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Case Reports
Intracardiac access for hemodialysis: A case series Siddhartha AGRAWAL, James Richard ALALY, Madhukar MISRA Division of Nephrology, University of Missouri, Columbia, Missouri, USA
Key words: Hemodialysis, catheter, intracardiac, intra-atrial
INTRODUCTION Maintenance of functioning vascular access has long been recognized as the Achilles heel of a patient undergoing hemodialysis (HD). A subset of patients on HD for endstage renal disease (ESRD) may progressively exhaust all forms of traditional vascular access. In these patients, exploration of nontraditional HD access sites becomes imperative and life saving. Although various nontraditional approaches exist to obtain emergent vascular access, the benefits of direct intracardiac catheters over others include the ability to use standard cuffed catheters, and the ability to function despite thrombosis or stenosis of the central venous system and vena cava. Since 2003, 3 patients with ESRD at our institution exhausted their traditional dialysis vascular access options. All 3 were not suitable candidates for peritoneal dialysis. Emergent and successful implantation of right atrial dialysis catheters was achieved in all patients, providing functioning HD access in a desperate situation.
CASE REPORTS Case 1 The first patient was a 65-year-old African American woman with ESRD secondary to diabetes mellitus type 2 on maintenance HD for 7 years. The patient had a long history of noncompliance on dialysis and was deemed unfit for kidney transplantation. She was also not a candidate for peritoneal dialysis due to dementia, patient’s Correspondence to: M. Misra, MD, FRCP, Division of Nephrology, University of Missouri, One Hospital Drive, Room CE422, Columbia, MO 65212, USA. E-mail:
[email protected]
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preference for HD, and lack of family support. The patient had a long history of difficult dialysis access with repeated failure of both arteriovenous fistulas and tunneled dialysis catheters. Management had been further complicated by noncompliance with dialysis, use of dialysis access to administer illicit drugs, and multiple self removals of tunneled dialysis catheters. Since 2003, attempts at obtaining permanent venous access had included 1 left upper extremity fistula-lost to subclavian thrombus and fistula infection, 3 subclavian tunneled dialysis catheters, 1 internal jugular tunneled dialysis catheter, 1 external jugular tunneled dialysis catheter, 12 femoral tunneled dialysis catheters, and 2 femoral Tessio catheters. The patient also had a nonfunctional right upper extremity fistula that had failed before the above interventions. Imaging studies, including ultrasound and venograms performed between 2003 and 2008, had showed gradual progressive occlusion of her venous system, with occlusion of bilateral subclavian, internal jugular, and iliac veins besides the superior and inferior vena cavae. These occlusions had progressed despite long-term Coumadin therapy. The patient was admitted in October 2008 after she pulled out her left femoral-tunneled dialysis catheter. Her last dialysis session had been 2 days before admission. Over the next 5 days, multiple attempts to place temporary noncuffed dialysis catheters failed. Venograms confirmed occlusion of all major draining veins and the occlusion of superior and inferior vena cava with multiple superficial collaterals (Figures 1 and 2). Because the patient was developing uremic symptoms along with severe hyperkalemia, the decision was made to urgently place an intracardiac dialysis catheter directly into the right atrium by cardio-thoracic surgery. The patient was placed under general anesthesia and an inframammary incision was made in the fifth intercostal
r 2009 The Authors. Journal compilation r 2009 International Society for Hemodialysis DOI:10.1111/j.1542-4758.2009.00415.x
Intracardiac access for hemodialysis
Figure 1 Angiogram of the right upper extremity showing thrombosis of the right subclavian vein, internal jugular veins, and superior vena cava along with multiple collaterals.
space and the right pleural space was entered by performing anterior thoractomy. The lung tissue was retracted gently and the pericardium was exposed laterally. The right atrium was identified and the pericardium was incised, opened, and a purse-string suture was made at the right atrium. Through a separate stab incision, a 14.5 F 23 cm Opti-Flow dual lumen catheter (Bard Access Systems Inc., Salt Lake City, UT, USA) was tunneled through the skin and into the right atrium using the dilator guide wire technique via the purse string suture. The purse string was then tied down and with the catheter firmly in place, a second purse string suture was tied down superficially and circumferentially to ensure more stability. Good hemostasis was achieved in the right atrium around the catheter. Additional stitches were used to secure the catheter in the right chest. The right chest was then drained with a number 28 F chest tube. Postprocedure radiographs confirmed the tip of the dialysis catheter into the right atrium (Figure 3). The patient was dialyzed through the catheter immediately after surgery, achieving blood flows of 400 mL/min. She was subsequently dialyzed 4 more times during her recovery and then discharged. She continued to maintain blood flows of 400 mL/min on outpatient HD.
