|Year : 2020 | Volume
| Issue : 4 | Page : 343-345
Operative surprise! A hitherto undiscovered dialysis catheter removed successfully from the external iliac vein during renal transplant - A case report
Nitin Agarwal, Anil Kumar Singh Rana, Manoj Kumar Dokania, Himank Goyal
Department of Surgery, Transplant Unit, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, Delhi, India
|Date of Submission||31-Jul-2020|
|Date of Acceptance||04-Oct-2020|
|Date of Web Publication||30-Dec-2020|
Prof. Nitin Agarwal
Department of Surgery, Transplant Unit, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, Delhi - 110 001
Source of Support: None, Conflict of Interest: None
The incidence of chronic kidney disease (CKD) has reached epidemic proportions in India over the past few decades. One of the reasons is the abnormally high prevalence of diabetes mellitus and hypertension. After conversion to end-stage renal disease, renal replacement therapy (RRT) either as dialysis or renal transplant is critical for survival. Facilities for hemodialysis are also abysmally low; this is compounded by poorly trained personnel in peripheral hospitals. These factors contribute to the poor outcome of CKD patients, even if RRT is initiated. We present a case of a middle-aged man who underwent renal transplant for CKD; during the mobilization of the right external iliac vein, a previously undocumented sequestered dialysis catheter was found in the lumen of the vein. This is probably the first such case in literature and highlights the paucity of optimal hemodialysis facilities in the country. The dilemma of continuing the transplant on the same side versus exploring the left side is also discussed. Timely transplant, preferably preemptive transplant, can mitigate many of the problems of chronic hemodialysis. These problems can arise from access to thrombosis or foreign bodies; preoperative accurate Duplex imaging is essential.
Keywords: Femoral dialysis catheter, hemodialysis hazards, migrated catheter, renal transplant
|How to cite this article:|
Agarwal N, Rana AK, Dokania MK, Goyal H. Operative surprise! A hitherto undiscovered dialysis catheter removed successfully from the external iliac vein during renal transplant - A case report. Indian J Transplant 2020;14:343-5
|How to cite this URL:|
Agarwal N, Rana AK, Dokania MK, Goyal H. Operative surprise! A hitherto undiscovered dialysis catheter removed successfully from the external iliac vein during renal transplant - A case report. Indian J Transplant [serial online] 2020 [cited 2021 Apr 11];14:343-5. Available from: https://www.ijtonline.in/text.asp?2020/14/4/343/305438
| Introduction|| |
The incidence of chronic kidney disease (CKD) has reached epidemic proportions in India over the past few decades. One of the reasons is the abnormally high prevalence of diabetes mellitus and hypertension. After conversion to end-stage renal disease (ESRD), renal replacement therapy (RRT) either as dialysis or renal transplant is critical for survival. Almost 200,000 patients are added every year to the renal transplant waiting list in India, of which only about 6000 can be performed. Facilities for hemodialysis are also abysmally low; this is compounded by poorly trained personnel in peripheral hospitals. These factors contribute to the poor outcome of CKD patients, even if RRT is initiated.
We present a case of a middle-aged man who underwent renal transplant for CKD; during the mobilization of the right external iliac vein, a previously undocumented sequestered dialysis catheter was found in the lumen of the vein. This is probably the first such case in literature and highlights the paucity of optimal hemodialysis facilities in the country.
| Case Report|| |
A 45-year-male presented to the outpatient clinic with a 3-week history of frequent headaches and vomiting. On clinical and laboratory evaluation, the average blood pressure readings were about 200/90 mm Hg; the serum creatinine level was 7.2 mg/dL. With a provisional diagnosis of CKD stage V, the patient was referred to the renal clinic and maintenance hemodialysis was started, with a plan for subsequent renal transplant. The hemodialysis was performed both by non tunneled right femoral catheters and by tunneled right internal jugular lines, depending on the clinical situation. On two occasions, due to a clinical emergency, dialysis was administered using femoral lines for 3 days at a time. Abdominal ultrasonography revealed bilateral medical renal disease and mild ascites. Preoperative Doppler study of the bilateral iliofemoral vessels showed normal caliber, waveforms, patency and velocity in bilateral common, external and internal iliac arteries, and corresponding veins. There was no evidence of thrombus, atherosclerosis, or foreign body in any of these vessels. After 3 months of dialysis, the patient underwent Live Related Renal Transplant (the donor was a sister). The left kidney of the donor was harvested through an open supra-11th rib flank incision, while the recipient was explored through a right extraperitoneal muscle cutting parainguinal approach. During the mobilization of the external iliac vein, we were surprised to palpate a hard free-floating foreign body of length about 5 inches in the lumen of the vein. This was extending from near the inguinal ligament below to the inferior vena cava (IVC) above. At this point, we were in a dilemma: whether to continue with the transplant after removal of the foreign body, or abandon and switch over to the contralateral side. However, since the foreign body appeared freely mobile in the lumen of the vein, the vessel wall was supple, the flow was adequate, and there was no apparent