1Belfast City Hospital, 2Antrim Hospital, Northern Ireland. Migration of a tunneled haemodialysis catheter into a right-sided partial anomalous pulmonary venous connection M. McCavert1, R. Sathyanarayana1, W.C. Loan1, R. McCrory2, R. Mullan2, J. Hanko1, M.P. Quinn2 1Belfast City Hospital, 2Antrim Hospital, Northern Ireland.

Disclosures None

Clinical history 56 year old man End stage renal failure secondary to amyloidosis Admitted for urgent dialysis Unsuccessful non-fluoroscopically guided attempt at permcath insertion via RIJV Referred to IR

Chest radiograph: Mal-positioned permcath

CT chest: Haematoma overlying RIJV 

Intervention – Insertion of permcath via left IJV Ultrasound-guided LIJV access 14.5F 32cm permcath inserted through peel-away sheath Unable to advance fully due to kink in SVC Hydrophilic guidewire inserted through Permcath initially passed beyond right lateral wall of SVC

Initial course of guidewire (illustrated on pre-procedure chest radiograph)

? SVC perforation Patient asymptomatic and stable No pericardial or pleural effusion Wire subsequently negotiated into IVC and permcath advanced without difficulty

Post insertion of permcath Wire subsequently negotiated into IVC and permcath advanced without difficulty CT chest performed

CT chest post insertion of permcath Anomalous pulmonary vein Paste relevant images of the intervention. You might create an extra slide to show all the relevant images. 

Complication Patient well until 4 weeks later Developed dyspnoea and haemoptysis during dialysis with resolution shortly afterwards

Chest radiograph post dialysis Imaging revealed migration of the tip of the permcath into the anomalous vein with a fluid congested pulmonary segment distally.

CT chest - migration of permcath into anomalous vein.

Management New permcath inserted on contralateral side. Contrast injection through malpositioned permcath revealed no contrast extravasation so it was removed

Contrast injection via LIJV permcath

Patient continues to undergo dialysis via RIJV permcath 8 months later Outcome Patient continues to undergo dialysis via RIJV permcath 8 months later

Discussion: THE PATIENT Please switch to the presentation mode to tick/ untick the check boxes. Make sure to safe your changes afterwards. Was this the right patient for this treatment? Was the treatment the best option for this patient (what were the alternatives)? Where these alternatives discussed with the patient? Was the patient discussed in a multi-disciplinary team? Was a safety checklist filled out? Was the patient informed about this possible complication? yes no  ☐  ☐  ☐ ☐   ☐ ☐ 

Discussion: COMPLICATION Please switch to the presentation mode to tick/ untick the check boxes. Make sure to safe your changes afterwards. ☐ Wrong indication Material failure or choice Insufficient training Unexpected Avoidable Other ☐ ☐  ☐ ☐

Discussion Did the patient suffer from this complication? Please switch to the presentation mode to tick/ untick the check boxes. Make sure to safe your changes afterwards. Did the patient suffer from this complication? We managed and patient did well Prolonged hospital stay, no permanent sequelae Permanent sequelae (explain) Dead Other ☐  ☐ ☐ ☐

Partial anomalous pulmonary venous return (PAPVR) Rare (0.5%) Usually single anomalous vein Right upper pulmonary vein to SVC/RA most common Usually associated with ASD Can lead to arrythmia, right-sided heart failure and pulmonary hypertension

Literature: PAPVR and mal-positioned catheters Aberrant positioning of a central venous dialysis catheter to reveal a left-sided partial anomalous pulmonary venous connection. Chintu MR, Chinnappa S, Bhandari S.Vasc Health Risk Manag. 2008;4(5):1141-3. Anomalous venous anatomy leading to malposition and unusual complication of a left subclavian Hickman line. Jepson SL1, Kenningham R. J Vasc Access. 2013 Oct 1;14(3):301-2. Partial anomalous pulmonary vein drainage of the left lower lobe: incidental diagnostic after central venous cannulation. Sobrinho S, Salcher J. Crit Care Med, 2003. 31(4):1271-2

What have you learned from this complication? Consider anomalous veins when wires or catheters take unexpected course Extra care should be taken in the positioning of catheters in patients with anomalous pulmonary veins Determination of catheter tip position is essential in acutely unwell patient undergoing haemodialysis