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

Abstract

BACKGROUND

End-stage renal disease (ESRD) continues to increase worldwide, and long-term hemodialysis requires reliable vascular access. Progressive exhaustion of peripheral and central venous routes poses a major therapeutic challenge and may necessitate unconventional surgical strategies.

CASE SUMMARY

We report two patients with ESRD and complete depletion of conventional vascular access who underwent direct right atrial hemodialysis catheter placement via video-assisted thoracoscopic minithoracotomy. The first patient was a 68-year-old man with extensive central venous thrombosis and multiple failed catheterizations. The second was a 32-year-old woman with lupus-related ESRD, recurrent catheter infections, and previous thoracic surgeries. In both cases, intra-atrial catheter placement was successfully achieved under direct thoracoscopic visualization. Both patients experienced uneventful postoperative courses, immediate catheter functionality, and sustained hemodialysis efficacy during an eight-month follow-up period.

CONCLUSION

Video-assisted minithoracotomy is a safe, effective salvage approach for right atrial hemodialysis catheter placement in patients with exhausted vascular access.

Key Words: Hemodialysis; End-stage renal disease; Vascular access; Right atrium; Video-assisted thoracic surgery; Case report

Core Tip: Patients with end-stage renal disease and complete exhaustion of conventional vascular access represent a major therapeutic challenge. This report of two cases highlights video-assisted right minithoracotomy as a minimally invasive salvage strategy for direct right atrial hemodialysis catheter placement, providing durable access and satisfactory mid-term outcomes in highly complex patients when performed in specialized centers.

INTRODUCTION

End-stage renal disease (ESRD) continues to rise globally, with projections estimating over 5.5 million patients requiring dialysis by 2030[1]. The main modalities of renal replacement therapy include hemodialysis, peritoneal dialysis, and continuous renal replacement therapy[2].

A reliable vascular access remains essential for effective hemodialysis, with the arteriovenous fistula regarded as the gold standard for long-term use. However, access failure due to thrombosis, stenosis, or infection often compromises its durability[3]. Peritoneal dialysis may also be contraindicated in patients with encapsulating peritoneal sclerosis (“frozen abdomen”), further complicating management.

When both conventional and alternative venous routes are exhausted, temporary accesses carry significant risks-infection, thrombosis, hemorrhage, and increased mortality[4]. In such scenarios, central mediastinal approaches may represent the final option for hemodialysis catheter placement.

Previous reports have described direct right atrial catheterization through thoracotomy, sternotomy, or parasternal minithoracotomy as feasible alternatives. Nevertheless, minimally invasive video-assisted thoracic surgery (VATS) allows enhanced visualization, reduced surgical trauma, and shorter recovery, representing an evolutionary step in this field[5,6].

However, these open approaches are associated with greater surgical trauma, increased postoperative pain, and longer hospital stays, which may be poorly tolerated in patients with ESRD and multiple comorbidities. In this context, minimally invasive VATS represents a necessary evolution, as it provides superior anatomical visualization, allows continuous visualization of the entire surgical team throughout the procedure, and enables rapid identification and immediate management of intraoperative complications.

Additionally, VATS minimizes chest wall trauma, facilitates precise catheter positioning under direct vision, reduces postoperative morbidity, and promotes faster recovery when compared with conventional open thoracic approaches, thereby justifying the use of advanced technology in highly complex patients with exhausted vascular access.

Importantly, VATS provides continuous and comprehensive visualization of the entire surgical field and all operative instruments throughout the procedure, enabling immediate recognition and prompt management of intraoperative complications, thereby enhancing procedural safety in these critically ill patients.

Herein, we report two complex ESRD cases requiring VATS-assisted right atrial catheter placement after complete exhaustion of peripheral and central vascular access routes.

CASE PRESENTATION

Chief complaints

Case 1: A 68-year-old man with ESRD requiring chronic hemodialysis and complete depletion of peripheral vascular access.

Case 2: A 32-year-old woman on maintenance hemodialysis presented with recurrent catheter-related infections.

History of present illness

Case 1: The patient presented with the inability to establish new vascular access for hemodialysis due to progressive central venous obstruction after multiple catheter placements and removals.

Case 2: She had persistent bloodstream infections related to femoral catheter use in the context of progressive vascular access exhaustion.