clot in the lumen, it was decided to continue with the transplant on the same side. Leaving it behind would have been life-threatening due to potential venous thrombosis and graft loss. Another dilemma was the site of retrieval; a separate venotomy close to the lower end of the catheter near the inguinal ligament, or higher up near the IVC? We decided to choose the site in the external iliac vein where we would normally join the graft vein and took proximal and distal control of the vein using silastic venous slings. The anesthesia team was informed to prepare for bleeding. The venotomy site was controlled by two fingers, as the slings were not as effective due to the presence of the intraluminal catheter. The lower end of the catheter was milked up until its lower end reached the venotomy site, and could be gently removed [Figure 1] and [Figure 2]. We deliberately allowed some bleeding after releasing the lower and upper controls sequentially to flush out any clots [Figure 3]. Thereafter, the graft vein and artery were anastomosed end-to-side with the external iliac vein and artery, respectively, as is our usual practice. Although we do not routinely use anticoagulant during and after kidney transplant, in this case, 2000 IU intravenous unfractionated heparin bolus was administered. Diuresis was immediate, brisk, and profuse; postoperative recovery was uneventful. Serum creatinine returned to 1.1 mg/dL on the 4th postoperative day. Color Duplex scan of the graft on the postoperative day 4 revealed a normal-sized graft with no thrombus and good flow (intrarenal resistive index = 0.7). The patient was discharged on the postoperative day 12 with a urine output of 3.2 L/day and is asymptomatic after a year of follow-up.
|Figure 1: Operative photograph showing the vascular control of the right external iliac vein with silastic slings, and the removal of the migrated dialysis catheter after venotomy|
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|Figure 3: After flushing of the vein with heparinized saline, the residual clots are removed|
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| Discussion|| |
Globally, most of the patients of CKD survive on maintenance hemodialysis. However, in sharp contrast to the scenario in the developed world, hemodialysis as a RRT of choice represents an arduous and gloomy process for most patients of ESRD in India. Unfortunately, many patients require immediate life-saving hemodialysis for which they have to go to nontransplanting dialysis units. These centers are mostly managed by precariously trained personnel due to a disproportion in the demand and supply of hemodialysis facility. Insertion of a nontunneled femoral venous catheter is usually the only feasible option in that situation. Tunneled internal jugular or subclavian catheters are preferable due to a lower rate of infectious and thrombotic complications. The best option, however, remains a preemptive or planned surgically created arteriovenous fistula, either radiocephalic or brachiocephalic. Creation and maintenance of these fistulae require specialized care and expertise. In our patient, the femoral catheter remained undetected for weeks before transplant. This represents the socioeconomic aspect of the problem.
Catheter fragments migrating to other locations through the blood vessels is well-documented and is termed catheter embolization, which is a rare complication, and in its most dangerous form, may involve the pulmonary arteries and even the coronary sinus!, Catheter fracture is more common, and the factors predisposing are poor technique, poor manufacturing quality, fibrin sheath formation, and pericatheter calcification. These complications can occur with all types of catheters, namely, pediatric peripherally inserted central catheters, permanently implantable central venous catheters, guide wires, and even, epidural catheters., Although the femoral route is commonly used for dialysis (vide supra), there are only a few reports of breakage of a dialysis catheter and migration/embolization.,,
Identification of a fractured and migrated/embolized catheter may require clinical suspicion and confirmation by radiology, usually plain X-rays. Chest radiographs are essential after all peripherally inserted central catheters in the jugular or subclavian veins., X-ray kidney ureter bladder is usually part and parcel of work-up of renal transplant to identify stones in the native kidneys, and/or, calcification in common, external, and internal iliac arteries. However, in our case, it was overlooked by the nephrology team. Ultrasound and doppler imaging may miss radio-opaque shadows and is also operator-dependant. Both these investigations may thus be complementary. Options for removal of a migrated catheter include careful observation, percutaneous retrieval, or surgical removal.,,, Although surgical removal is the most definitive, Sheth and colleagues have demonstrated successful percutaneous removal of 25 out of 26 intravascular foreign bodies, using a Dormia basket technique.
After extraction of the catheter in our patient, we continued with the transplant on the same side. We reasoned that the inherent coagulopathy of CKD, coupled with the high flow rate in the external iliac vein, would be sufficient to ensure graft survival with a low probability of thrombosis. The usual timeframe for anastomosing vessels after a puncture or clot is at least 6 weeks. To the best of our knowledge, this is the first reported case of retained femoral catheter discovered intraoperatively during renal transplant.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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