Department of Nephrology, University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
Core Laboratory, University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
Blood Purif. 2019;48(1):1-9. doi: 10.1159/000497231. Epub 2019 Feb 14.
Central venous catheter (CVC) is commonly used to provide access for hemodialysis (HD) when arteriovenous access is not available. The misplacement of CVC into azygos vein (AV) is a rare but a potential serious complication. Previous reports communicated the opinion that left-sided catheterization predisposed to AV misplacement, but these reports concentrated on peripherally inserted CVCs, placed for indications rather than HD. Unintended AV misplacement of HD catheters (HDCs) has not been well studied. We seek to investigate factors associated with inadvertent AV miscannulation during HDC placement.
We are to present a case of unintentional misplacement of a tunneled HD catheter (tHDC) into the azygos arch from right internal jugular vein (RIJV) despite real-time fluoroscopy guidance. Additionally, we have undertaken a systematic literature search in Pubmed to study the anatomical and other factors related to unintended AV misposition in HD setting.
From 2005 to August 31, 2018, a total of 11 articles containing 16 cases of misplacement of HDCs into AV were identified. Of the 17 cases of unintentional AV misposition including ours, the majority of the misguided HDCs (94.1%, 16/17) were tHDCs and only 1 case was related to a temporary (non-tunneled) catheter. Most catheter misplacements (88.2%, 15/17) were performed without real-time radiological guidance. The reported incidence of inadvertent AV cannulation from different institutions varied between 0.6% and 3.8%. Among the 16 misplaced tHDCs, the rates of AV misposition that arose from RIJV and left internal jugular vein (LIJV) insertion are even at 50%.
Based upon anatomical and case studies, we have found that AV may join posterior aspect of superior vena cava at different directions and levels. Hence, this might explain why AV misplacement might occur whether an HDC is inserted from the LIJV or RIJV approach. By raising the awareness of this potential complication and how we may minimize it, we hope to reduce the future complication of AV misposition.
当动静脉通路不可用时，中心静脉导管（CVC）常用于提供血液透析（HD）通路。CVC 误入奇静脉（AV）是一种罕见但潜在严重的并发症。以前的报告表明左侧置管更容易导致 AV 错位，但这些报告集中在因其他原因而非 HD 而插入的外周插入的 CVC 上。HD 导管（HDC）意外误入 AV 尚未得到很好的研究。我们旨在研究与 HD 导管放置过程中无意 AV 置管相关的因素。
我们将介绍一例从右颈内静脉（RIJV）隧道 HD 导管（tHDC）意外误入奇静脉弓的病例，尽管进行了实时荧光透视引导。此外，我们还在 Pubmed 上进行了系统文献检索，以研究与 HD 环境中无意 AV 错位相关的解剖和其他因素。
从 2005 年 8 月 31 日，共确定了 11 篇包含 16 例 HDC 误入 AV 的文章。在包括我们在内的 17 例无意 AV 错位中，大多数误导性 HDC（94.1%，16/17）为 tHDC，仅有 1 例与临时（非隧道）导管有关。大多数导管错位（88.2%，17/17）在没有实时放射学指导的情况下进行。不同机构报告的无意 AV 插管发生率在 0.6%至 3.8%之间不等。在 16 例错位的 tHDC 中，从 RIJV 和左颈内静脉（LIJV）插入的 AV 错位率相同，均为 50%。
基于解剖和病例研究，我们发现 AV 可能以不同的方向和水平连接上腔静脉的后侧面。因此，这可能解释了为什么无论 HDC 是从 LIJV 还是 RIJV 插入，都可能发生 AV 错位。通过提高对这种潜在并发症的认识以及如何将其最小化，我们希望减少未来 AV 错位的并发症。
