Central venous catheters are used for delivering medications and parenteral nutrition, measuring hemodynamic variations, and providing long-term intravenous access. In our clinic, during liver transection using a living-liver donor, peripherally inserted central venous catheters are generally preferred because they involve a less invasive technique with a lower risk of complications. In this report, we present the case of a 36-year-old male liver donor into whom we peripherally inserted a central venous catheter from his left basilic vein. After transecting the hepatic vein, the surgeon found foreign material inside the venous lumen, which turned out to be the distal segment of the catheter.

Key words : Donor hepatectomy, Venous access, Catheter malposition, Peripherally inserted central venous catheters

Introduction

Central venous catheter (CVC) insertion is a common procedure used in providing parenteral nutrition, delivering medications, measuring hemodynamic variations, and providing long-term intravenous access. During CVC insertion, several complications have been observed, such as pneumothorax, infection, malposition, arterial puncture, hematoma, and thrombosis. Owing to a low complication rate, the use of peripherally inserted central venous catheters (PICCs) is preferred in some cases. In our clinic, we generally prefer to insert a PICC into a liver donor. Here, we present a case in which the distal tip of a CVC was found inside the grafted hepatic vein after being inserted from the left basilic vein of a liver donor.

Case report

A 36-year-old man weighing 67 kg with a height of 164 cm presented to our hospital to be a liver donor to his son, who had been diagnosed with cholestatic hepatitis. The donor was assessed as American Society of Anesthesiologists physical status class I. To induce general anesthesia, we administered 0.03 mg/kg midazolam, 2 mg/kg fentanyl, and 0.5 mg/kg rocuronium. For anesthesia maintenance, we administered 2% sevoflurane in a 50%/50% oxygen–air mixture and remifentanil (0.05 mcg/kg/min) and started an infusion of rocuronium (0.01 mg/kg/min). After inducing anesthesia, we inserted peripherally a CVC through left basilic (Cavafix 14G, 70 cm, Braun Duo 475, Melsungen AG, Germany) and pushed it forward 70 cm. No difficulty or obstruction was observed during catheter insertion.

During donor hepatectomy, the surgeon dissected the left hepatic vein and noticed a certain toughness about the vessel lumen. After transecting the hepatic vein, the surgeon found foreign material inside the vein lumen. The foreign material was found to be the 4-cm distal segment of the catheter, which had been inserted from the left basilic vein (Figure 1). After the surgeons cut off a 5-cm piece of catheter during hepatic vein dissection, we continued to use the catheter in the procedure after removing it 12 cm out of its malposition (Figure 2). The operation continued without any other complications, and the liver transplant was completed successfully.

Discussion

Central venous catheter insertion is a simple and relatively inexpensive method for monitoring central venous pressure; administering some drugs, blood, and blood products; giving parenteral nutrition; and providing long-term intravenous access.^1,2 The commonly preferred technique for inserting CVCs is through the internal jugular or subclavian veins; however, a CVC also can be peripherally inserted (Figure 3).¹ A PICC is a trusted and essential component of modern-day critical care medicine and anesthesiology.² More than 15% of patients with CVCs inserted, experience catheter related com­plications.² As compared to PICC, CVCs have been reported to have a lower risk of complications.³ Numerous trials of this intervention have shown an increased risk of complications. Thromboembolic complications have reportedly occurred in 2% to 26% of patients, infectious complications occurred in 5% to 26%, mechanical complications occurred in 5% to 19%, and catheter malpositions occurred in 3% to 4%.^2,4 Catheter malposition can induce complications that are potentially fatal.² In addition, catheter malposition can lead to incorrect measurement of central venous pressure, intravascular clot formation, catheter erosion, and increased risk of chemical and bacterial thrombophlebitis.¹ Peripherally inserted central venous catheters have been suggested as an alternative to standard CVCs because PICCs have a lower rate of adverse events.

Catheter malposition locations for PICCs are the upper or middle third of the superior vena cava (36%), the ipsilateral subclavian vein (27%), the right atrium (15%), the ipsilateral internal jugular vein (12%), and the axillary vein (6%); rarely, a PICC can be coiled in the superior vena cava.^5,6 In the literature, Lindner and associates accidentally found a hemodialysis catheter tip inside the hepatic vein,⁷ and Josiak and associates incidentally found a PICC inside the renal vein during thorax tomography.8 However, no similar cases of finding a PICC inside the hepatic vein have been reported.

In our case, a living donor was donating part of his liver to his son. During the transplant procedure, we inserted the catheter from his left basilic vein, drew it through the superior vena cava, right atrium, and inferior vena cava, and reached the left hepatic vein. As a result of this successful procedure, it appears that catheters such as Cavafix are unlikely to confer the risk of malposition complications related to their longevity.

References:

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