1. 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.

2. Disclosures
None

3. 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

4. Chest radiograph: Mal-positioned permcath

5. CT chest: Haematoma overlying RIJV

6. 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

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

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

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

10. 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. 

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

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

13. CT chest - migration of permcath into anomalous vein.

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

15. Contrast injection via LIJV permcath

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

17. 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  ☐  ☐  ☐ ☐   ☐ ☐ 

18. 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 ☐ ☐  ☐ ☐

19. 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 ☐  ☐ ☐ ☐

20. 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

21. 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):
Anomalous venous anatomy leading to malposition and unusual complication of a left subclavian Hickman line. Jepson SL1, Kenningham R. J Vasc Access 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, (4):1271-2

22. 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