I want to run this interesting case by all the experts to get their insights:
A 62 year old male using a right IJ tunneled catheter for dialysis presented for a dysfunctional catheter. A preoperative examination showed good flow from both ports. However, considering the long duration of the catheter, a cathetergram was done after retracting the tip high in the neck. It showed a fibrin sheath, as expected. It was angioplastied and free flow of contrast was demonstrated. Catheter was replaced but had a 'catch' to suction of either port. Repeat cathetergram (Figure 1) suggested either a remnant of fibrin sheath or brachiocephalic vein stenosis which was angioplastied (Figure 2). The catch persisted but was intermittent. Patient left without dialysis.
At this point, I have the following questions:
Q1. What does the figure 1 show- left over sheath vs. brachiocephalic stenosis?
Q2. Does anyone have a different technique to ensure that the sheath is completely disrupted?
Q3. In either case, the tip of the catheter was in lower right atrium. Why was there resistance to suction?
The patient returned 4 days later as the catheter was again found to be 'positional' in dialysis. Repeat cathetergram (figure 3) showed a well formed sheath again (in 4 days!). This was angioplastied and catheter was replaced, but the 'catch' was again evident. The patient was convinced to get an AVG placed the next week and was sent to dialysis where it was able to be done, with only occasional alarm.
Q4. What else can be done to diagnose the issue?
Q5. Is the time to reformation of sheath proportional to the dwelling time of catheter?
Q6. Would use of antiplatelet of anticoagulant help reduce growth of sheath at all?
A week later, the patient returned for similar issues. A new IJ catheter was placed on the left side. Patient is scheduled to get an AVG placed.