Single-lumen displacement of a hemodialysis catheter into the azygos vein on a chest radiograph
Article information
A 59-year-old male patient with a history of heart failure, end-stage renal disease for which he was receiving hemodialysis via a tunneled catheter, coronary artery disease, and hypertension presented with weakness. Initial evaluation revealed hyperkalemia and no evidence of fluid overload on exam or bedside ultrasound. Nephrology was consulted for hemodialysis, and a chest radiograph was ordered.
The radiograph demonstrated malposition of the catheter, with one lumen in the azygos vein and the second in the right brachiocephalic vein (Fig. 1A). Interventional radiology was consulted for catheter replacement to allow hemodialysis to be safely performed (Fig. 1B).
Chest radiograph images. (A) Malposition of the hemodialysis catheter with one lumen in the azygos vein (white arrow) and the second at the junction of the right brachiocephalic vein and superior vena cava (black arrow). (B) Correct position of the hemodialysis catheter (black arrow) based on the patient’s chest radiograph during his last emergency department visit.
Hemodialysis catheters have a 1-year complication rate of 30% [1]. Complications can include thrombosis, infection, dislodgment, and stenosis. Central venous catheters can also migrate with patient position; therefore, initial correct placement does not ensure fixed placement in the original location. While the right internal jugular vein (IJV) is the preferred insertion site, the left IJV may be used when the right is contraindicated [2]. Risk factors for displacement include left IJV placement (due to increased length and reduced entry angle from the left brachiocephalic vein), insufficient insertion depth, and increased right atrial pressure, which dilates the azygos vein [3,4]. Recognizing azygos vein displacement is essential due to increased risk of thrombus, vessel perforation, and stenosis [5]. The azygos vein runs along the right thoracic vertebra and branches upward and medially into the superior vena cava. This migration can be identified on a chest radiograph as a catheter that runs obliquely across the midline and then follows a caudal and medial course or abrupt bending of the catheter tip [6]. Once identified, repositioning is necessary before using the catheter for hemodialysis.
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Ethics statement
Written informed consent for publication of the research details and clinical images was obtained from the patient.
Author contributions
Conceptualization: MG; Investigation: all authors; Project administration: all authors; Supervision: MG; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
Michael Gottlieb is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
References
Article information Continued
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Capsule Summary
What is already known
Hemodialysis catheters can be misplaced or migrate to an inappropriate position, which increases the risk of complications such as thrombosis, vessel perforation, and stenosis, as well as malfunction of the line itself.
What is new in the current study
This case highlights the importance of recognizing a malpositioned hemodialysis catheter lumen within the azygos vein on chest radiography to prompt specialist consultation for replacement to avoid complications.