Case Discussion about Fibrin Sheath, the culprit for CVC failure by Dr. Hardik B. Patel with Glom India

Fibrin Sheath is the culprit for Central Venous Catheter (CVC) failure.

38 years old female, k/c/o DM,DR and CKD stage V; on MHD came us with poor flow in her Tunneled Cuffed Catheter(TCC) and also, CRBSI(Catheter Related Blood Stream Infection).

In November 2017 she was initiated on HD through right IJV TCC. She had Left BC AVF (Brachiocephalic AV fistula) primary failure. She continued 3/week MHD(Maintenance Hemodialysis) with intradialytic weight gain of 3-4 kg and also experienced repeated hypotension episode after large volume rapid ultrafiltration.

No further attempt was made for AVF creation in view of repeated hypotension episode and poor vessels. She had one episode of CRBSI before coming to us.

In Feb 2018 she presented to us with CRBSI and poor flow in TCC, resulting in under dialysis and volume overload. At MPUH after starting her on treatment for CRBSI her right IJV TCC was changed to RT IJV DLC. After one session of HD again she had poor flow in DLC. Return through catheter was smooth but outflow was poor. Her catheter position was checked and it was normal.

Subsequently we pulled DLC slight back over guidewire in Cath lab and dye study was performed to rule out any sheath around catheter. Unfortunately, there was long fibrin sheath throughout the length of catheter and beyond it. We did fibrin sheath disruption with 8 mm balloon and placed new TCC through same channel. Subsequently her infection got cleared. She was dialyzed and dry weight reduction was done. After stabilization, she underwent right BC AVF construction.

Here, the take home message is that Fibrin sheath is one of the common cause for CVC(Central Venous Catheter) occlusion.

Figure 1 – Algorithm for management of a Central Venous Catheter Obstruction. CVC: Central Venous Catheter.

Catheter occlusion by fibrin sheath

A fibrin sheath is common causes for thrombotic obstruction of CVC. It can occur within 24 hours after catheter placement and usually develops within 2 weeks. Generally, it does not affect catheter function, but may cause outflow problem by creating a one-way valve over the catheter tip due to development of negative pressure while aspirating blood, which pulls the fibrin sheath over catheter tip. The obstruction resolves when there is inflow (as there is no negative pressure) allowing for easy passage of fluids into the catheter. So same we can observe in this case (outflow issues) that get relieved after fibrin sheath disruption.

Diagnosis requires dye study through catheter; if possible, dye study after catheter withdrawal is one of the best ways to detect any sheath formation. So, any long-term catheter change over guidewire should be preceded by dye study or, the same problem can happen in new catheter as well.

Sheath disruption with balloon is reasonably easy to perform and has a better long-term outcome.

In last one year we have done 5 sheath disruptions and, with every patients, we were able to use the same channel for a longer term. One of the patients had repeated sheath formation and required same procedure for more than once(unfortunately it is one and only access left for her).

 


Article Courtesy: Dr. Hardik B Patel

Dr. Hardik B Patel has done DNB Nephrology from Muljibhai Patel Urological Hospital, Nadiad (Gujarat) and MD from B J Medical College. He is currently working at Muljibhai Patel Urological Hospital, Nadiad as a Consultant Nephrologist and Transplant physician. He is having active interest in Intervention Nephrology.

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1 Comment
  1. […] have already discussed about fibrin sheath in last case report. Formation of a fibrin sheath begins at the venous insertion site and then propagates distally […]

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