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Two months after discharge, she was admitted for a history of multiple falls and weakness. While undergoing maintenance inpatient HD, it was noted that flow rates through the intracardiac catheter were suboptimal. Angiographic evaluation of the catheter by injection of contrast by interventional radiology showed no obstruction or abnormal resistance, and it was determined that the obstruction was positional. After the patient was repositioned, dialysis proceeded without difficulty without any surgery or manipulation of the catheter. However, her hospital course was prolonged by an episode of seizures. During this prolonged hospital course, she also grew 2/2 blood cultures positive for coagulase-negative staphylococcus. The patient was started on a 6-week course of vancomycin while on outpatient dialysis. The patient continued to dialyze through the intracardiac catheter without further incidents through April 2009, a total of 7 months, before succumbing to septic complications unrelated to the catheter.
Case 2 The second patient was a 41-year-old African American male with a history of ESRD on HD since age 10. Three
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Figure 2 Angiogram of the inferior vena cava showing thrombosis along with collaterals.
previous kidney transplants between 1977 and 1991 had failed. After a period on HD complicated by access-related difficulties, including multiple failed grafts and permanent catheters, he had to be switched to peritoneal dialysis. However, the patient experienced multiple episodes of peritonitis over time, with resulting loss of ultrafiltration.
The patient initially presented to our institution in July 2002 with active bleeding from a right upper extremity arteriovenous fistula, after having recently moved to the area. At that time he also had a peritoneal dialysis catheter in situ that had been placed at an outside institution, but it had never functioned properly owing to prior peritoneal sclerosis. Records of the imaging studies performed in his previous hometown showed a complete occlusion of bilateral internal jugular, subclavian, and femoral veins, besides the inferior vena cava. The fistula was determined to be infected and thrombosed and was removed by vascular surgery. The nonfunctional peritoneal dialysis catheter was also removed, leaving the patient with no access. Temporary HD catheters placed during his hospitalization functioned briefly before failing repeatedly. As the patient began developing uremic symptoms and hyperkalemia, nontraditional access methods were considered. The patient underwent urgent right thoracotomy with placement of an intracardiac LifeSites (Vasca Inc., Tewksbury, MA, USA) dialysis catheter directly into the right atrium. He was successfully dialyzed and discharged after recovery. The patient continued to receive dialysis through this catheter for the next 4 years, during which he had multiple admissions for both methicillin-sensitive Staphloccus aureus (MSSA) and methicillin-resistant Staphloccus aureus (MRSA) line infections and recurrent abscess development and swelling around the port site. He was evaluated for transplant but was determined to be moderate-high risk secondary to an ejection fraction of 20% and very high panel reactive antibodies from prior transplants. In February 2006, the patient was admitted for obstruction of the LifeSites dialysis catheter. Angiogram showed a
Figure 3 Chest X-ray (A) PA and (B) lateral view showing the position of the tip of the catheter into the right atrium.
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fibrin sheath surrounding the catheter, which could not be disrupted. The patient underwent repeat right thoracotomy with placement of a 14.5 F 35 cm Opti-Flow dual lumen catheter (Bard Access Systems Inc.) directly into the right atrium, the technique being similar to that described previously. The LifeSites was scarred in and was left in place to avoid unnecessary tissue damage. However, 3 months later, it became infected with blood cultures growing MRSA, necessitating repeat thoracotomy and removal of LifeSites. The tunneled intracardiac catheter continued to be used, achieving blood flows of 350 to 400 mL/min. In October 2006, the patient had Staphylococcus epidermidis bacteremia, which was successfully treated with intravenous (IV) vancomycin. In March 2007, the patient’s tunneled intracardiac dialysis catheter fell out on its own twice. On both occasions, it was replaced over a guidewire by interventional radiology. In August 2007, it required yet another replacement due to malfunction, this time by cardiothoracic surgery via anterior thoracotomy. However, poor blood flows on HD prompted another replacement in 1 month, which was achieved over a guidewire. In December 2007, another bout of bacteremia due to streptococcus pneumoniae was successfully treated with outpatient vancomycin. In March 2008, the patient required further repositioning of the intradialysis catheter with advancement of the tip into the right atrium under fluoroscopic guidance. The catheter was used again without any complications. In June 2008, the patient was admitted with severe diarrhea and was found to be positive for Clostridium difficile. Subsequently, he developed pneumatosis intestinalis and small bowel obstruction, and underwent exploratory laparotomy twice, but unfortunately expired from septic shock. The use of an intracardiac dialysis catheter prolonged survival for approximately 25 months in this patient.
