Translumbar catheters offer an alternative life-saving option in patients without conventional dialysis access, though their use and complication rates are poorly understood. We report the first case in the medical literature of a translumbar catheter inducing a central venous stenosis. This occult sequela converted what is usually a subclinical complication from an arteriovenous graft thrombectomy into a life-threatening one. This unusual clinical presentation highlights the need for clinicians to recognize the potential serious implications of translumbar catheter-induced occult central venous stenosis

Butty, Sabah D.

Friedman, Allon N.

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A. N. Friedman

S. D. Butty

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Clinical Kidney Journal

Life-threatening post-thrombectomy hypotension due to residual complications from a translumbar catheter

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NDT Plus (2010) 3: 465–467doi: 10.1093/ndtplus/sfq112Advance Access publication 22 June 2010Case ReportLife-threatening post-thrombectomy hypotension due to residualcomplications from a translumbar catheterAllon N. Friedman1 and Sabah D. Butty21Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA and 2Department of Radiology,Indiana University School of Medicine, Indianapolis, IN 46202, USACorrespondence and offprint requests to: Allon N. Friedman; E-mail: allfried@iupui.eduAbstractTranslumbar catheters offer an alternative life-saving optionin patients without conventional dialysis access, thoughtheir use and complication rates are poorly understood.We report the first case in the medical literature of a trans-lumbar catheter inducing a central venous stenosis. Thisoccult sequela converted what is usually a subclinicalcomplication from an arteriovenous graft thrombectomyinto a life-threatening one. This unusual clinical presenta-tion highlights the need for clinicians to recognize the poten-tial serious implications of translumbar catheter-inducedoccult central venous stenosis.Keywords: arteriovenous graft; stenosis; thrombectomy; translumbarcatheterBackgroundComplications such as vascular stenosis or thrombosisfrequently necessitate the abandonment of haemodialysisaccess sites. In patients with no remaining conventionalaccess sites, haemodialysis catheters placed in the inferiorvena cava (IVC) through a translumbar approach (so-called translumbar catheters) offer an alternative life-savingoption. There is little information on translumbar catheteruse or its complications, perhaps in part because such cathe-ters are generally considered an access of ‘last resort’. How-ever, patients can live with such catheters for years andoccasionally even regain the option of using more conven-tional access sites [1]. The following case describes how apreviously unreported sequela of translumbar cathetersconverted a typically subclinical arteriovenous (AV) graftthrombectomy-related complication into a life-threateningone.Case reportA 53-year-old black male with end-stage renal disease onchronic haemodialysis for 12 years presented to his neph-rologist with acute onset of hypotension, weakness andgastroenterological symptoms. The patient had a historyof hypertension, hepatitis C, prostatic hyperplasia, gas-troesophageal reflux disease, a previous translumbar dia-lysis catheter placement due to multiple upper chestvascular thromboses and a remote trial of peritoneal dia-lysis for 2 years that was stopped for unclear reasons.He was in his usual state of health until 1 day prior topresentation when he underwent a successful mechanicalthrombectomy using a percutaneous thrombolytic device(Arrow-Trerotola, Arrow International, Reading, PA) fora severe venous stenosis of his left thigh AV graft. Uponpresentation to his outpatient haemodialysis unit the fol-lowing morning, his blood pressure was 89/48 mmHg,markedly different from his baseline systolic pressure of140–150 mmHg. Symptomatic hypotension precludedultrafiltration that day. Though the patient's symptomswere initially attributed to the residual effects of anaesthe-sia, his course over the ensuing 2 weeks worsened as hemanifested nausea, constipation, progressive weakness tothe point of requiring a wheelchair and continued inabilityto remove any fluid due to persistent hypotension. A chestX-ray revealed only parenchymal chronic scarring. Twelvedays after the thrombectomy, the patient was admitted tothe hospital for further evaluation.Upon admission, an abdominal and pelvic CT scan withcontrast was performed to evaluate his GI symptoms. It re-vealed a thrombus within the IVC extending from the renalto the hepatic veins (Figure 1). Extensive venous collater-alization was also noted, suggesting a chronic condition.Two days later, a diagnostic venography revealed acuteon chronic thrombus material that completely occludedthe IVC. An IVC thrombectomy was performed, and arepeat venography demonstrated the presence of a pre-occlusive chronic stenosis in the midportion of the IVC(Figure 2). An IVC stent was placed that resolved thestenosis and normalized blood flow. Of note, angiographydid not reveal any residual stenosis in the patient's patentleft thigh AV graft.The IVC thrombectomy and stenting were accompaniedby immediate normalization of the patient's blood pres-© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.For permissions, please e-mail: journals.permissions@oxfordjournals.org at Ruth Lilly Medical Library on March 18, 2016http://ckj.oxfordjournals.org/Downloaded from Fig. 1. Occluded IVC (indicated