History of past illness

Case 1: His medical history included chronic pulmonary thromboembolism, systemic hypertension, protein C and S deficiency, hyperhomocysteinemia, and severe stenosis of the right brachiocephalic trunk, superior vena cava, and left jugulo-subclavian confluence.

He had previously undergone laparoscopic cholecystectomy, right nephrectomy, and cadaveric renal transplantation, later complicated by humoral rejection and cytomegalovirus infection, requiring allograft nephrectomy.

Case 2: Her history included ESRD secondary to chronic nephropathy, secondary hyperparathyroidism, systemic lupus erythematosus, prior renal transplant rejection, eosinophilic colitis, coronavirus disease 2019 pneumonia, and chronic pulmonary thromboembolism under full anticoagulation.

She had undergone more than 45 central venous catheterizations, five peritoneal catheters, three arteriovenous fistulas, and two previous right anterior minithoracotomies-one for intra-atrial catheter placement and another for catheter removal eight years later.

Personal and family history

Case 1: No relevant personal or family history beyond those described.

Case 2: No relevant family history was reported.

Physical examination

Case 1: The patient was hemodynamically stable and afebrile. Cardiopulmonary examination was unremarkable, with regular heart rhythm and clear bilateral breath sounds. Multiple scars from prior central venous catheterizations were present, with no functional peripheral or central vascular access. No signs of acute infection or heart failure were observed.

Case 2: Physical examination showed a clinically stable patient with unremarkable cardiopulmonary findings. Multiple scars from previous vascular access procedures and thoracic surgeries were evident. There were no signs of peripheral edema, heart failure, or active systemic infection.

Laboratory examinations

Case 1: There were no findings that specifically indicated the need for surgical intervention.

Case 2: Blood cultures obtained from a femoral catheter grew methicillin-sensitive Staphylococcus aureus.

Imaging examinations

Case 1: Venography revealed contrast flow obstruction in the right brachiocephalic trunk, left jugulo-subclavian confluence, and inferior vena cava thrombosis, confirming absence of viable access routes (Figure 1).

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

Case 2: Transthoracic and transesophageal echocardiography ruled out intracardiac vegetations or thrombi.

MULTIDISCIPLINARY EXPERT CONSULTATION

Case 1

Given the complete exhaustion of peripheral and central venous access, the patient was evaluated by a multidisciplinary team including nephrology, cardiothoracic surgery, and interventional radiology. The team recommended video-assisted right minithoracotomy for direct right atrial hemodialysis catheter placement as the safest and most feasible option

Case 2

Due to progressive vascular access exhaustion and recurrent catheter infections, a multidisciplinary team including nephrology, infectious disease, hematology, cardiology, and cardiothoracic surgery recommended a new intra-atrial hemodialysis catheter via redo video-assisted minithoracotomy.

FINAL DIAGNOSIS

Case 1

ESRD with complete exhaustion of peripheral and central venous vascular access secondary to extensive central venous obstruction, requiring direct right atrial hemodialysis catheter placement.

Case 2

ESRD with severe vascular access exhaustion complicated by recurrent catheter-related bloodstream infections, requiring redo direct intra-atrial hemodialysis catheter placement.

TREATMENT

Case 1

Consequently, video-assisted right minithoracotomy was indicated for direct right atrial catheter insertion.

Surgical procedure (Video): Under general anesthesia with endotracheal intubation, a right bronchial blocker was placed under flexible bronchoscopy guidance (Figure 2).

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

With the patient in supine position, a 1 cm incision was made at the second right parasternal intercostal space for thoracoscopic port placement, followed by a minithoracotomy through the third intercostal space (Figure 3).

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.

After dissection into the pleural cavity and achieving adequate right lung collapse, the parietal pericardium was opened, exposing the right atrial appendage.

A purse-string suture with 2-0 polypropylene was placed (Figure 4A and B). The hemodialysis catheter was tunneled subcutaneously to the thoracic incision and inserted directly into the right atrial appendage through a small atriotomy under direct visualization (Figure 4C and D).

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.

Intraoperative transesophageal echocardiography confirmed appropriate catheter positioning (Figure 5A).

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.

Case 2

Under general anesthesia, a 5 cm incision was made at the third right intercostal space. Dense pleuropericardial adhesions were bluntly dissected under thoracoscopic guidance to expose the right atrium.

The need for a relatively longer incision was related to the redo nature of the procedure, the presence of dense pleuropericardial adhesions from prior thoracic surgeries, and the requirement for safe dissection under direct visualization to avoid cardiac or pulmonary injury.