Case 3 The third patient was a 42-year-old white female, with ESRD secondary to systemic lupus erythematosus who had been on maintenance HD for 10 years. She was no longer a candidate for peritoneal dialysis secondary to recurrent peritonitis. The patient had a history of difficult vascular access secondary to recurrent thrombosis due to the antiphospholipid antibody syndrome. Her previously failed accesses included both upper and lower extremity arteriovenous fistulae and multiple tunneled dialysis catheters.
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In June 2003, the patient presented with obstruction of her right internal jugular tunneled dialysis catheter. Attempts at replacing the catheter over a wire failed due to superior vena cava thrombus, and attempts at placement of a new temporary catheter failed as the guidewires could not be advanced downstream into the vein. Ultrasonography and venogram were performed, which revealed occlusion of the bilateral internal jugular, subclavian, and common femoral veins, besides an incomplete obstruction of the inferior vena cava. At this point, the patient had been without dialysis for several days and was developing hyperkalemia with EKG changes despite medical therapy. The decision was made to pursue nontraditional access, and a right anterior thoracotomy was performed by cardiothoracic surgery in a similar fashion as described above, with placement of a 14.5 F 23 cm Opti-Flow dual lumen catheter (Bard Access Systems Inc.) intracardiac dialysis catheter. Dialysis was successfully performed immediately after the surgery. The patient consistently achieved blood flows of 350 to 400 mL/min on dialysis. She continued to receive dialysis through the intracardiac catheter until receiving live unrelated renal transplant 15 months later.
DISCUSSION Vascular access is the lifeline for ESRD patients on HD. Nephrologists are going to increasingly encounter HD patients with progressive failure of vascular access. In patients who have exhausted conventional vascular access options, and who are not candidates for peritoneal dialysis, the use of nontraditional dialysis access sites for intravascular catheters is the only option while awaiting renal transplantation. Types of nontraditional access are numerous and varied. These include supradiaphragmatic approaches such as cannulation of the innominate vein, surgically entering the SVC (Superior Vena Cava),1 or cannulating the small thoracic or neck collaterals.2 Infradiaphragmatic approaches include cannulation of the hepatic vein via the transhepatic route,3 azygos vein via the percutaneous translumbar route,4,5 the renal vein via the percutaneous transrenal route,6 the aorta via the femoral artery,7 and surgical cannulation of the IVC (Inferior Vena Cava).8 Archundia et al. described a case report of insertion of a Hickman catheter into the superior vena cava via right parasternal access using an extra pleural technique.9 Lau et al. had limited success in placement of catheters in the innominate veins of 2 dialysis patients.1 Funaki et al.
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reported placement of tunneled HD catheters in small thyrocervical collateral veins or in occluded veins in the neck or the chest in 24 patients with central venous occlusion.2 The study reported relatively low primary patency rates of only 25% at the end of 12 months. Stavropoulos et al. described placement of 36 transhepatic dialysis catheters in 12 patients.10 However, a primary patency period of only 27 days was observed due to a high rate of thrombosis—other complications included catheter migration and sepsis. Additional complications of the transhepatic method reported in the literature are acute Budd-Chiari syndrome,11 intraperitoneal hemorrhage, and hepatic vein thrombosis.3 Lund et al. described percutaneous translumbar inferior vena cava cannulation.8 Seventeen percutaneous translumbar dialysis catheters were placed in 12 patients. Cumulative patency was 52% at 6 months and 17% at 12 months. Complications noted were thrombosis, catheter defects requiring removal, and infection. Interestingly, no catheter migration was noted. Percutaneous translumbar placement of catheters into the azygos vein has also been reported.5 The patient was given oral anticoagulation prophylactically and the catheter worked without any thrombosis for 9 months. Percutaneous transrenal access into the renal vein has been reported, which worked well for 6 months, after which the patient was lost to followup.6 Punzi et al. described the successful insertion of a 70 cm Tesio catheter (MCTC 1070 K-A, Medcomp, PA, USA) directly into the abdominal aorta via the right femoral artery.7 The catheter was still working at 7 months after placement without complications. Inferior vena cava cannulation via a surgical approach has also been reported, performed through a right lateral abdominal incision under general anesthesia.12 At 6 months postoperatively, the catheter was still functioning properly. Experiences with intracardiac dialysis catheters are limited and anecdotal. In our literature search, the