, 27 cases had their TCC replaced by the modified method of replacement through a fibrin sheath crevice and were referred to as the sheath crevice group, while 25 cases underwent in situ catheter replacement and were referred to as the in situ group. The primary outcome indicators included maximum blood flow in hemodialysis catheter and the urea clearance rate calculated by Kt/V values at the 1, 3, and 6-month follow-ups. The secondary outcomes included dialyzer alarms being set off and catheter-related infections during follow-up. Results There was no significant difference between the general data of the two groups. There was no massive blood loss during the replacement procedure. Neither were there cardiac tamponade, catheter-associated infections, or other complications. Follow-ups were made 1, 3, and 6 months after the replacement procedure. The sheath crevice group had higher catheter blood flow and Kt/V values at the 6-month follow-up than the in situ group did ([241.85±9.62] mL/min vs. [234.40±11.21] mL/min, P=0.014 and 1.31±0.55 vs. 1.27±0.49, P=0.005, respectively). During the follow-up process, access alarms were reported in 5 patients (three in the in situ group and two in the sheath crevice group) during dialysis. No catheter-associated infection occurred in either group. Conclusion The catheter replacement method of balloon dilation-assisted catheter insertion through a fibrin sheath crevice is safe and effective, resulting in better long-term catheter blood flow compared with that of in situ catheter replacement.
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Affiliation(s)
- 骊珠 金
- 四川大学华西医院 肾脏内科 (成都 610041)Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
- 成都市第三人民医院 肾脏内科 (成都 610014)Department of Nephrology, The Third People's Hospital of Chengdu, Chengdu 610014, China
| | - 慧 王
- 四川大学华西医院 肾脏内科 (成都 610041)Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 天蕾 崔
- 四川大学华西医院 肾脏内科 (成都 610041)Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 若西 廖
- 四川大学华西医院 肾脏内科 (成都 610041)Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
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Yoon SY, Jeon GS, Jung S. Image-guided placement of totally implanted vascular access device: retrospective analysis of the clinical outcomes and associated risk factors. BMJ Support Palliat Care 2021:bmjspcare-2021-002917. [PMID: 33927012 DOI: 10.1136/bmjspcare-2021-002917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/25/2021] [Accepted: 04/19/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine risk factors for catheter survival and complications after image-guided implantation of a totally implanted vascular access device (TIVAD). METHODS A total of 2883 TIVADs (2735 patients, 63.5±13 years old, 1060 men, 1675 women) implanted under guidance by ultrasound and fluoroscopy in our institution from January 2010 to December 2019 were evaluated retrospectively. We used the log rank test and logistic regression to analyse risk factors associated with catheter survival and complications. RESULTS Female patients (n=1778; 61.7%; mean catheter survival days: 780.6 days) and those with a haematological malignancy (n=277; 10.1%; mean catheter survival days: 1019 days) had significantly better catheter survival than male patients (n=1105; 38.3%; mean catheter survival days: 645.9 days) and those with a solid organ malignancy (n=2447; 89.5%; mean catheter survival days: 701 days) (p<0.001 and p=0.003). Patients with haematological malignancies and benign vascular inflammatory disease (n=11; 0.4%) were vulnerable to infection (n=96; 3.3%) (p<0.001 and p=0.004). Thrombotic malfunction (n=38; 1.3%) was significantly more common in females than males (p=0.005). Non-thrombotic malfunction (n=16; 0.6%) showed a significant association with left positioning of the TIVAD (n=410; 14.2%) (p=0.043). Wound dehiscence (n=3; 0.1%) was significantly more frequent in punctured veins other (n=23; 0.8%) than the internal jugular vein (p<0.001). CONCLUSIONS Increased attention should be paid to patients with an underlying haematological malignancy, underlying vascular inflammatory disease, female patients, older patients, those accessed via a vein other than the IJV, those with left positioning of the TIVAD system or those with a prolonged TIVAD maintenance.
