Prolonged use of an intracardiac catheter for dialysis in a patient with multiple venous access failure

Sir, We report a case of prolonged use of an intracardiac catheter for dialysis in a patient with total exhaustion of vascular access and without any possibility of kidney transplantation or peritoneal dialysis. A 33-year-old female with a history of myelocele began chronic dialysis therapy at 20 years of age, due to chronic interstitial nephritis. The course was complicated by early thrombosis of arteriovenous fistulas, leading to the placement of several temporary and permanent central venous catheters. By the age of 27, she was transferred to peritoneal dialysis, but soon returned to haemodialysis due to diffuse peritoneal sclerosis. The possibility of kidney transplantation was considered, but the presence of bilateral iliac hypoplasia made it impracticable. By the age of 28, the permanent dysfunction of a femoral tunnelled catheter led to the surgical placement of an inferior vena cava venous catheter. The most relevant causes of coagulopathy, including genetic disorders, were excluded. Ten months later, the inferior vena cava catheter was surgically replaced but partial venous thrombosis ensued and the catheter was removed. Due to the exhaustion of other possible vascular accesses for dialysis, the insertion of an intracardiac catheter was considered [ 1 , 2 ]. For this purpose, the patient was submitted to sternotomy and right atrium placement of a dual lumen Ash-Split® catheter. No specific aseptic measures were applied in the daily management of this vascular access. Thirty-six months later, the patient is still using the same catheter and no major complications have been observed. The direct placement of an intravascular catheter in the right atrium is a common practice in paediatric cardiac surgery [ 3 ]. The procedure is technically simple, easily performed by any cardiac surgeon with no additional risks beyond those inherent to the thoracic procedure; the complications are mainly related to the general condition of the patient. In paediatric patients, the transthoracic catheter is always used on a temporary basis and removed by simple traction, without significant complications. The use of transthoracic intracardiac catheters for haemodialysis access has been reported only once before; in that report however, the catheter was frequently replaced due to recurrent infection episodes and was used for only a few months [ 4 ]. In the present case, the catheter has been functioning uninterruptedly for more than 36 months without any serious associated complications. A repeated sternotomy would be necessary for intracardiac catheter replacement or removal, should it become infected. This is, as far as we are aware, the first report of an intracardiac catheter used as a permanent vascular access for dialysis, for more than 2 years [ 5 , 6 ]. We suggest that the intracardiac placement of a central venous catheter may be a safe and long-lasting option in cases of total vascular access exhaustion, allowing the maintenance of the patient on regular haemodialysis therapy. Conflicts of interest statement . None declared. 1Unit of Research and Development of Nephrology Faculty of Medicine2 Cardiothoracic Surgery Hospital S. João Porto, Portugal