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CASE REPORT Table of Contents  
Ahead of print publication
A rare cardiac complication of left-sided tunneled hemodialysis catheter insertion

1 Department of Nephrology, Institute of Nephro Urology, Bengaluru, Karnataka, India
2 Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
3 Department of Cardiothoracic Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

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Date of Submission22-Jul-2021
Date of Decision27-Oct-2021
Date of Acceptance20-Nov-2021
Date of Web Publication23-Feb-2022


Left atrial perforation during central venous catheter insertion is an extremely rare complication which can have catastrophic outcomes if left unrecognized. We describe a rare case of the left atrial catheter malposition during tunneled hemodialysis catheter insertion from the left internal jugular vein, which was managed successfully by surgical reposition and simultaneously vascular access was secured by salvaging the same catheter in a patient with poor arteriovenous anatomy for surgical arteriovenous fistula.

Keywords: Hemodialysis, left atrial perforation, tunneled catheter, vascular access

How to cite this URL:
Shankar M, Ravindranath NK, Moorthy N, Jayanth Kumar H V. A rare cardiac complication of left-sided tunneled hemodialysis catheter insertion. APIK J Int Med [Epub ahead of print] [cited 2022 Oct 6]. Available from: https://www.ajim.in/preprintarticle.asp?id=338153

  Introduction Top

The use of tunneled hemodialysis catheters is a preferred choice of access in patients with multiple access failures, those with anatomically unsuitable vessels for fistula or graft creation, and limited life expectancy.[1]

Tunneled hemodialysis catheters are inserted into the central veins. The choice of the site for insertion depends on the dialysis urgency, general condition of the patient, type of dialysis, and any history of previous access placements.[2]

The preferred site for both tunneled and nontunneled hemodialysis catheters is the right internal jugular vein (IJV) because it takes a straight path to the superior vena cava. The left IJV placement is comparatively difficult because two right angle turns are required before it reaches the superior vena cava and is used often when the insertion through the right IJV is not feasible due to various reasons. Hence, the complication rates are higher with the left internal jugular catheter placement. A retrospective study of 532 catheters showed that the left internal jugular catheters had a higher rate of complications compared to the right internal jugular catheters.[3] The femoral vessels are preferred site in patients with bilateral central vein obstruction.[4] Mechanical complications during catheter insertion are largely operator-dependent and are usually diagnosed at the time of insertion.[5]

In this case report, we describe an interesting case of the left IJV tunneled catheter malposition in the heart, and the corrective measures are taken for the same.

  Case Report Top

A 65-year-old woman with diabetic end-stage renal disease was initiated on hemodialysis through a temporary right internal jugular catheter on an emergency basis. Arteriovenous fistula creation was deferred in view of poor anatomy of the vessels of both the upper limbs. In due course of time, the catheter failed and there was no flow. Ultrasound and Doppler of the right IJV showed a thrombus in the vessel. Hence, she was planned for the left internal jugular tunneled catheter placement.

After obtaining informed consent, the patient was taken up for the procedure. Under local anesthesia and ultrasound guidance, the left IJV was identified with a 16G needle attached to a 5cc syringe and guidewire was secured. The position of the guidewire in the inferior vena cava was confirmed with fluoroscopy. Serial dilators were used, and a cuffed dual-lumen hemodialysis catheter of diameter 14.5 French and cuff to tip (symmetrical) length of 28 cm was inserted through this left IJV (BARD 14.5 Fr, 28 cm). Minimal resistance was noted during the use of dilators. A gentle suction with a syringe showed adequate blood flow. The procedure was completed and postprocedure check X-ray was performed.

The check X-ray [Figure 1] showed an abnormal position of the catheter tip in the mediastinum. To confirm the position, the blood was aspirated into the syringe immediately following insertion. There were no flow problems at any time. The blood gas analysis was suggestive of arterial blood. The presence of arterial blood in the catheter indicated the possibility of inadvertent entry into an artery or the rare possibility of entry into a left-sided cardiac chamber. The mean pressure was 12 mmHg, not suggestive of an artery indicating possible entry into the left atrium (LA). The catheter tip position in the LA was confirmed by fluoroscopy. The reason for entry into the LA could be a persistent left superior vena cava draining abnormally into the LA or a traumatic procedural perforation from the brachiocephalic vein (innominate vein) entering the LA. A computed tomography (CT) scan was done, confirmed the course of catheter from the left IJV→left brachiocephalic vein perforated, entered into the mediastinum, then perforated and entered into the LA as shown in [Figure 2].
Figure 1: Chest X-ray AP view showing malposition of the catheter tip in the left side of the mediastinum

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Figure 2: Computed tomography image showing catheter course from the left internal jugular vein → left brachiocephalic vein → left atrium

