Dialysis catheter 'fibrin-sheath stripping': a cautionary tale!

Permcath@ (Quinton Instrument, Co. Seattle) was Introduction inserted and a primary arteriovenous fistula created in the operating theatre. Four weeks later the patient Dual-lumen cu ed catheters have assumed an increaspresented with a fever and subsequently Staphylococcus ingly important role for shortand long-term vascular aureus was cultured from his blood. The Permcath was access for the provision of life-sustaining renal replaceremoved and he was dialysed for 2 weeks via intermitment therapy. Dual-lumen cu ed catheters are particutent femoral catheters. Prior to discharge he had a larly useful for vascular access in patients with severe second Premcath inserted into to his left internal congestive cardiac failure or ischaemic heart disease jugular vein. Surveillance blood cultures after 4 weeks who cannot tolerate the increased cardiac output assoof intravenous vancomycin were sterile. Three weeks ciated with either a primary arteriovenous fistula or a later the catheter began to malfunction, and despite polytetrafluoroethylene (PTFE) graft. Dual-lumen the instillation of 5000 units of Urokinase it was catheters are also frequently used as a bridge to more not possible to achieve a blood flow of 300 ml/min. definitive vascular access, or in patients who have Utilizing meticulous sterile technique the patient underexhausted all traditional forms of vascular access. went an uncomplicated catheter stripping procedure in The most frequent reason for dysfunction of one of the angiography suite, with restoration of a blood flow these catheters is catheter thrombosis or the developrate of 400 ml/min. Six weeks later the catheter again ment of a fibrin sheath around the tip of the catheter. failed to provide adequate blood flow despite the We recently described a strategy for treating catheter instillation of urokinase into the catheter. dysfunction using a combination of intra-catheter He was referred for repeat catheter stripping. thrombolytic agents and snare-mediated fibrin sheath A catheter study was performed, which demoncatheter stripping [1,2]. The technique involves the strated a moderate sized fibrin thrombus at the end initial performance of a catheter study by the injection of the catheter (Figure 1). Subsequently a 25-mm of contrast through the catheter. If this confirms the Microvena@ gooseneck snare was introduced via the presence of a fibrin sleeve, a snare catheter (Microvena, femoral vein and a fibrin sheath was successfully White Bear Mountain, MN) is inserted through the removed from the catheter, with restoration of good femoral vein, and under fluoroscopic guidance the tip blood flow through the catheter and repeat contrast of the catheter is snared and the fibrin sleeve is injection through the central venous catheter showed ‘stripped’ from the end of the catheter. In our initial no evidence of the fibrin sheath. observation we noted this to be a safe and e ective Twenty minutes after completion of the procedure procedure without any complications. We have now performed this procedure on more than 100 occasions the patient experienced rigors, dyspnoea, tachypnoea, in 58 patients. tachycardia, fever of 40.1°C, and he became hypotensRecently we observed a serious complication of the ive with a systolic blood pressure of 90 mmHg. A procedure, which we report herein. clinical diagnosis of pulmonary embolus was made and he was placed on 100% inhaled oxygen. Arterial blood gases demonstrated an arterial 2 of 174 mmHg and Case report a pCO2 of 26 mmHg. He underwent an emergency ventilation/perfusion scan, which revealed an interA 54-year-old black male presented to Duke University mediate probability of pulmonary embolus (Figure 2). Medical Center with end-stage renal disease of The patient was treated with intravenous antibiotics unknown aetiology. A right internal jugular vein and heparin. The day after admission blood cultures were reported as growing Citrobacter freundii and coagulase-negative staphylococcus. Because the infecCorrespondence and o print requests to: Peter J. Conlon MB, MHS, tion was presumed to be arising from the Permcath, FRCPI, Division of Nephrology, Duke University Medical Center, Box 3014, Durham, NC 27710, USA. anticoagulation was discontinued and the catheter