Intravenous misplacement of the nephrostomy catheter into the inferior vena cava and secondary thrombosis following percutaneous nephrostolithotomy: A case report and literature review

Abstract

Nephrostomy catheter misplacement into the inferior vena cava after percutaneous nephrolithotomy is an extremely rare complication, and subsequent catheter-related thrombosis has been more rarely reported. Here, we report a rare case of nephrostomy catheter misplacement after percutaneous nephrolithotomy. During the procedure, due to bleeding upon establishing the puncture channel, a renal fistula catheter with a balloon was inserted to facilitate hemostasis. However, the catheter inadvertently migrated into the inferior vena cava, with the inflated balloon obstructing venous return, resulting in thrombosis formation within the inferior vena cava. The patient was urgently transferred to our hospital for intervention. Upon administering anticoagulation and antimicrobial therapy, we first placed a filter in the patient's inferior vena cava to prevent thrombus embolism to the pulmonary arteries during catheter removal. Under fluoroscopy, the catheter was withdrawn into the renal vein, followed by catheter-directed thrombolysis and thrombus aspiration. Eventually, the renal fistula catheter was gradually removed in stages without any bleeding and pulmonary embolism occurring throughout the treatment process. Through a review of relevant literatures, we analyzed the reasons for catheter misplacement and summarized the associated treatment experience.

1. Introduction

Percutaneous nephrolithotomy (PCNL) is one of the main methods for treating urinary tract stones, favored by urologists for its minimally invasion, high stone clearance rate, and rapid postoperative recovery. Its complications mainly include bleeding, infection, and adjacent organ injury [1]. It has been reported that during the percutaneous puncture and establishment of access, catheter misplacement into the renal vein or inferior vena cava (IVC) is extremely rare, with an incidence of about 0.5 % [2]. In recent years, there have been scattered case reports of post-PCNL complications involving catheter misplacement into the renal vein or IVC. However, cases simultaneously involving catheter misplacement and thrombosis in IVC are rarely reported. Here, we report a case of post-PCNL complication involving catheter misplacement into the IVC with subsequent thrombosis formation. We treated the patient with catheter-directed thrombolysis (CDT) and thrombus aspiration under IVC filter protection and successfully removed the catheter by gradually withdrawing it. After anticoagulant therapy, the filter was removed one month later, and the patient was discharged after recovery. We present the diagnosis and treatment process of this patient and discuss it in conjunction with a literature review.

2. Case presentation

A 51-year-old male patient was admitted to the hospital 5 days after PCNL and 1 day after the discovery of abnormal positioning of the fistula tube. Five days prior, the patient underwent PCNL for “left kidney stones” at a local hospital. During the procedure, due to bleeding obscuring the surgical field, an 18F fistula tube with a balloon was implanted to compress the channel for hemostasis, and a second channel was established to complete the stone removal operation. One day before admission, the patient's abdominal CT examination revealed an abnormal position of the fistula tube: its distal end entered the IVC through the left renal vein, and the catheter balloon filled with fluid precisely blocked the main trunk of the IVC. Worse still, a large amount of thrombus had formed in the IVC below the balloon (Fig. 1 A−D). For further treatment, the patient was urgently transferred to our hospital. Upon admission, the patient's vital signs were stable with tenderness in the left waist but no chills, high fever, and some other discomfort.

Fig. 1.

Abdominal CT and DSA examinations

(A−D) Preoperative CT examination of the patient, shows the renal fistula tube entering the IVC at the liver segment through the left renal vein, with the catheter balloon located in the IVC and a large filling defect image below it. (E) Implantation of a filter in the IVC under fluoroscopy. (F) Withdrawal of the fistula tube into the left renal vein under fluoroscopy, and insertion of a thrombolysis catheter into the thrombus segment of the IVC. (G, H) Partial and complete removal of the fistula tube. (Red arrows indicate the thrombus, yellow arrows indicate the fistula tube and green arrows indicate the balloon).

Routine tests showed: HGB 80 g/L, CRP 61.94 mg/L, D-Dimer 6.65 μg/mL, and urine red blood cells qualitative (+++). The patient underwent a multidisciplinary consultation for a consensus treatment plan, followed by initiation of anticoagulant and antimicrobial therapy. With the patient's and guardian's consent and adequate rescue preparation, we first placed a filter (COOK, USA) in the IVC above the left renal vein to ensure that no thrombus would dislodge into the pulmonary arteries during catheter removal (Fig. 1 E). Then, under fluoroscopic guidance, we carefully retracted the fistula catheter into the left renal vein (Fig. 1 E, F). Subsequently, we inserted a thrombolysis catheter into the thrombus segment of the IVC and infused urokinase (400,000 U/24h) for thrombolysis treatment (Fig. 1 F). After returning to the ward, the fistula tube was gradually removed in stages. Throughout the procedure, the patient's vital signs remained stable, with no active bleeding or specific discomfort. Follow-up CT scan showed thrombus formation in the left renal vein after catheter removal, with no hematoma formation around the kidney or retroperitoneum (Fig. 1 G, H).