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Affiliation(s)
- So Yeon Yoon
- Department of Radiology, Bundang CHA Medical Center, Seongnam, Gyeonggi-do, Korea (the Republic of)
| | - Gyeong Sik Jeon
- Department of Radiology, Bundang CHA Medical Center, Seongnam, Gyeonggi-do, Korea (the Republic of)
| | - Sanghoon Jung
- Department of Radiology, Bundang CHA Medical Center, Seongnam, Gyeonggi-do, Korea (the Republic of)
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Yu H, Xin Q, Wang X, Jia L, Wang J, Meng X, Li B, Wei F, Jiang A. Effects of different catheter replacement methods on catheter service time and complications in hemodialysis patients: A cohort study. J Vasc Access 2019; 21:497-503. [PMID: 31820667 DOI: 10.1177/1129729819891336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Central venous catheter insertion for long-term vascular access is not recommended in clinical practice. However, since arteriovenous fistula creation is difficult to perform in some patients, central venous catheter insertion for long-term vascular access is performed. This study aimed to assess the complications and service time of central venous catheters replaced using different methods and to determine the influencing factors of service time. METHODS Study design: A retrospective observational cohort study. Setting and participants: Patients who underwent tunneled dialysis catheter malfunction (2009-2019) and had to undergo another dialysis catheter insertion were enrolled. Exposures: Ectopic replacement and in situ replacement. Outcomes: Factors such as age, sex, primary patency rate, secondary patency rate, early complications, and late complications were considered. Analytical approach: This study used a Cox proportional hazards regression model. RESULTS The first and the newly replaced catheter service time were 37.779 ± 24.563 months and 32.468 ± 26.638 (25) months in the ectopic group and 37.075 ± 20.550 months and 26.349 ± 22.672 months in the in situ group, respectively. In the early service time, the newly replaced catheter resulted in significant bleeding from the tunnel. The first catheter had the least complications, most adequate blood flow, and longest service time. Ectopic catheter replacement and the tip shape of the catheter were the independent factors for catheter service time. Catheter service time increased with age. CONCLUSION Ectopic catheter replacement can improve the primary patency rate and auxiliary primary patency rate of catheters. Ectopic catheter replacement may require sufficient surgical skills with digital subtraction angiography, resulting in a better prognosis.
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Affiliation(s)
- Haibo Yu
- Kidney Disease and Blood Purification Treatment Department, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Qi Xin
- Department of Pathology, Third Central Hospital of Tianjin, Tianjin, China
| | - Xuewen Wang
- Department of Cardiology, Key Laboratory of Ion and Molecular Function of Cardiovascular Diseases and Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Lan Jia
- Kidney Disease and Blood Purification Treatment Department, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | | | - Xianhai Meng
- Infectious Diseases Department, Heping District Center for Disease Control and Prevention, Tianjin, China
| | - Bo Li
- Kidney Disease and Blood Purification Treatment Department, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Fang Wei
- Kidney Disease and Blood Purification Treatment Department, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Aili Jiang
- Kidney Disease and Blood Purification Treatment Department, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China
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Maldonado-Cárceles AB, García-Medina J, García-Alfonso JJ, Árense-Gonzalo JJ, Torres-Cantero AM. Patency rates of dysfunctional central hemodialysis venous catheter: Comparison between catheter exchange alone and catheter exchange with fibrin sheath angioplasty. Diagn Interv Imaging 2018; 100:157-162. [PMID: 30262173 DOI: 10.1016/j.diii.2018.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/10/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to compare patency rates and risk of obstruction of catheter exchange (CE) with that of CE with fibrin sheath angioplasty (CE+FSA) in dysfunctional tunneled central hemodialysis venous catheter (CHVC). MATERIALS AND METHODS A total of 107 consecutive patients with dysfunctional CHVC were retrospectively included. There were 66 men and 41 women with a mean age of 67.8±12.5 (SD) years (range: 23.0-86.0 years). Seventy-three of 107 patients (68.2%) underwent CE procedure and 34 of 107 (31.8%) underwent CE+FSA. Kaplan-Meier log-rank test and multivariate Cox regression analyses were performed to determine patency rates and risk of obstruction according to type of endovascular procedure. RESULTS Patency rates after endovascular procedures at 3, 6, 12, 24 and 36 months follow up were 75%, 75%, 65%, 65% and 65% in CE+FSA group and 70%, 65%, 62%, 30% and 0% in CE group. Mean time until obstruction of CHVC was 778.4 days after CE+FSA and 497 days after CE (P=0.211). Endovascular procedure was unrelated to risk of obstruction in adjusted model (HR=1.34; P=0.515). CONCLUSIONS Our findings suggest that both techniques are equivalent in terms of patency and safety results, so other aspects as cost assessment should be considered when choosing between both techniques.
