Tunneled Dialysis Catheter Perforating the Myocardium can Occur as a Delayed Complication

Dear Editor,

Cardiac perforations from central venous catheters can be catastrophic and are usually noticed immediately after the catheter insertion. Here, we report a rare case of delayed catheter tip migration into the pericardial space due to a long-term tunneled hemodialysis (HD) catheter.

A 70-year-old female with end-stage kidney disease and on maintenance HD through right jugular tunneled HD catheter (14.5 Fr) which was inserted 9 months ago came for a routine HD session and was noticed to have aspiration of straw-colored fluid of about 15 ml from both the catheter ports with no blood flow. CT chest confirmed the catheter tip in the pericardial cavity perforating the inferior surface of the right atrium [Figure 1]. Echocardiogram did not show significant pericardial effusion. Under close supervision of a cardiac surgeon and taking control of the right atrial perforated site by taking purse string sutures after mini-thoracotomy, the tunneled catheter was pulled back by a few centimeters to keep the catheter tip in mid right atrial position. Purse string sutures were tightened after pulling the catheter out of the pericardial space. No major complications including hemopericardium were noted.

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Figure 1:

High-resolution CT chest (a) topogram, (b) axial, and (c) reconstructed coronal images showing the tip of the tunneled dialysis catheter in the pericardial cavity.

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Although rare, cardiac perforations from the catheters can be lethal and can lead to life-threatening complications such as pericarditis, pericardial effusion, hemopericardium, cardiac tamponade, and arrest. These most commonly arise early due to trauma from the introducer needle, guidewire (particularly if the stiffer side is inserted instead of the soft j-tipped end), dilators, or the catheter itself. The incidence of such complications was reduced in recent years due to new-generation catheters, and procedures were guided by ultrasonography or fluoroscopy. Perforations resulting from tunneled catheters can be catastrophic due to their larger diameter. The exact reasons for right atrial perforation as a delayed complication, after 9 months in our case are unknown. Probably with catheter migration or a deeper tip position into the right atrium indenting its inferior surface and with repeated cardiac contractions, the catheter tip might have eroded and perforated the right atrial wall. As the catheter itself acts as a barrier to bleeding, unsupervised manipulation or removal of these large bore catheters can be catastrophic as the perforated site can allow the entry of blood into the pericardium causing hemopericardium and catastrophic tamponade. Early recognition of this complication and proper management saved the patient from a potentially fatal situation.