Malpositioning of a Tunneled Hemodialysis Catheter into the Azygos Vein: A Case Report and Literature Review

tured under local anesthesia without any guidance. Nonpulsatile blood flow was obtained before vessel dilation and catheter insertion. A Palindrome TM tunneled catheter (14.5 Fr, symmetrical tip, 36 cm) was placed. The blood from the catheter was aspirated and flushed readily. A routine anteroposterior chest radiograph was performed to assess the catheter tip position following catheter placement. It was noted that the catheter tip kinked apparently, inclined medially at the right tracheobronchial angle ( Fig. 1 a). Persistent and mild back pain developed. Therefore, malpositioning of the catheter tip into the azygos vein was suspected. An axial CT scan confirmed the suspicion ( Fig. 1 b).The catheter was withdrawn and placed again through RIJV under the fluoroscopy guidance. The catheter tip was in proper position this time. Risk factors for malpositioning into the azygos vein include left internal jugular venous access, use of catheters with long venous tips, and catheter insertion in a patient with fluid overload [6] . However, the patient under reference had no fluid overDear Editor, The percutaneous catheterization of central veins is increasingly used in nephrological practice as a permanent vascular access. Jugular vein catheterization is considered to have the lowest risk of complications and is usually the site of choice for catheter placement. To achieve the best outcome, the tips of the catheter should be positioned in the superior vena cava, the cavoatrial junction [1] . Inadvertent placement of a hemodialysis catheter into the azygos vein through the right internal jugular vein (RIJV) is rare and difficult to detect [2] , and to our knowledge, there were only 3 such cases reported to date [3–5] . We present a case of an uncommon cannulation of the azygos vein through RIJV with a tunneled hemodialysis catheter. A 47-yearold female patient was admitted to the department of Nephrology. She was diagnosed with end-stage renal disease and hemodialysis had to be initiated immediately because nausea and vomiting had developed half a month ago. Therefore, tunneled dialysis catheter was the preferred vascular access for her. The RIJV was easily puncReceived: January 27, 2017 Accepted: April 6, 2017 Published online: April 29, 2017