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Malposition of a hemodialysis catheter in the accessory hemiazygos vein.

A 30-year-old Caucasian female underwent a kidney transplant but experienced delayed graft function, necessitating dialysis. Her previous right internal jugular dialysis catheter had been removed during surgery. On ultrasound, her right internal jugular vein was found to be stenosed proximally, and a left internal jugular vein dialysis catheter (20cm, 12 Fr) was placed under ultrasound guidance with no complications. A chest X-ray was obtained to confirm the correct position, and it was concerning for cannulation of the aorta (arrow in Figure 1, Panel A). A blood gas analysis done from the dialysis catheter suggested venous blood. Fluoroscopy showed the catheter coursing from left internal jugular vein into the accessory hemiazygos vein (arrow in Figure 1 Panel B). The catheter was repositioned, and the tip was correctly advanced to the junction of superior vena cava and right atrium. For comparison, a chest X-ray image of a properly placed hemodialysis catheter in a different patient is demonstrated in Figure 2.

Hemodialysis catheters are associated with several complications such as pneumothorax, bleeding, arrhythmias, thrombosis, infections, and malposition. (1) Malposition complicates 1% to 33% of hemodialysis catheter placements and should be promptly identified due to the risk of vascular laceration or perforation. (2) Malposition usually occurs within the major tributaries of the superior vena cava, including subclavian, internal thoracic, pericardiophrenic, and superior intercostal veins. (1) Hemodialysis catheters can also be misplaced outside the venous system into adjacent structures like pleura. (1) Physicians should also be aware of accidental arterial cannulation. (1) Cannulation of the accessory hemiazygos vein is rare but can happen when the accessory hemiazygos vein drains into the left brachiocephalic vein instead of the azygos vein normally. (1) Interestingly, accessory hemiazygos vein has been reported to be used for placement of hemodialysis catheter in a patient with unusual anatomy of central venous system, including bilateral occlusion of brachocephalic veins and drainage of left internal jugular and subclavian veins directly into superior vena cava through an enlarged accessory hemiazygos vein. (3)

REFERENCES

(1.) Muhm M, Sunder-Plassmann G, Druml W. Malposition of a dialysis catheter in the accessory hemiazygos vein. Anesth Analg. 1996; 83: 883-5.

(2.) Stolic RV, Stolic DZ. A left jugular vein catheter for hemodialysis malpositioned in right brachiocephalic vein. Iran J Kidney Dis. 2012; 6:98.

(3.) Letachowicz K, Kolodziej M, Miedzybrodzki K, et al. Tunneled-cuffed catheter implanted into the accessory hemiazygos vein because of occlusion of the left innominate vein. Hemodial Int. 2012; 16: 310-4.

Brian Revis, MD; Mohammad Kazem Fallahzadeh, MD; Neeraj Singh, MD

Dr. Revis is with the Division of Nephrology, Department of Internal Medicine at The Ohio State University. Dr. Fallahzadeh is with the John C. McDonald Regional Transplant Center, Willis Knighton Health System in Shreveport, Louisiana. Dr. Singh works with Dr. Revis at Ohio State and Dr. Fallahzadeh at the John C. McDonald Regional Transplant Center. He is also in the Division of Nephrology, Department of Internal Medicine at Louisiana State University Health Sciences Center in Shreveport.

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Author:Revis, Brian; Fallahzadeh, Mohammad Kazem; Singh, Neeraj
Publication:The Journal of the Louisiana State Medical Society
Article Type:Case study
Date:Jan 1, 2014
Words:491
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