Dialysis catheters (DCs) play a crucial role in providing vascular access for hemodialysis in patients with end-stage renal disease (ESRD).1 Nevertheless, their utilization is not free of challenges. Among these, iatrogenic vascular injuries stand out as significant complications. Iatrogenic venous injury is a quite commonly reported complication of DC insertion.2 However, injury to the inferior vena cava (IVC) during this procedure is extremely rare and can have dire consequences.

We present a case of a 29-year-old woman with a history of ESRD, who was transferred to our hospital in a serious general condition subsequent to an unsuccessful attempt of femoral vein DC insertion at another medical facility. The procedure was carried out by an experienced physician, a specialist who had performed over 200 procedures of this type. The implanted material was a polyurethane HemoStar 14.5-F catheter (Becton Dickinson, Franklin Lakes, New Jersey, United States; total length, 28 cm; length from the cuff to the tip, 23 cm). The patient was not considered to be at an increased risk of perforation. Apart from ESRD, she was not diagnosed with any other diseases. She was not taking anticoagulants, antiplatelet drugs, or steroids. Computed tomography showed a substantial retroperitoneal hemorrhage stemming from the perforation of the IVC caused by the DC (Figure 1A–1E). The patient was operated on urgently; a laparotomy was performed. The catheter’s tip extended approximately 3 cm beyond the compromised vascular wall (Figure 1F). The management involved evacuation of an extensive retroperitoneal hematoma, coupled with extraction of the DC from the compromised venous wall, followed by IVC suturing. Subsequently, under X-ray control, a guidewire was threaded into the central canal of the IVC. The wire facilitated insertion of the DC into the appropriate venous lumen (Figure 1G). The postoperative period was uneventful. The catheter, now appropriately repositioned, facilitated continuation of the hemodialysis procedures.

Figure 1. A – computed tomography (CT), side projection, showing the dialysis catheter (arrows) in the perforated inferior vena cava. B – three-dimensional (3D) CT reconstruction image showing the dialysis catheter (DC; arrow) in the perforated inferior vena cava (IVC); the arterial system is visualized, while the venous system remains invisible. C – CT, axial section, showing a massive retroperitoneal hemorrhage; the DC is marked by the arrow. D – CT, coronal section, showing a massive retroperitoneal hemorrhage; the DC is marked by the arrow. E – CT, 3D multiplanar reconstruction, showing the DC (arrow) in the perforated IVC (outlined in purple); disruption of vessel wall continuity is visible. F – intraoperative image showing the DC (arrow) extending beyond the perforated IVC, and a surrounding hematoma; G – intraoperative X-ray image showing the repositioned DC (arrow) in the IVC lumen

Hemodialysis is a life-sustaining renal replacement therapy used to manage ESRD by removing waste products and excess fluids from the blood. While this procedure significantly improves the quality of life of patients with ESRD, the use of a DC to access the vascular system entails a range of possible complications that must be carefully considered.3 From infection and thrombosis to stenosis and malpositioning, these complications can lead to serious morbidity and mortality. A DC should be utilized only when vascular access options, such as arteriovenous fistulas and grafts, are unavailable or not suitable due to the patient’s medical condition or vessel quality.4 During catheter insertion, improper technique or anatomical variations can lead to inadvertent vascular perforation. It is reasonable to always have a backup plan in the case of periprocedural complications. Access to blood products and the possibility to perform a transfusion need to be ensured. The procedure should only be performed if the patient can be quickly attended to by an experienced surgical team, if needed. It is crucial to follow a detailed, elaborated prevention strategy to minimize risks. If the procedure is unsuccessful, the operator and the team should be provided with additional training before another attempt is made. In more complex cases, finding a more experienced operator might be worth considering. The position of the patient during femoral DC insertion is important; making slight hip rotations and using a pillow under the lower back might be helpful. In the case of resistance during insertion of the wire, retreating should be considered. If the patient can lie down, using the jugular vein for the DC insertion should be considered as an alternative. The use of imaging guidance, such as ultrasound or X-ray, may be helpful, especially in anatomically difficult cases.5 Fluoroscopy is a widely embraced technique for precise insertion and positioning of a cuffed DC. It boasts user-friendliness, exceptional accuracy, reliability, and a notably low incidence of complications. It facilitates accurate assessment of the position of the DC’s tip. When combined with continuous monitoring of the guidewire resistance, it serves to prevent inadvertent perforations. Real-time ultrasound plays an essential role in the insertion of the DC within the internal jugular veins. The DC implantation procedure may follow either the traditional Seldinger technique, relying on anatomical landmarks, or a contemporary approach involving direct visualization via ultrasound. Ultrasonography notably excels in the initial cannulation of the suitable vein. Nevertheless, the catheter placement can be easily confirmed with X-ray. Ultrasonography is a versatile tool used for various dialysis access procedures, including central venous catheter placements, vascular mapping, hemodialysis access establishment and maintenance, as well as peritoneal DC placements.

Perforation can damage vessel walls leading to massive, life-threatening hemorrhage. As medical research advances, innovations in catheter design and care protocols offer promise in reducing the risks associated with DC usage and in improving the overall quality of hemodialysis therapy.