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Affiliation(s)
- A B Maldonado-Cárceles
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, IMIB-Arrixaca, 30100 Espinardo, Murcia, Spain; Department of Preventive Medicine, General University Hospital "Reina Sofia", 30003 Murcia, Spain.
| | - J García-Medina
- Department of Vascular and Interventional Radiology, General University Hospital "Reina Sofia", 30003 Murcia, Spain
| | - J J García-Alfonso
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, IMIB-Arrixaca, 30100 Espinardo, Murcia, Spain
| | - J J Árense-Gonzalo
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, IMIB-Arrixaca, 30100 Espinardo, Murcia, Spain
| | - A M Torres-Cantero
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, IMIB-Arrixaca, 30100 Espinardo, Murcia, Spain; Department of Preventive Medicine, University Hospital "Virgen de la Arrixaca", 30120 El Palmar, Murcia, Spain
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Rambhia S, Janko M, Hacker RI. Laser Recanalization of Central Venous Occlusion to Salvage a Threatened Arteriovenous Fistula. Ann Vasc Surg 2018; 50:297.e1-297.e3. [DOI: 10.1016/j.avsg.2017.11.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/29/2017] [Accepted: 11/06/2017] [Indexed: 11/25/2022]
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Mogi N, Nakagawa M, Matsumae H, Hattori A, Shimohira M, Shibamoto Y. Fibrin sheath of a peripherally inserted central catheter undepicted with gray-scale (real-time B-mode) ultrasonography: A case report. Radiol Case Rep 2018; 13:537-541. [PMID: 29849853 PMCID: PMC5966624 DOI: 10.1016/j.radcr.2018.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/07/2018] [Indexed: 11/25/2022] Open
Abstract
An 11-year-old male was admitted to our hospital with the acute exacerbation of chronic heart failure. A peripherally inserted central catheter (PICC) was inserted from the left forearm. Ten days after its insertion, the withdrawal of PICC was attempted because of occlusion. However, it was not possible to remove PICC because a fibrin sheath had attached around its tip. A color Doppler and probe compression technique revealed the presence of a fibrin sheath, which could not be detected by gray-scale (real-time B-mode) ultrasonography. This case demonstrated that the color Doppler and probe compression technique is useful for detecting a fibrin sheath.
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Affiliation(s)
- Naoko Mogi
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Motoo Nakagawa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Hidekazu Matsumae
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences
| | - Ayako Hattori
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences
| | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Japan
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Lee KA, Ramaswamy RS. Intravascular access devices from an interventional radiology perspective: indications, implantation techniques, and optimizing patency. Transfusion 2018; 58 Suppl 1:549-557. [DOI: 10.1111/trf.14501] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Kristen A. Lee
- Dotter Interventional Institute, Oregon Health and Science University; Portland Oregon
| | - Raja S. Ramaswamy
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis; Missouri
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Abstract
Central venous catheters (CVCs) are essential in the management of hemodialysis patients, but they also carry unintended negative consequences and in particular thrombosis and infection, adversely affecting patient morbidity and mortality. This review will focus on the etiology, prevention, and management of CVC-related dysfunction, which is mainly associated with inadequate blood flow. CVC dysfunction is a major cause of inadequate depuration. Thrombus, intraluminal and extrinsic, as well as fibrous connective tissue sheath (traditionally indicated as fibrin sheath) formation play a central role in establishing CVC dysfunction. Thrombolysis with urokinase or recombinant tissue plasminogen activator (rTPA) can be undertaken in the dialysis unit, restoring adequate blood flow in most patients, preserving the existing catheter, and avoiding an interventional procedure. If thrombolytics fail, mainly because of the presence of fibrous connective tissue sheath, catheter exchange with fibrin sheath disruption may be successful and preserve the venous access site. Prevention of CVC dysfunction is important for containing costly pharmacologic and interventional treatments, which also affect patients’ quality of life. Prevention is based on the use of anticoagulant and/or thrombolytic CVC locks, which are only partially effective. Chronic oral anticoagulation with warfarin has also been proposed, but its use for this indication is controversial and its overall risk-benefit profile has not been clearly established.
