Migration of hemodialysis catheter into the heart:: A case report
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A woman in her fifties was admitted to our hospital with generalized weakness in July, 2008. Her blood urea nitrogen was 102.1 mg/dL and creatinine was 9.9 mg/dL. We performed hemodialysis with catheterization into her right femoral vein on the admission day. The catheter was an Argyle<SUP>®</SUP> double lumen hemofiltration catheter, slide type. Four days later, the catheter was exchanged using a guide wire because of blood flow failure. In 2010, the migration of the catheter into her heart was discovered in another institute. Retrospectively chest X-ray imaging in our hospital after the replacement procedure showed that the inner catheter had migrated into the right ventricle via the superior vena cava and the right atrium. It was retrospectively clarified that the catheter had separated into the inner and outer parts because of cutting at the bifurcation, and so the inner catheter had migrated into the patient's heart. In the catheter manual, there is a caution which states that; "cutting is prohibited because of the risk of migration into the patient's body". This accident was due to a very careless mistake in the catheter replacement procedure. We very deeply regretted that one of our staff had replaced catheter without reading the manual. Reading a manual for a catheter, or indeed any piece of equipment, is a fundamental attitude that all physicians should continuously bear in mind, especially when they have had no prior experience with the same type of catheter. This patient has been carefully followed up with warfarin, and a pulmonary embolism was found with a regular pulmonary blood flow scintigram in August, 2012. We increased the dosage of warfarin immediately. There has been no symptom so far. We report herein on a case with migration of a hemodialysis catheter into a patient's heart because of a very careless mistake on the part of our staff.
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