A purse-string suture using 3-0 polypropylene was placed, followed by a small atriotomy for catheter insertion. Fluoroscopic guidance confirmed optimal positioning of the catheter tip within the right atrial cavity.

OUTCOME AND FOLLOW-UP

Case 1

The patient was extubated in the operating room without complications. Postoperative recovery was uneventful, with chest X-ray demonstrating complete pulmonary re-expansion (Figure 5B). He was discharged on postoperative day 5 with a functional catheter and remained asymptomatic after eight months of follow-up (Figure 5C).

Case 2

The atriotomy and catheter insertion are shown in (Figure 6A). The patient was extubated in the operating room, with adequate lung re-expansion on chest X-ray (Figure 6B) and stable hemodynamics without vasopressor support. Hemodialysis resumed 24 hours postoperatively with adequate flow and no complications. The previous femoral catheter was removed due to persistent bleeding at the insertion site.

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.

She was discharged on postoperative day 7 and remained asymptomatic with a fully functional intra-atrial catheter after eight months of follow-up (Figure 6C).

The longer hospital stay was mainly attributable to her complex medical background, ongoing systemic infection requiring targeted intravenous antibiotic therapy, anticoagulation management due to chronic pulmonary thromboembolism, and the need to ensure adequate hemodialysis delivery after catheter replacement.

DISCUSSION

Exhaustion of conventional vascular access represents a major clinical challenge in long-term hemodialysis management. Central venous stenosis, thrombosis, and recurrent catheter infections often preclude use of peripheral arteriovenous fistulas or tunneled catheters, necessitating alternative surgical strategies.

When both peripheral and central routes are non-viable, direct right atrial catheterization becomes a last-resort option for dialysis access. Successful outcomes with intra-atrial catheter placement in patients with exhausted access have been reported[5], highlighting its feasibility and safety

This approach allows adequate blood flow for effective hemodialysis while avoiding complications associated with multiple failed access attempts.

VATS has further improved this technique. It has been demonstrated that the minimally invasive approach significantly reduces postoperative pain, hospital stay, and recovery time compared with traditional open thoracotomy[2].

From a technical and anatomical perspective, access through the right third intercostal space provides a direct and safe route to the right atrium, allowing optimal exposure while minimizing chest wall trauma. The use of a limited incision reflects a balance between adequate surgical access and preservation of minimally invasive principles, particularly in redo procedures with pleuropericardial adhesions (Figure 7).

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.

The choice of a minimally invasive VATS approach over open thoracotomy is especially justified in patients with ESRD, who often present with multiple comorbidities and limited physiological reserve. VATS offers superior magnified visualization of mediastinal structures, continuous visualization for the entire surgical team, and precise catheter placement under direct vision, while reducing surgical stress, length of hospital stay, and overall healthcare costs.

Nevertheless, potential complications-including atrial arrhythmias, catheter thrombosis, and infection-remain relevant. Despite favorable outcomes, tunneled atrial catheters may be associated with thrombotic events, emphasizing the need for strict follow-up and anticoagulation protocols[6].

In this context, VATS facilitates early recognition and immediate management of intraoperative complications through enhanced visualization, meticulous surgical technique, and close multidisciplinary collaboration between cardiothoracic surgeons, anesthesiologists, and nephrologists.

Alternative unconventional routes, such as translumbar and transhepatic accesses, have been described but are often limited by anatomical constraints and higher complication rates[3]. Thus, VATS-guided intra-atrial catheterization remains an essential option in selected complex cases.

Our two cases underscore the clinical feasibility, safety, and durability of this approach, with excellent long-term function and no infectious or thrombotic complications during eight months of surveillance.

CONCLUSION

Video-assisted right minithoracotomy for direct right atrial hemodialysis catheter placement is a safe and effective minimally invasive alternative in patients with exhausted vascular access. This technique provides durable catheter function, reduces complications associated with repeated central venous attempts, and enhances postoperative recovery. Its implementation in specialized cardiothoracic centers offers a valuable solution for managing complex chronic hemodialysis patients. Meticulous postoperative monitoring remains crucial for early detection of thrombotic or infectious events.

ACKNOWLEDGEMENTS

The authors would like to thank Dr. Pedro Christian País Cedeño for his valuable contribution to the preparation of the audio abstract of this manuscript.