Journal of the Louisiana State Medical Society
Malposition of a Hemodialysis Catheter in the Accessory Hemiazygos Vein
Brian Revis, MD; Mohammad Kazem Fallahzadeh, MD; Neeraj Singh, MD
Figure 1, Panel A
Panel B
A 30-year-old Caucasian female underwent a kidney transplant but experienced delayed graft function, neces- sitating dialysis. Her previous right internal jugular dialysis catheter had been removed during surgery. On ultrasound, her right internal jugular vein was found to be stenosed proximally, and a left internal jugular vein dialysis catheter (20cm, 12 Fr) was placed under ultrasound guidance with no complications. A chest X-ray was obtained to confirm the correct position, and it was concerning for cannulation of the aorta (arrow in Figure 1, Panel A). A blood gas analysis done from the dialysis catheter suggested venous blood. Fluoroscopy showed the catheter coursing from left internal jugular vein into the accessory hemiazygos vein (arrow in Figure 1 Panel B). The catheter was repositioned, and the tip was correctly advanced to the junction of superior vena cava and right atrium. For comparison, a chest X-ray image of a properly placed hemodialysis catheter in a different patient is demonstrated in Figure 2.
Hemodialysis catheters are associated with several complications such as pneumothorax, bleeding, arrhyth- mias, thrombosis, infections, andmalposition. 1 Malposition complicates 1% to 33% of hemodialysis catheter placements and should be promptly identified due to the risk of vas- cular laceration or perforation. 2 Malposition usually occurs within the major tributaries of the superior vena cava, including subclavian, internal thoracic, pericardiophrenic, and superior intercostal veins. 1 Hemodialysis catheters can also be misplaced outside the venous system into adjacent structures like pleura. 1 Physicians should also be aware of accidental arterial cannulation. 1 Cannulation of the acces- sory hemiazygos vein is rare but can happen when the ac- cessory hemiazygos vein drains into the left brachiocephalic vein instead of the azygos vein normally. 1 Interestingly, accessory hemiazygos vein has been reported to be used for placement of hemodialysis catheter in a patient with unusual anatomy of central venous system, including bilat-
26 J La State Med Soc VOL 166 January/February 2014
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