Maintenance of definitive vascular access (VA) for patients with end-stage renal disease can be a challenge, particularly in those who have been established on hemodialysis (HD) for many years. The optimal access route for patients on HD has long been thought to be an arteriovenous fistula (AVF), as high blood flow rates and improved clearance can be achieved, furthermore there are reduced risks of long-term complications and often financial benefits compared with other types of long-term VA (e.g., arteriovenous grafts and tunneled HD catheters [THCs]).1, 2, 3 Over recent years there has been an increase in the number of patients commencing HD via THC due to the ease and speed by which VA can be obtained using this method.4 UK Renal Registry data suggest that as many as 50% of incident HD patients commenced HD via THC or temporary central venous catheters (CVCs) in 2018. Furthermore, a significant proportion of prevalent patients on HD continue to dialyse via THC at 1 year.
THCs are considered to be a less desirable form of long-term HD access because of the increased risk of complications and all-cause mortality, when compared with other forms of VA.5, 6, 7, 8 Common complications include localized and systemic infections, central venous thromboses (CVTs) and stenosis, and poor blood flow.9,S1 The use of AVF for HD, although preferred, also can be associated with complications, including infection, aneurysm, ischemic steal syndrome, venous hypertension, and thrombosis.
We present a case of a patient who presented with chest pain while dialysing through an AVF, after previously starting HD via a left internal jugular THC. Investigation demonstrated a mediastinal hematoma, hemopericardium, and hemothorax from a bleeding mediastinal collateral vessel. To our knowledge, there are no previous reports describing this presentation. It highlights the risks of THC use as well as the importance of, where possible, establishing optimal long-term access in the form of an AVF in all patients before commencing HD.
Reference:Roper, T., De Figueiredo, F., Ammar, T. and Ford, M. (2020) Collateral Damage-The Risks of Central Venous Hemodialysis Catheters. Kidney International Reports. 5(5), p.746-750. doi: 10.1016/j.ekir.2020.02.1029. eCollection 2020 May.