Perforation of the left innominate vein during placement of a hemodialysis catheter

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Abstract

Introduction: The left internal jugular vein courses through two angles, joining the subclavian vein and joining the right brachiocephalic vein to form the superior vena cava. These angles are challenging for hemodialysis access during puncture.

Clinical case: This is a 32-year-old man with polycystic kidney disease who required hemodialysis for six years. After a failed kidney transplant, he required resumption of hemodialysis due to uremia. A central approach was chosen for the left internal jugular vein. The initial procedure was uneventful.

Diagnostic workshop: A follow-up chest x-ray revealed an anomalous catheter trajectory projecting along the left edge of the aortic arch. CT angiography confirmed perforation of the left brachiocephalic vein by the catheter.

Treatment: The patient underwent thoracotomy, revealing a perforation in the anterior wall of the left innominate vein with the catheter tip lodged in the pericardial fat. The catheter was removed, and the venous laceration was repaired. A tunneled catheter was inserted through the right internal jugular vein.

Outcome: The patient recovered uneventfully and was discharged.

Conclusions: Difficult passage of the guidewire or dilator should alert to a possible abnormal position or kinking of the guidewire, which could result in vascular injury. Abnormal post-placement chest X-rays should alert to extravascular position, arterial position, or venous variants, even though the placement procedure was uneventful.