Perforation of left innominate vein during dialysis catheter placement.

To cite: Gupta S, Gummalla KM, Punamiya SJ, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014206870 DESCRIPTION A 67-year-old man presented with non-functioning left brachiocephalic arteriovenous fistula (AVF). The patient was referred for left internal jugular vein (IJV) dialysis catheter placement while awaiting right AVF creation. Ultrasound-guided left IJV puncture was successfully obtained, and a guide wire parked in the inferior vena cava through the access site. A 28 cm palindrome was placed, in what we thought was the superior vena cava, after tunnelling through the anterior chest wall. At the end of the procedure, no blood could be aspirated through either port of the palindrome. Contrast injected through the palindrome extravasated into the pleural cavity (figure 1). CT scan confirmed perforation of the mid innominate vein. Venogram of the left innominate vein was obtained through an 8 Fr sheath, placed in the left cephalic vein to ascertain the site of perforation. After securing the site with an 8×4 mm balloon, the dialysis catheter was removed. A covered stent was then placed over the site of perforation through another 9 Fr sheath placed in the left groin. Completion venogram showed no active extravasation of contrast (figure 2). Another palindrome was placed with smooth flow of blood through both the ports at the end of the procedure. After an uneventful 24 h of observation in the wards, dialysis was started through the catheter and carried on successfully until the AVF creation. Apart from perforation, other complications encountered during dialysis catheter placement are arterial puncture, haematoma, pneumothorax, malposition, central venous stenosis, thrombosis, infection and phrenic nerve injury. 3