Atypical placement of hemodialysis catheters in patients with complete and irreversible obstruction of central venous vessels.

Purpose: This article describes the approach to atypical placement of central venous catheters (CVC) in dialysis patients with complete untreatable obstruction of central venous vessels.
Methods: Five patients with complete obstruction of central venous vessels underwent CT venography and digital venous angiography. After ultrasound-guided and radioscopic-assisted cannulation of the internal jugular vein, permanent CVCs were placed in atypical locations: in two patients a preliminary venous angioplasty was performed to facilitate the catheter positioning in a mediastinal enlarged collateral vein and in a persistent left superior vena cava; in three patients the CVC was placed in the azygos vein, enlarged because of the obstruction of the superior vena cava.
Results: In all cases, we achieved satisfactory morphological and functional immediate results. Hemodialysis (HD) was carried out long term in all patients except one who presented a non-functioning CVC after 4 months. In one case the catheter, still functioning well after 9 months, was removed due to kidney transplantation. The CVC in the left superior vena cava was replaced with a longer one after 12 months, and it is still functioning well 3 months after replacement. The patency of the other two catheters has to date been kept for 9 and 18 months.
Conclusions: The placement of CVC for HD in atypical sites can be considered a viable option in extreme cases; adequate imaging support is paramount in order to facilitate the procedure and to avoid complications.