Successful removal of stuck and infected haemodialysis catheter via endoluminal balloon dilatation after unsuccessful surgical cut‐down

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We describe a case of successful removal of an adherent dialysis catheter after an unsuccessful attempt with surgical cut down on the internal jugular vein. A 57‐year‐old female on maintenance haemodialysis via a left internal jugular tunnelled catheter (Hemoglide, BARD) had an attempted removal of her 17‐month‐old line after a leak was noted at the catheter hub. By this stage, she had just commenced full cannulation of a left brachiobasilic fistula which had been slow to mature. She had coincidentally been admitted to hospital 2 days prior for treatment of a urinary tract infection from which she was recovering.
Under sterile conditions and local anaesthetic, an incision was made in the tract, and the cuff was easily mobilised. The line was transected at the cuff, and the distal segment discarded. The clamped proximal segment was then withdrawn 3 to 4 cm. At this stage, despite moderate traction, the line appeared adherent at the clavicle. After surgical consultation, a CT venogram was requested that appeared to show scarring around the internal jugular vein. With the line clamped (but exposed), she proceeded to theatre the next day. Despite mobilising the IJ extensively and applying moderate axial traction, the catheter could not be removed. The line was then shortened more, transfixed with a suture and secured in the bed of the sternocleidomastoid muscle.
Blood cultures (from admission) were reported subsequently to be growing Candida parapsilosis, and this was presumed to be from the line. Although she continued to remain clinically well, she was taken back to theatre. Via the original incision line, a surgical cut down to the buried catheter was performed by the surgical team. The line was freed, and 014‐inch guide wires (V14, Boston Scientific) were inserted with pre‐loaded 5 mm × 100 mm long balloon catheters (Coyote, Boston Scientific) into each lumen via the open‐ended dialysis catheter lumina. Using fluoroscopic guidance, the balloons were briefly and simultaneously inflated to 12 atm along the length of the catheter at three overlapping stations. Figure 1 the catheter was then removed with no resistance or difficulty during careful entry site control and with subsequent surgical closure. The catheter was examined and confirmed to be intact. The tip was sent for culture, and this subsequently cultured the same species of Candida. She has remained well, and multiple subsequent blood cultures have remained sterile.
Multiple methods for removal of stuck lines have been described in the literature with only modest success with surgical techniques.1 Catheters can often be left in situ after an unsuccessful procedure, and this poses long‐term risks of infection and occlusion as has been our experience. Endo‐luminal dilatation is a safer and more effective procedure and, as our case demonstrates, can even be employed on catheters that have been buried. We believe surgery should be undertaken in patients only after failure of radiological techniques.
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