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The complications of leaving the catheter tip in the LA area were that it would be a nidus for thrombus formation and any inadvertent entry of air/thrombus during dialysis could lead to systemic embolization including stroke. Hence, it was decided to remove the catheter. Two methods were considered. The first method was surgical removal of the catheter and sealing the perforation areas. The second method was just a percutaneous withdrawal of catheter, watchful monitoring with emergency backup for surgical exploration. However, as the catheter was relatively large-sized (14.5 Fr), the patient also needed an access for hemodialysis, and in view of underlying chronic kidney disease, the possibility of her rapid deterioration was considered in case of mediastinal bleeding after catheter withdrawal. Hence, she was decided to be subjected to a surgical correction. Intraoperative findings were consistent with the CT findings showing the catheter exiting the left brachiocephalic vein and entering the LA as shown in [Figure 3]. The catheter was removed from the LA, perforation areas sutured and was repositioned in the left brachiocephalic vein as shown in postprocedure chest X-ray [Figure 4]. The patient tolerated the procedure well without any hemodynamic compromise. Hemodialysis was also performed through the repositioned tunneled catheter.
Figure 3: Intraoperative image showing catheter (yellow arrow) exiting from the left brachiocephalic vein (green arrow) and entering into the left atrium (blue arrow)

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Figure 4: Postprocedure chest X-ray – Catheter tip secured in the left brachiocephalic vein

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Fluoroscopy guidance was used initially during the procedure to confirm the position of the guidewire when it was placed first. During the use of dilators, the guidewire could have been displaced. The position of the guidewire after using the dilators and during catheter insertion was not confirmed with fluoroscopy.

  Discussion Top

Multiple mechanisms lead to catheter malposition. Methodological inaccuracy is the most common cause, followed by anatomical variation. Interoperator variability also predisposes to malposition of the catheter.[6] Anatomical variations include tortuosity of the veins, branches of vessels, very acute angles of the vessels, stenosis of the veins, congenital variations of the vessels, and so on. These may increase the risk of catheter malposition.[6]

Guidewire plays a major role in navigating the catheter to its ideal position.[7] The wire may kink or enter into another vein leading to malpositioning of the catheter. It can also get obstructed by following an incorrect path to the thorax, neck, arm, or to the contralateral side.[8] If excessive force is used inadvertently, the guidewire can get forced out of the vein into the mediastinum, pleura, and other surrounding structures which will lead to dangerous and fatal outcomes.[9] Hence, any resistance should raise suspicion of malpositioning and investigation with further imaging is required.

Left atrial perforation is reported during percutaneous cardiac procedures such as balloon mitral valvotomy, atrial septal defect, and the LA appendage closures. Often it leads to pericardial effusion, cardiac tamponade needing aspiration, and rarely surgical closure. In our case, as the catheter had sealed the perforation, there was no leak into the pericardium/mediastinum. Leaving the catheter in the LA was not an option as it would be a nidus for thrombus formation and any inadvertent entry of thrombus/air would lead to systemic embolization including stroke. Attempts to remove catheter by pulling back could be dangerous as it could lead to rapid mediastinal/pericardial accumulation leading to tamponade. Even if attempted, it should be done only with emergency cardiothoracic surgical backup. The preferred option would be surgical correction as done in our case. On performing extensive literature search, we found that this is a rare complication. To the best of our knowledge, this is the first case report of malposition of the catheter into the LA, which was successfully managed by surgery, and the catheter tip was repositioned into the left brachiocephalic vein hence rescuing the catheter in the process.

  Conclusion Top

Inadvertent catheter malposition into the LA is a rare complication that should be considered during the left IJV insertion that needs early recognition and can be successfully managed by surgery with repositioning of the catheter. Inaccurate methodologies can lead to various complications which can be avoided.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the family has given consent for patient's images and other clinical information to be reported in the journal. The family understands that patient's name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.


We thank the Director, Medical Superintendent, Head of the Departments – Nephrology, Cardiology, Cardiovascular Surgery of Institute of Nephro urology and Sri Jayadeva Institute of Cardiovascular Sciences.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis 2020;75:S1-164.  Back to cited text no. 1
Bander SJ, Schwab SJ. Central venous angioaccess for hemodialysis and its complications. Semin Dial 1992;5:121.  Back to cited text no. 2
Engstrom BI, Horvath JJ, Stewart JK, Sydnor RH, Miller MJ, Smith TP, et al. Tunneled internal jugular hemodialysis catheters: Impact of laterality and tip position on catheter dysfunction and infection rates. J Vasc Interv Radiol 2013;24:1295-302.  Back to cited text no. 3
Silberzweig JE, Sacks D, Khorsandi AS, Bakal CW; Society of Interventional Radiology Technology Assessment Committee. Reporting standards for central venous access. J Vasc Interv Radiol 2003;14:S443-52.  Back to cited text no. 4
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 5
Bodenham A. Reducing major procedural complications from central venous catheterisation. Anaesthesia 2011;66:6-9.  Back to cited text no. 6
Nayeemuddin M, Pherwani AD, Asquith JR. Imaging and management of complications of central venous catheters. Clin Radiol 2013;68:529-44.  Back to cited text no. 7
Pikwer A, Bååth L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: A prospective cohort study in 1619 patients. Anaesth Intensive Care 2008;36:30-7.  Back to cited text no. 8
Gallieni M, Martina V, Rizzo MA, Gravellone L, Mobilia F, Giordano A, et al. Central venous catheters: Legal issues. J Vasc Access 2011;12:273-9.  Back to cited text no. 9

Correspondence Address:
Nishanth Khandenahallipalya Ravindranath,
#54, 4th Sector, HSR Layout, Bengaluru - 560 102, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajim.ajim_79_21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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