Case 13: Tunnelled Dialysis Cath insertion done elsewhere. Referred for no backflow. What next? . #irad #MedTwitter #MedEd SIR RFS SIR ECS Society of Interventional Radiology Keith Pereira MD, #VIrad Keerthi Prasad Kumar Madassery Lorenzo Patrone Mark Lessne, MD Srini Tummala MD FSIR FSVM Venkat Tummala MD MBA

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Never seen a trans-venous PTEG access before

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Classic dilation from left IJ perf through bottom of left brachiocephalic. Pull over a wire and drop some coils at the perf site. Find who did it and educate.

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai extravascular space. It occurs when wire is pushed and it penetrates through posterior wall. Take similiar jugular access , negotiate into IVC, take balloon catheter and put it at same site where there must be rent at crossing point. Slight inflation , remove previous catheter.

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Agree mediastinal placement- prob inject to check on esophagus . Curious where it left the vein… Seen 1 case of esophageal perf from tunneling …

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Easy diagnosis even on the xray.. catheter in the azygos.. remove and reposition. Is the SVC thrombus chronic? To try to aspirate/remove it should be considered to avoid SVC obstruction in the future...

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Felt it’s actually in the mediastinum. Not in a vein or collateral. As per the CT

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai The final distal ct images are concerning for possible esophagus. Which is just plain weird.

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Yes. Looks like it’s in the paraesophageal soft tissue. In the mediastinum. Probably due to rough wire manipulation

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Obviously need to determine if esophageal perf is real. Water-soluble contrast study either fluoro or CT. If no leak, pull the catheter. If the esophagus is perforated, get your friendly esophageal surgeon involved to discuss mgmt.

@SIRRFS @SIR_ECS @SIRspecialists @keithppereira @KprasMD @kmadass @vascularIR @LessneVIR @SriniTummala @t_intheleadcoat @_backtable @IVISymposium @Vascular_India @iRadRock @TheRealDoctorOs @monteromiguel @IRadPatwary @iRadBIR_Chennai Does look a lot like it’s in the esophagus but that would be close to impossible to achieve, but hey who knows? Endoscopy and if no esophageal perf then just pull.