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Self-Centering Split-Tip Catheter versus Conventional Split-Tip Catheter in Prevalent Hemodialysis Patients. J Vasc Access 2016; 17:233-8. [DOI: 10.5301/jva.5000529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2016] [Indexed: 11/20/2022] Open
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11
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Sonavane SK, Milner DM, Singh SP, Abdel Aal AK, Shahir KS, Chaturvedi A. Comprehensive Imaging Review of the Superior Vena Cava. Radiographics 2015; 35:1873-92. [DOI: 10.1148/rg.2015150056] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Calvagna GM, Ceresa F, Morgante A, Patanè S. Transvenous extraction of a left subclavian dialysis catheter: A new challenge in cardiology. Int J Cardiol 2015; 185:144-7. [PMID: 25795205 DOI: 10.1016/j.ijcard.2015.03.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 03/07/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Giuseppe Mario Calvagna
- Cardiologia Ospedale San Vincenzo-Taormina (Me), Azienda Sanitaria Provinciale di Messina, 98039 Taormina, Messina, Italy.
| | - Fabrizio Ceresa
- Cardiochirurgia Ospedale Papardo Messina, Azienda Ospedaliera Ospedali Riuniti Papardo Piemonte, 98158 Messina, Italy
| | - Alessandro Morgante
- Cardiochirurgia Ospedale Papardo Messina, Azienda Ospedaliera Ospedali Riuniti Papardo Piemonte, 98158 Messina, Italy
| | - Salvatore Patanè
- Cardiologia Ospedale San Vincenzo-Taormina (Me), Azienda Sanitaria Provinciale di Messina, 98039 Taormina, Messina, Italy
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Eleftheriadis T, Liakopoulos V, Antoniadi G, Pissas G, Leivaditis K, Stefanidis I. Late onset of clinically apparent central vein stenosis due to previous central venous catheter in a patient with inherited thrombophilia. Hemodial Int 2013; 18:540-3. [PMID: 24350639 DOI: 10.1111/hdi.12122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We describe a case of a patient with a functional kidney transplant who was admitted to our department with clinically evident central vein stenosis (CVS) 7 years after the removal of a central venous catheter (CVC) from the right internal jugular vein. The catheter was used as a hemodialysis access for a 2-month period. In the interval before his last admission, the patient suffered two episodes of deep vein thrombosis. Investigation revealed heterozygosity for factor V Leiden, the most common inherited thrombophilia encountered in 5% of Caucasians, and anticoagulation treatment was started. Magnetic resonance angiography showed stenosis just after the convergence of the right subclavian vein with the internal jugular vein to the innominate vein. Transluminal angioplasty restored venous patency and right upper arm edema resolved. Coexistence of CVS, accompanied by hemodynamic changes and endothelial dysfunction, with thrombophilia fulfill all the elements of the Virchow's triad. Therefore, the patient was at great risk for central vein thrombosis, from which he was possibly protected by the early administration of anticoagulant treatment. This case indicates that CVS can be asymptomatic for several years after CVC removal and also raises the question if thrombophilia workup and investigation for CVS may be beneficial in every patient with CVC placement in order to avoid any harmful outcomes.
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