Stuck hemodialysis catheter, a case of dreaded, rare complication after kidney transplantation

Tunneled cuffed hemodialysis catheters are at an elevated risk of incarceration or becoming ‘stuck’ via fibrotic adhesion to the central veins when left in situ for prolonged periods. Stuck catheters cannot be removed using standard techniques such as bedside dissection of the cuff. While several strategies have been published for the removal of these incarcerated lines, there is a lack of consensus on the best approach.

Cameron Burnett, Princess Alexandra Hospital, Woolloongabba, QLD, Australia, and colleagues described the case of a 66-year-old female on hemodialysis presented for kidney transplantation with a tunneled-cuffed hemodialysis catheter in situ for five years. Following the transplantation, line removal was unsuccessful despite cuff dissection, with traction causing a choking sensation with tracheal movement. Eventually, line removal was done without complications utilizing sequential balloon dilatation by interventional radiology, and the patient was discharged without complications.

The patient was a 66-year-old female on maintenance hemodialysis with a history of hypertension, lupus nephritis, and post-menopausal osteoporosis. She had no previous lines or central vascular devices. She had been maintained on hemodialysis via a left internal jugular tunneled cuffed catheter that had been in situ for five years due to patient preference. When she presented for deceased donor kidney transplantation, she was clinically well.

The patient underwent kidney transplantation with immediate graft function and without surgical or medical complications. On day five postoperatively, the line was planned for routine removal and attempted at the bedside with local anesthesia infiltration. Following the uncomplicated dissection of the cuff, the tension on the catheter led to a choking sensation in the patient with the evident ipsilateral movement of the midline structures including the trachea.

Further attempts at bedside, and later in theater by cardiothoracic and vascular surgeons had the same result. A CT venogram showed a contracted superior vena cava around the vascular catheter as it passed into the right atrium. An initial attempt by interventional radiology with dissection of the tract using blunt forceps and fluoroscopy was abandoned after fluoroscopy again revealed discomfort with attempted traction and tracheal displacement. The laser sheath was considered unsuitable due to the excessive size of the patient’s hemodialysis catheter.

Following a multidisciplinary team discussion, a decision was made to undertake a second fluoroscopic technique using the Hong technique. A guidewire was passed down into the IVC from a lumen of the central venous catheter, and the doctors undertook sequentially from the distal to proximal component of the line. Following this, the line was able to be removed safely. The patient suffered no complications and was discharged home on day eight post-transplantation.

"This case serves as a timely reminder of the risks of long-term tunneled hemodialysis catheters and as a caution towards proceeding with kidney transplantation in patients with long-term hemodialysis catheters," the team wrote. "More invasive strategies could be avoided by greater nephrologist awareness of interventional radiology techniques for this challenging situation."

"The risks of a stuck catheter should be included in the discussions about the optimal vascular access and transplantation suitability for a given patient," they concluded.

Reference:

Burnett, C., Chandler, S., Jegatheesan, D. et al. The stuck haemodialysis catheter—a case report of a rare but dreaded complication following kidney transplantation. BMC Nephrol 25, 104 (2024). https://doi.org/10.1186/s12882-024-03507-z