by the arrow).Fig. 2. Post-thrombectomy IVC stenosis (indicated by the arrow).466 A.N. Friedman and S.D. Butty at Ruth Lilly Medical Library on March 18, 2016http://ckj.oxfordjournals.org/Downloaded from sure, leading again to successful ultrafiltration. The patientwas discharged in excellent condition soon thereafter.DiscussionOn first glance, the patient's clinical presentation appearspuzzling and not clearly related to his dialysis access.However, the subsequent medical evaluation revealedtwo processes—a chronic IVC stenosis with collateraliza-tion and a superimposed acute thrombus completely oc-cluding the stenotic region—that in concert led to hislife-threatening symptomatology. Each of these, in turn,arose directly from separate access complications.Central venous stenosis has long been a recognizedcomplication of haemodialysis catheter placement andmay be related to endothelial denudation and injury andsubsequent blood flow turbulence along the catheter shaft[2]. Though central venous stenosis is usually reported inthe setting of internal jugular, subclavian or femoral cathe-ters, there is no reason to believe that translumbar catheterscannot induce a similar effect. Such catheters are insertedvia the translumbar spinal region directly into the IVCunder fluoroscopic guidance. In this particular patient,the translumbar catheter was used for <1 year and was re-moved ∼3 years prior to the current presentation. Based onthe following reasons, it is eminently reasonable to con-clude that the IVC stenosis was causally related to thetranslumbar catheter. First, the chronicity of the IVC sten-osis (as demonstrated by venous collaterals) is consistentwith an old injury arising from a remote catheter place-ment. Second, the translumbar catheter rested in the sameregion where the stenosis was later observed. Third, the pa-tient had no other history of catheter placement within theIVC that could have precipitated a stenotic reaction. This,then, is the first medical report of a translumbar catheter-related central venous stenosis. The prevalence of suchstenoses are unknown, but it is certainly plausible that theyare as under-recognized as are other catheter-related cen-tral stenoses [3,4].In fact, the IVC stenosis might never have become clin-ically relevant had an AV graft thrombectomy not beenperformed. A thrombectomy involves the maceration orfragmentation and removal of the thrombus via a varietyof specialized devices. A well-recognized complication ofsuch manoeuvres is the formation of microthrombi [5],some of which inevitably embolize distally. While on oc-casion these emboli can be clinically significant and evenlife-threatening [6–8], clinical experience demonstratesthat the vast majority are not.How, then, to explain the acute thrombus that developedat the IVC stenosis? The temporal link between the thromb-ectomy procedure and the subsequent rapid onset of symp-toms helps establish causality. In all likelihood, thethrombectomy released microemboli that under normal cir-cumstances would have dissipated into the venous systemwithout consequences. However, these emboli were caughtat the stenotic site where blood flow was stalled and per-turbed and consequently propagated. Once complete venacaval thrombotic occlusion occurred, the patient wouldhave been dependent entirely upon venous return fromthe collateral venous system developed over time aroundthat circumvented the stenosis. This would explain the sud-den development of hypotension that precluded effectiveultrafiltration, a problem that immediately disappeared afterthe clot was dissolved.This unusual clinical presentation highlights the need forclinicians to recognize potential complications associatedwith translumbar catheters. One such complication—occultcentral venous stenosis—may, under the proper circum-stances, be life-threatening.Acknowledgements. A.N.F. is supported by the National Institutes ofHealth (K23 RR019615).Conflict of interest statement. None declared.References1. Power A, Singh S, Ashby D et al. Translumbar central venous cathetersfor long-term haemodialysis. Nephrol Dial Transplant 25: 1588–15952. Agarwal AK. Central vein stenosis: current concepts. Adv ChronicKidney Dis 2009; 16: 360–3703. Taal MW, Chesterton LJ, McIntyre CW. Venography at insertion oftunnelled internal jugular vein dialysis catheters reveals significantoccult stenosis. Nephrol Dial Transplant 2004; 19: 1542–15454. MacRae JM, Ahmed A, Johnson N et al. Central vein stenosis: acommon problem in patients on hemodialysis. ASAIO J 2005; 51:77–815. Trerotola SO, Johnson MS, Schauwecker DS et al. Pulmonary embolifrom pulse-spray and mechanical thrombolysis: evaluation with an ani-mal dialysis-graft model. Radiology 1996; 200: 169–1766. Swan TL, Smyth SH, Ruffenach SJ et al. Pulmonary embolism follow-ing hemodialysis access thrombolysis/thrombectomy. J Vasc IntervRadiol 1995; 6: 683–6867. Vesely TM. Complications related to percutaneous thrombectomy ofhemodialysis grafts. J Vasc Access 2002; 3: 49–578. Grebenyuk LA, Marcus RJ, Nahum E et al. Pulmonary embolismfollowing successful thrombectomy of an arteriovenous dialysis fistula.J Vasc Access 2009; 10: 59–61Received for publication: 24.5.10; Accepted in revised form: 26.5.10Translumbar catheter complications 467 at Ruth Lilly Medical Library on March 18, 2016http://ckj.oxfordjournals.org/Downloaded from 

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Life-threatening post-thrombectomy hypotension due to residual complications from a translumbar catheter

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