Stuck catheters are becoming increasingly common due to the widespread use of tunneled catheters. Stuck catheters are typically diagnosed by nephrologists and often prompt multispecialty involvement, usually from vascular or cardiothoracic surgeons or interventional radiology (IR). Stuck catheters are understood to become tethered, typically to the superior vena cava, by fibrotic adhesions and stenosis that develop secondary to neointimal hyperplasia from shear forces relating to turbulent blood flow [3]. This is congruent with the situation that occurred in our patient and was demonstrated on our CT venogram outlined in Fig. 1. The first successful IR approach for the removal of stuck haemodialysis catheters was published in 2011 and was named the Hong technique. A guidewire is first introduced through a lumen of the affected line, followed by sequential endoluminal balloon dilatation along the length of the catheter, presumably disrupting fibrotic bands and concurrently treating central stenosis allowing easier removal of the line [5, 7]. Several case reports have since documented the use of modified Hong techniques or other balloon and snare strategies for stuck central lines of different kinds with excellent outcomes [3, 5, 7, 8, 9]. This include d a timely and uncomplicated removal of a stuck hemodialysis catheter tethered amidst pacemaker leads [8], suggesting IR as a favourable first-line approach.

Historically, rescue approaches for stuck catheters included “cutting and burying” the catheter to leave a portion in situ, or surgical removal following sternotomy [6]. There are limited data available on the safety and long-term outcomes of thoracotomy for stuck haemodialysis catheters. A recently published survey [2] of 72 stuck haemodialysis catheters across 30 centres in Italy revealed that 11 patients were not subject to advanced procedures, with 3 lines left in situ and the other 8 were buried. There was a 77% success rate for stuck catheters undergoing advanced procedures (47 were removed and 14 were left in situ or buried). Success rates were slightly higher (87%) in those undertaking sequential balloon dilation specifically (26 of 30 lines). However, 4 patients (13%) whom this approach was used had complications including a haemopericardium, catheter fragmentation, guidewire entrapment and severe pain requiring advanced anaesthetic support, suggesting that utilization of advanced procedures for stuck catheters should be done at a centre with advanced resuscitation support with access to intensive care and cardiothoracic surgery. Over 70% of the stuck catheters were at least 24 months old, suggesting time in situ is a risk factor for line incarceration. In terms of the feasibility and safety of burying these catheters, a retrospective case series examined the safety of cutting and burying stuck catheters in six patients, with mixed outcomes. Three of these patients needed anticoagulation for a chronic organising thrombus adjacent to the retained line and developed central stenosis, two of these patients successfully underwent transplantation with retained lines in situ. Of the three remaining patients, two eventually had the line removed by cardiothoracic surgery without the need for thoracotomy, and the last patient died of line-related sepsis. This approach predisposes to ongoing line-related access complications and should be considered as a last resort, although further observational data would provide insight into the longer-term safety of this approach.

Retrospective analyses have demonstrated that patients with stuck haemodialysis catheters often proceed directly to sternotomy or internalization of a retained line without being offered an IR approach first. This is probably a reflection of variability in training and experience with managing stuck haemodialysis catheters as well as clinical characteristics of the patients [6]. Forneris and colleagues have provided a thorough overview of safe management for stuck haemodialysis catheters, suggesting that unfamiliarity of IR techniques or limited experience in stuck dialysis catheters may contribute to unnecessary internalization or sternotomy [10, 11]. In centers limited by geographic considerations or resources, transfer to an IR-capable facility should be considered along with the patient characteristics prior to internalization. Among the options considered for removal of a stuck catheter, endoluminal sequential balloon dilatation appears to be the best approach [2]. Nephrologists should be aware of the utility of such techniques and consider its feasibility prior to discussing the best management strategy with the patient.

The KDOQI 2019 vascular access guidelines suggest that dialysis catheter utilization rates be limited to less than 20% of kidney failure patients, yet some centers have published prevalence as high as 42.9%, with a third of patient refusing AVF creation or subsequent revision or replacement [12, 13]. In a survey of perceived barriers and attitudes toward AVF creation and use, reasons for refusal varied from concern about the risks of surgery (42.5%), lack of understanding (23.3%), fear of needles (15.1%), denial of disease or need for HD (17.8%) and cosmetic reasons (1.4%) [13]. Naturally, prevention of long-term tunneled haemodialysis catheter use would reduce stuck catheter incidence, while poor fistula maturation, vessel quality and patient refusal are risk factors for dialysis catheter use long term [12, 13]. Improved nephrologist awareness to this complication is important in prioritizing and facilitating arteriovenous access creation, including an exploration and addressment of potentially modifiable reasons for patients that refuse fistula creation. The risks of a stuck haemodialysis catheter should be included in discussion when considering the optimal vascular access for a given patient, whilst also considering individual characteristics and goals of care.

Careful consideration should be made when assessing these patients for transplantation suitability considering the risks associated with stuck dialysis catheters. Fortunately, our patient tolerated the procedure well without complication. However, attempting to remove stuck dialysis catheters acutely following transplantation lends itself to unique considerations. Complications arising from advanced procedures including fragmentation or hemopericardium may place the patient at significant risk of morbidity including infection as well as chronic organizing thrombosis and potentially mortality. Further procedures may worsen graft dysfunction secondary to hypoperfusion or precipitate the need for blood transfusions. This may in turn increase sensitization, increasing the risk of rejection and complicating future transplantation. Furthermore, manipulation of the tract and introducing guide wires through a central line peri-operatively may carry a higher infection risk post immunosuppression and extended intravenous antibiotic coverage could be considered for difficult cases.