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.