Cardiac tamponade following insertion of an internal jugular vein catheter for hemodialysis

Abstract

Percutaneous cannulation of the internal jugular vein (IJV) is widely used for patients suffering with end stage renal disease. As with all invasive procedures, it is associated with a number of recognized complications. Cardiac tamponade is one such complication. Cardiac tamponade is thought to arise from the guide-wire, the dilator and venous cannulation perforating the right atrium, the right ventricle and on rare occasion the superior vena cava. We report here on a case of cardiac tamponade that was caused by perforating the inferior vena cava (IVC) via the guide-wire while attempting IJV catheterization under echographic guidance. Case Report: A 62-year-old woman with end stage renal disease secondary to diabetic nephropathy presented with anorexia and dyspnea. Because the patient had severe uremic symptoms, we planned to start emergency hemodialysis. Her arteriovenous fistula for hemodialysis was not adequately created; therefore, IJV catherization was needed. With the patient in the Trendelenberg position, we inserted a soft j-tipped guide-wire into the right jugular vein under echographic guidance. No resistance was encountered when inserting the guide-wires, dilators or catheters. Over the next few minutes, the patient's systolic blood pressure gradually decreased to 70 mmHg. The jugular venous pressure was not elevated, and her heart sounds were normal. Yet an emergency echocardiogram and chest CT scan were done because it was necessary to rule out occult vascular injury associated with the procedure. A large pericardial effusion was identified on the emergency echocardiogram and chest CT scan. An exploratory median sternotomy was immediately performed. The pericardial sac was tense and it contained a large amount of blood with grossly visible clots. In the IVC adjacent to the RA, a scratch and a 1mm sized hole was found and then primary closure was done. These lesions were thought to be due to penetration of the IVC wall by a guide-wire because of the distance from the access site to the perforation site. The vital signs of the patient were stabilized after the operation. The postoperative course was uneventful, and the patient was discharged 22 days later.

Ultrasound validation of Trendelenburg positioning to increase internal jugular vein cross-sectional area in chronic dialysis patients

“…2,7 Use of the right IJV is more favorable than the left IJV because of its direct route to the superior vena cava, its position being far from the pleura and the absence of a thoracic duct in the right side of the chest. [2][3][4] In addition, the right IJV has a much wider diameter and runs more superficially than the left IJV, and anatomical variations of the left IJV may partly account for the difficulty in achieving successful cannulation of the left IJV in certain patients.…”

“…2,4 Inadvertent CA puncture is seen in up to 21% 6 of patients during IJV catheterization and may result in serious morbidity, and even mortality, in high-risk hemodialysis patients. 7,8 Ultrasound guidance has been recommended to increase the success of IJV catheterization and decrease the incidence of complications but it is not always routinely used. 4 Thus, it would be of great interest to clinicians if one approach could be shown to increase the CSA and decrease the overlap with the CA in order to improve patient safety.…”

Wszczepialne systemy dostępu naczyniowego u chorych na nowotwory

“…Wywołana jest przebiciem ściany jam serca lub żyły głównej górnej w obrębie worka osierdziowego [28]. Dezorientacja, dys-komfort lub ból w klatce piersiowej, nudności, duszność, tachy-lub bradykardia to niespecyficzne objawy mogące występować w trakcie tamponady serca.…”

Soft J-tipped Guide Wire-induced Cardiac Perforation in a Patient with Right Ventricular Lipomatosis and Wall Thinning

“…It was predicted that the incidence of lethal complications of cardiac perforation could be reduced by using soft J-tipped guide wires (2). Only two previous cases of cardiac tamponade due to soft J-tipped guide wires have been reported (3,4). These two cases differed from ours in two important respects: 1) in both of them, the CVCs were inserted via the right jugular vein, whereas in our case, the point of entry was the right subclavian vein, and 2) in neither of these cases was a pathological reason for the perforation identified (3,4).…”

“…Only two previous cases of cardiac tamponade due to soft J-tipped guide wires have been reported (3,4). These two cases differed from ours in two important respects: 1) in both of them, the CVCs were inserted via the right jugular vein, whereas in our case, the point of entry was the right subclavian vein, and 2) in neither of these cases was a pathological reason for the perforation identified (3,4). We herein report a case of fatal cardiac perforation by a soft J-tipped guide wire after insertion via the right subclavian vein, and describe the abnormal histological features of the myocardium in this patient that were concluded to be responsible for the perforation.…”