Case presentation
An 87-year-old woman was transported to our institute for evaluation and treatment of an acute disturbance of consciousness and right hemiplegia. Her medical history was notable for chronic renal failure due to diabetic nephropathy that required regular hemodialysis (HD). Upon admission, she was diagnosed with cerebral infarction by computed tomography (CT) and magnetic resonance image (MRI) that was treated via a thrombectomy. Given her clinical condition, we were concerned that conventional HD would be associated with a high risk of disequilibrium syndrome; as such, CRRT was recommended. An initial effort was made to obtain central access via insertion of a triple-lumen catheter into the right internal jugular vein; this effort failed due to accidental arterial puncture.
On day 2, we inserted a triple-lumen catheter (Gentle Cath™® COVIDIEN) via the left internal jugular vein under fluoroscopic guidance (Fig. 1). The catheter advanced easily and was secured with sutures. Appropriate positioning of the tip was confirmed via blood withdrawal/regurgitation and saline flushes through all three of the catheter lumens. After initiation of CRRT, a chest radiograph taken on day 3 revealed an enlarged mediastinum; at that time, vital signs remained within normal limits. CT was performed on day 6; this examination revealed mediastinitis which suggested the possibility of a vascular injury associated with catheter insertion (Fig. 2). However, we were able to continue with CRRT without issues or difficulty. Trans-catheter angiography performed on day 7 revealed extravasation of the contrast media from the proximal lumen, a finding that was consistent with vascular injury (Fig. 3); as such, an emergency thoracotomy was performed. During the procedure, we determined that the infusion port of the catheter had penetrated one wall of superior vena cava (SVC); both drainage and return ports remained inside vessel (Fig. 4). The catheter was removed and the site of perforation was sutured. Her postoperative course was uneventful, and she was transferred to a rehabilitation hospital on 20 day after surgery.