A CT scan of the thorax on a 16-slice scanner was done in the unenhanced, first pass and delayed venous phase with standard image reconstruction algorithms. Due to his complaint of progressive facial and neck swelling, central venous occlusion was suspected and he was referred to our radiology department for a thoracic CT venogram as our center did not have fluoroscopic services to perform a diagnostic catheter venogram. Initial chest radiograph done on admission showed no significant lung pathology apart from mild blunting of the left costophrenic angle likely due to mild left pleural effusion. Exploration of the basilic vein at left distal arm was done with shortening of the vein and placement of a 3-cm (polytetrafluoroethylene) PTFE patch graft juxta anastomosis 2 weeks prior to presentation. An ultrasound done during that time noted severe juxta-anastomosis intimal hyperplasia. Due to slow flow and reduced thrill in the fistula for about 1 month prior to presentation, he was referred to a private AVF center for assessment. Since then, he was dialyzed via a left brachiobasilic fistula (BBF). He then had a long-term tunneled CVC insertion into his right internal jugular vein (IJV) for hemodialysis, which lasted for 2 years and was removed 5 years ago. However, after multiple episodes of infection, he was subsequently converted to hemodialysis via a CVC, which was changed every 2 weeks. Due to primary failure of his right brachiocephalic fistula, he was dialyzed via peritoneal dialysis. He had been on dialysis for the past 8 years since being diagnosed with end-stage renal failure secondary to nephrotic syndrome. He also complained of progressive neck and facial swelling for the past 2 weeks following a revision done to his arteriovenous fistula (AVF). We report a case of a retained calcified intravascular fibrin sheath causing central venous obstruction, mimicking a retained catheter fragment, which was diagnosed 5 years after removal of a long-term tunneled dialysis catheter in an adult with end-stage chronic renal disease.Ī 33-year-old male with underlying renal failure was referred from a dialysis center to our district hospital due to acute shortness of breath 3 h post-hemodialysis. When calcified, they may mimic a retained catheter fragment, causing diagnostic confusion and unnecessary interventions. reported that retained fibrin sheaths were present in 13.6% of 147 patients studied, of which 45% were calcified. Retained fibrin sheaths post-catheter removal are less common and are rarely calcified. These sheaths may cause various complications such as infection, venous thrombosis and even pulmonary embolism. Fibrin sheaths, also known as catheter-related sheaths, sleeves or cast are a common complication, with varying reported incidence ranging from 10 to 56% in radiology case series to as high as 100% in experimental studies. They are commonly inserted in the internal jugular, subclavian and femoral veins. Calcified fibrin sheaths should also be considered as a differential diagnosis of radio-opaque intravascular structures or venous calcifications post-CVC removal.Ĭentral venous catheters (CVC) are commonly used for various purposes, including drug administration, parenteral nutrition, fluid resuscitation, long-term venous access, blood taking, central venous pressure monitoring as well as hemodialysis. However, further scrutiny revealed a retained calcified intravascular fibrin sheath as the cause of occlusion.Īwareness of the radiological discriminating features of calcified fibrin sheaths are important to prevent misdiagnosis and unnecessary interventions as these sheaths may mimic retained catheter fragments. CT venography revealed a linear tubular hyperdensity within the right brachiocephalic vein and superior vena cava, which at first glance looked like a retained catheter fragment. We report a case of a patient with end-stage renal disease and a history of multiple prior CVC insertions presenting with symptoms of central venous occlusion post-revascularization of his stenosed arteriovenous fistula. When retained sheaths are calcified, they may cause diagnostic confusion on imaging, as they may mimic a retained catheter fragment. Post-catheter removal, these sheaths may sometimes be retained in the vein however, are rarely calcified. Long-term placements of central venous catheters (CVCs) are known to cause various complications, among which include fibrin sheath formation, causing catheter dysfunction, infection and thrombosis.
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