Video-assisted minithoracotomy for right atrial hemodialysis catheter placement after vascular access exhaustion: Two case reports

Figure 1 Preoperative venography showing obstruction of the left jugulosubclavian venous confluence, right brachiocephalic trunk, and thrombosis of the inferior vena cava.

Figure 2 Selective intubation using a bronchial blocker. A: Right bronchial blocker insertion under flexible bronchoscopy guidance; B: Final positioning confirmed by bronchoscopy.

Figure 3 Minimally invasive thoracic approach under video-assisted thoracoscopy. A: Anterior right minithoracotomy incision in the third intercostal space (arrow), and second intercostal space for thoracoscopic port insertion (asterisk); B: Final thoracoscopic camera positioning.

Figure 4 Placement of the hemodialysis catheter. A: Purse-string suture with 3-0 polypropylene for vascular control and fixation; B: Right atriotomy performed with cold scalpel; C: Enlargement of the atriotomy with Kelly hemostatic clamp; D: Insertion of the hemodialysis catheter.

Figure 5 Postoperative evaluation of the right intra-atrial catheter. A: Transesophageal echocardiography confirming correct catheter position (arrow); B: Postoperative chest radiograph showing adequate pulmonary re-expansion; C: Eight-month outpatient follow-up demonstrating functional catheter without complications.

Figure 6 Final outcome of high-flow right intra-atrial catheter placement in a patient with multiple previous vascular accesses. A: Intraoperative view through video-assisted anterior right minithoracotomy; B: Postoperative chest radiograph confirming correct hemodialysis catheter positioning; C: Multiple thoracic and abdominal scars from previous dialysis access procedures.

Figure 7 Graphical illustration of video-assisted right minithoracotomy for right atrial hemodialysis catheter placement. The thoracoscopic port is introduced through the second intercostal space and the anterior right minithoracotomy is performed in the third intercostal space to allow catheter insertion into the right atrium. VATS: Video-assisted thoracic surgery; ICS: Intercostal space.