In this case report, we present the case of a 72-year-old Chinese male hemodialysis patient with catheter-related SVCS. The patient’s clinical symptoms improved after undergoing PTA and stenting of the superior vena cava (SVC). However, one week after the procedure, the patient developed hemorrhagic pericardial tamponade. Following pericardiocentesis, the patient was discharged in good condition with a functioning catheter.

A 72-year-old male patient presented with uremia, and had been receiving maintenance hemodialysis for the past five years. Following the diagnosis of end-stage renal disease caused by obstructive nephropathy, a left arteriovenous fistula (AVF) was created in 2014 for dialysis. Unfortunately, the AVF malfunctioned after only 9 months. As a result, a cuffed tunneled double-lumen dialysis catheter was placed in the right internal jugular vein (RIJV) of the patient in the local hospital. For various reasons (the absence of surgical facilities at the local hospital and the short duration of the initial fistula usage), the patient refused a second internal fistula surgery thereafter. The patient has been undergoing regular dialysis treatment for the past 5 years using this central venous catheter (CVC). He had experienced a catheter-related infection once. After antimicrobial therapy, the patient continued using the catheter for dialysis. His medical history included urinary calculi, obstructive nephropathy, hypertension and paroxysmal atrial tachycardia (arrhythmia).

In July 2019, the patient began experiencing dysfunction with his dialysis catheter. During dialysis, there was a noticeable decrease in blood flow (approximately 180–190 ml/min), and repeated intraluminal urokinase administrations (injecting steady doses of 5000 U/ml urokinase to fill the entire catheter lumen for 30 min) at the hemodialysis unit did not provide any improvement. As a result, the patient was transferred to our hospital for further treatment. Upon physical examination, the patient appeared well-oriented with stable vital signs. There was mild swelling in the right upper limb and a few visible dilated collateral veins over the chest wall. A slight catheter prolapse was also observed. Laboratory investigations revealed the following results: hemoglobin: 9.9 g/dL, serum calcium: 2.03 mmol/L, serum phosphorus: 2.32 mmol/L, blood urea nitrogen: 17.53 mmol/L, serum creatinine: 1153 umol/L, prothrombin time (PT): measured value 12.3 s (control value 12.2 s, ± 3 s), activated partial thromboplastin time (APTT): measured value 26.7 s (control value 29.5s, ± 10s), and fibrinogen: 4.32 g/L (2–4 g/L). Preoperative cardiac ultrasound showed no obvious abnormalities. A chest X-ray revealed that the distal ends of the catheter were positioned around the sixth thoracic vertebra (upper part of the SVC), suggesting a mispositioned catheter. Further enhanced computed tomography angiography (CTA) confirmed a clear occlusion of the lower part of the SVC, significant compensatory dilatation of the azygos vein, and the presence of abundant subcutaneous collaterals.

After diagnosing CVC-related SVCS, a procedure called PTA and endovascular stent placement was performed to treat the stenosis. A catheter was used to carry out a venography, which revealed that the downstream SVC (superior vena cava) from the distal end of the dialysis catheter to the entrance of the right atrium was almost completely blocked, with the occluded segment measuring about 3 cm in length (Fig. 1). During the operation, it was extremely challenging for wire (V-18 Control Wire, Boston Scientific, America, 0.018 in*300 cm) to pass through the severe stenosis. Several unsuccessful attempts were made to clear the occlusion in the SVC. A 6 F sheath dilator was introduced, followed by the insertion of a supporting catheter to hold the opening of the superior vena cava. Later, the V-18 guidewire’s hard tip was used to attempt sharp opening. The advancement of the guidewire met with significant resistance. A “smoking” appearance became noticeable after the guidewire progressed a certain distance, followed by an outward spillage of the contrast agent. Considering that the sharp opening by the guidewire did not enter the lumen of the superior vena cava blood vessel, it may have pierced the vessel and entered the mediastinum. The guidewire was then withdrawn, and the soft tip end of the guidewire was used for further attempts. The patient had no complaints of discomfort and there were no changes in vital signs. The surgery proceeded. During the attempt, the guidewire eventually entered the lumen of the superior vena cava through the right side of the dialysis catheter and confirmed entry into the true lumen of the superior vena cava. Balloon (5 mm) dilation was then performed, followed by the release of a 13 mm*5 cm covered stent (Viabahn, Ameica) to restore blood flow in the SVC (Fig. 2). The follow-up angiography showed that the stent expansion was successful, and the blood flow in the superior vena cava has been fully restored, with no leakage of contrast agent, with no further visualization of peripheral collateral circulation. At the same time, the dialysis catheter was replaced in its original position with both distal ends located inside the right atrium, using the guidewire. No fibrous sheath or thrombosis was found in the original catheter. After the operation, the patient was prescribed anticoagulant therapy with enoxaparin sodium injection (4000 IU, administered via hypodermic injection, once daily). Coagulation tests conducted 4 days post-operation showed the following results: prothrombin time (PT) measured value of 12.8 s (control value 11.9 s, ± 3 s), activated partial thromboplastin time (APTT) measured value of 37.1 s (control value 28.7 s, ± 10 s), fibrinogen level of 5.05 g/L (normal range: 2–4 g/L). The swelling in the patient’s right upper limb was gradually subsiding, and the dilated veins on the chest wall had also diminished. The catheter functioned well, with blood flow increasing to 280 ml/min during dialysis.

Venography. Venography revealed nearly complete occlusion of the distal end of the catheter in the superior vena cava (SVC). (Arrow: azygos vein; triangle: SVC)

Blood flow restoration after intervention. Venography conducted through the catheter demonstrated restoration of blood flow in the SVC

However, one week after the intervention, the patient began experiencing worsening chest tightness and shortness of breath. Before hemodialysis, the blood pressure was measured at 120/95mmHg and heart rate at 110 beats per minute. However, after 3 h of dialysis with an ultrafiltration of 2200 ml, the patient suddenly developed hypotensive shock with a blood pressure of 84/60mmHg, respiratory rate of 30 breaths per minute, heart rate of 168 beats per minute (showing atrial tachycardia on electrocardiogram), and oxygen saturation of 80% as measured by pulse oximetry. Following rescue efforts, a chest CT scan revealed pericardial effusion (Fig. 3). Approximately 600 ml of bloody fluid was drained through pericardiocentesis, which alleviated the patient’s symptoms of cardiac tamponade. After excluding pericardial effusion caused by tumors or inflammation, we considered the newly developed hemorrhagic pericardial effusion to be related to the endovascular treatment. Eventually, the patient was discharged in good condition with proper functioning of the catheter. The patient has not experienced any recurrence of SVCS, and thus far, the catheter has continued to work well during follow-up visits. We recommended that the patient undergo another venous fistula surgery, but the patient has not agreed so far.

Postoperative chest CT examination. Chest CT examination revealed the presence of pericardial effusion (star)