earliest case report of successful prolonged use of direct intracardiac catheter for dialysis was by Chavanon et al. in 1999.13 The authors described the placement of an intracardiac catheter 3 times in a single patient, with the third replacement being used for 12 months before line bacteremia necessitated its removal. In 2005, Negoi et al. reported placement of the intracardiac dialysis catheter in patient #2 above, whose course we report here with successful transition to transplant after 15 months.14 In 2006, Santos-Arau´jo et al. reported use of an intracardiac dialysis catheter for 361 months in 1 patient without complications.15 In 2007, Yasa et al. reported an impressive series of 8 patients who received intracardiac dialysis catheters, 7 of whom continued dialysis for the duration
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of follow-up for a mean time of 10.2 months.16 In 2008, Wales et al. reported placement of an intracardiac dialysis catheter at the time of coronary artery bypass grafting, with successful dialysis continuing at 3 months’ followup.17 We report a small case series of patients with successful placement of intracardiac dialysis catheters. The longest duration of primary patency was 4 years and the shortest was 16 months, with one patient’s catheter being used for only 6 months before renal transplant and removal. These experiences confirm the results of previous reports that direct intracardiac placement of a dialysis catheter via thoracotomy is a viable alternative access method. The intracardiac approach eliminates certain theoretical risks of traditional dialysis access catheters, such as catheterinduced central vein thrombosis and stenosis. Primary complications include infection, malposition, and catheter thrombosis. The success achieved in our group is encouraging if measured by placement rate and length of dialysis through these catheters, especially because all our patients were at a high risk for access failure with a history of recurrent thrombosis and occlusion. However, unsuccessful placements of intracardiac catheters or those that fail rapidly are less likely to be reported in the literature. As such, it must be emphasized that the direct intracardiac approach should be strictly reserved for failure of traditional access sites and may only be considered as a viable alternative to other nontraditional access sites. When evaluating the risks of the procedure, mortality risk from the open thoracotomy to place the intracardiac catheters in dialysis patients should be considered. Some experts believe that it may be entirely viable to place the catheter using minimally invasive techniques such as video-assisted thoracic surgery.18 Care of the catheter after placement must also be considered, as accidental removal may require repeat thoracotomy for replacement, although replacement over a wire via the fistula tract was performed multiple times in our patient. In conclusion, direct intracardiac dialysis catheters may provide a technically feasible, life-saving option for ESRD patients who have exhausted traditional access sites for HD and are not candidates for peritoneal dialysis, especially those awaiting (buying time until) renal transplantation. However, further experience is needed to elucidate its potential advantages over other nontraditional access sites and its future role in HD.
ACKNOWLEDGMENT Disclosure: The authors have no conflicts of interest to declare.
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10 Stavropoulos SW, Pan JJ, Clark TW, et al. Percutaneous transhepatic venous access for hemodialysis. J Vasc Interv Radiol. 2003; 14(Part 1):1187–1190. 11 Pieters PC, Dittrich J, Prasad U, Berman W. Acute BuddChiari syndrome caused by percutaneous placement of a transhepatic inferior vena cava catheter. J Vasc Interv Radiol. 1997; 8:587–590. 12 Matsagas MI, Gouva CD, Charissis C, Katopodis KP, Fatouros M, Kappas AM. Vascular access for haemodialysis in extreme situations: Surgically placed inferior vena cava catheter. Nephrol Dial Transplant. 2004; 19:752. 13 Chavanon O, Maurizi-Balzan J, Chavanis N, Morel B, Blin D. Successful prolonged use of an intracardiac catheter for dialysis. Nephrol Dial Transplant. 1999; 14:2015– 2016. 14 Negoi D, Schmaltz R, Misra M. Successful use of a right atrial catheter for hemodialysis. Am J Med Sci. 2005; 329:104–106. 15 Santos-Arau´jo C, Casanova J, Carvalho B, Pestana M. Prolonged use of an intracardiac catheter for dialysis in a patient with multiple venous access failure. Nephrol Dial Transplant. 2006; 21:2670–2671. 16 Ya¸sa H, Lafcı B, I˙lhan G, et al. Placing of permanent catheter through right anterior mini thoracotomy in patients with chronic renal failure. Eur J Vasc Endovasc Surg. 2007; 13:90–91. 17 Wales L, Anderson JR, Power A, Dosani T, Hakin NS. End stage vascular access: Direct intra-atrial insertion of a dialysis catheter. Exp Clin Transplant. 2008; 6:169–170. 18 Birnbaum PL, Michas C, Cohen SE. Direct right atrial catheter insertion with video-assisted thoracic surgery. Ann Thorac Surg. 1996; 62:1197.
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