Blood at the end of tunnel‐rare complication of tunneled cuff catheter

Dear Editor, A 48-year-old lady with chronic kidney disease, hemodialysis (HD)-dependent, presented with secondary arteriovenous fistula (AVF) failure. Tunneled cuff catheter (TCC) insertion was planned due to urgent need of vascular access. The right-sided internal jugular vein was localized in the supine position using ultrasound. After local anesthesia, a palindromic chronic carbonate dual lumen catheter of size 14.5 F, 23 cm, having side holes, was inserted through a splitting sheath. Postprocedure, there was no blood outflow. Chest x-ray (Figure 1) was done following TCC insertion and findings were suggestive of hemothorax and penetration of the catheter tip into the mediastinum with the possibility of vascular injury. The catheter was left in situ for easy detection of the puncture site. The cardiothoracic surgeon removed the catheter and repaired the subclavian vein by emergent thoracotomy. The patient recovered following the procedure. A new catheter was reinserted after 1 week for HD, which remained uneventful, and the patient was discharged thereafter. TCCs are used as urgent vascular access in incident HD patients and in case of AVF failure [1]. Approximately 65% of the chronic HD population commences therapy via TCC. Accidental puncture and perforation of blood vessels or injury to nearby structures following TCC insertion are common complications and often result in catastrophe. Iatrogenic hemothorax is an immediate but rare complication of TCC insertion. The risk factors include body mass index (>30 or <20 kg/m2), female gender, previous catheterization in the same blood vessel, previous major surgery or radiation therapy in the procedural region, <1 year of training in vascular access, and more than two needle passages during TCC insertion [2]. In our patient, female sex and previous catheterization in the same blood vessel were the risk factors for hemothorax. A radiological investigation (chest x-ray, ultrasound, or computed tomography scan) should be done immediately with a catheter in situ if TCC is inserted up to full length and no blood flow is obtained. Early identification of this life-threatening complication, followed by urgent vascular repair, significantly decreases morbidity and mortality [3]. Sincere thanks to the Department of Medicine and CTVS Indira Gandhi Medical College Shimla, who helped in the management of the patients. The authors declare no conflicts of interest. A written informed consent was taken from the patient before taking his picture, including the consent for publication.