Speakers - 2027

Title: Malposition of hemodialysis catheter in vertebral artery in a pediatric patient: Decoding the Serpiginous Path

Abstract

Introduction

Haemodialysis (HD) catheters are large-bore catheters used for renal replacement therapy in both acute and chronic renal failure. Malposition of catheters have been reported in both intravascular and extravascular spaces including the subclavian vein on both ipsilateral and contralateral sides, azygous vein, accessory hemi-azyguos vein, internal mammary vein, hepatic vein, carotid artery, pleural and mediastinal spaces.¹ Insertion of central venous access catheters for haemodialysis under ultrasound guidance can reduce the chance of arterial punctures; however, it cannot completely trace out its distal course and tip position.We report a case of remarkable rarity of malposition of haemodialysis catheter attempted to place into right Internal Jugular Vein (IJV); inadvertently being placed into the vertebral artery with the tip reaching the Ascending Aorta.

Case History

In a 9-year-girl, known case of nephrotic syndrome on haemodialysis for the past 2 months, 10 Fr haemodialysis (HD) catheter was placed in the right IJV under ultrasound guidance. Post insertion chest X-ray was suspicious of catheter misplacement.  Contrast injected through the HD catheter revealed aortic enhancement through the right subclavian artery with its tip reaching the sino-tubular junction in the ascending aorta on fluoroscopy. Interventional cardiac radiology team opined it being unsuitable for endovascular management and referred for surgical removal of HD catheter. In the operation theatre, under general anaesthesia, intraoperative transesophageal echocardiography (TEE) revealed the HD catheter traversing through the ascending aorta to end in close proximity to the sino-tubular junction.

Discussion

Malposition of HD catheter in vertebral artery is an extremely rare complication with reported incidence of 0.099 to 0.775%.² Definitive management necessitates either endovascular intervention or surgical exploration for extraction. Management of such a case involves multi-modality imaging for diagnoses including Xray, fluoroscopy, echocardiography. Anaesthetic implications in successful surgical removal of catheter along with images/videos shall be discussed at the time of presentation.

Conclusion

A high index of suspicion for malposition of the HD catheter into the arterial tree is warranted upon identifying an abnormal catheter course on chest X-ray. Malposition of catheter in vertebral artery can be a rare possibility during IJV cannulation. Accurate recognition of catheter trajectory and potential misplacement hinges on clinicians’ knowledge of adjacent anatomical structures. CT angiography imaging serves as a valuable adjunct for confirming and delineating catheter malposition involving the aorta and its major branches. Multi-disciplinary consultation should be done to formulate an optimal management strategy.