After 24 hours of CDT therapy, treatment was discontinued due to gross hematuria. CT reexamination revealed a large amount of residual thrombus in the IVC and an unsatisfactory thrombolysis effect (Fig. 2 A, B). Therefore, we used a 10 F thrombus aspiration catheter (Aco Stream, China) to almost completely remove the residual thrombus in the IVC (Fig. 2 C, D). The patient was discharged 3 days after the procedure and continued oral anticoagulant therapy. One month later, the patient was readmitted for reexamination, confirming there was no thrombus in the IVC and the veins of both lower limbs, and the filter was successfully removed (Fig. 2 E, F). At the 6-month follow-up, the IVC maintained smooth blood flow, with no residual thrombus in the vessel (Fig. 2 G, H). The laboratory examinations showed normal renal function, haemoglobin level of 136 g/L, normalized CRP, normal coagulation function, and no abnormalities in urine examination.

Fig. 2.

CT examinations before and after interventional therapy and DSA images during the treatment process.

(A, B) After CDT therapy for 24 hours, a large amount of thrombus remained in the IVC. (C, D) DSA images of IVC before and after thrombus aspiration. (E) Removal of the filter by a recovery sheath from the IVC. (F) IVC patency after filter removal. (G, H) Abdominal CTV images of the patient 6 months postoperatively. (Red arrows indicate thrombus, and white arrows indicate the IVC).

3. Discussion

During PCNL, a renal fistula catheter is typically inserted to monitor and maintain urine drainage, prevent potential urinary extravasation, and ensure hemostasis [3]. Classical methods for managing bleeding during PCNL involve clamping the renal fistula catheter or applying local pressure with a large-caliber balloon catheter. Due to the opening at the front of the balloon catheter, postoperative bleeding can be effectively assessed. Cases of vascular injury during PCNL resulting in fistula catheter entry into the renal vein or IVC are rare, and cases of subsequent thrombus formation are even rarer. Gupta et al. first reported a case of inadvertent renal vein injury during PCNL resulting in massive bleeding in 1997 [4]. To date, cases of renal fistula catheter misplacement into the renal vein or IVC during PCNL remain uncommon. We retrieved 14 articles containing a total of 20 relevant case reports from the PubMed database and summarized the relevant data in Table 1. The age of these patients ranged from 28 to 70 years old, with fistula catheter sizes ranging from 12 to 28 F. Thirteen cases (65 %) involved fistula catheters placed in the IVC, while six cases (30 %) involved catheters placed in the renal vein, including two cases of contralateral renal vein misplacement (10 %). Additionally, two patients had their fistula catheters misdirected into the right atrium and renal artery, respectively. Among these patients, only three cases were complicated by IVC thrombosis, with two cases of thrombus extending to the iliac vein or lower limb veins. Some patients also had severe complications such as renal arteriovenous fistula, pseudoaneurysm of the renal artery, and renal rupture. All patients experienced bleeding, manifested as intraoperative bleeding or abnormal bloody drainage from the renal fistula catheter observed postoperatively. Through timely symptomatic treatment, including surgical operation, interventional embolization, anticoagulation, and thrombolysis, these patients all achieved recovery. Misplaced fistula catheters were successfully removed through surgical, gradually withdrawn, two-step, or one-step methods.

Table 1.

Reports of intravenous misplacement of a nephrostomy tube after PCNL.

Year/Ref.	Age/Sex	Catheter type	Location	Catheter withdrawal	Complication	Subsequent treatment
2023 [3]	45, F	24 F nephrostomy tube	IVC	One-step under fluoroscopy	Hemorrhage, renal AVF	Selective TAE
2023 [5]	65, M	16 F foley catheter	Right atrium	Two-step under fluoroscopy	Hemorrhage, tachyarrhythmia	Antibiotic, anticoagulation
2022 [6]	64, M 51, M 70, W	Fistula tube Double-J tube 12 F nephrostomy tube	RV IVC Right RV	Gradually withdrawn Gradually withdrawn Gradually withdrawn	Hemorrhage, thromboses in IVC, and LEDVT Hemorrhage Hemorrhage	Anticoagulation, thrombolysis Not mentioned Not mentioned
2021 [7]	48, W	16 F double-lumen catheter	IVC	Gradually withdrawn	Hemorrhage, infection, thromboses in IVC	Antibiotic, anticoagulation
2020 [8]	58, M	18 F nephrostomy tube	IVC	Two-step under fluoroscopy	Hemorrhage	Not mentioned
2017 [9]	68, M 28, M	18 F nephrostomy tube Nephrostomy tube	RV IVC	Exploratory laparotomy Exploratory laparotomy	Hemorrhage, kidney rupture Hemorrhage	Not mentioned Anticoagulation
2014 [2]	42, M 38, W 48, M	18 F nephrostomy tube Nephrostomy tube Nephrostomy tube	IVC IVC IVC	Two-step under CT Two-step under DSA One-step under ultrasound	Hemorrhage Hemorrhage Hemorrhage	Not mentioned Not mentioned Not mentioned
2014 [10]	48, M	Nephrostomy tube	CRV	Exploratory laparotomy	Hemorrhage	Not mentioned
2013 [11]	50, M	12 F nephrostomy tube	IVC	Open operation	Hemorrhage, thromboses in IVC and iliac vein	Anticoagulation
2013 [12]	32, W 41, W	Nephrostomy tube Double-J tube	IVC IVC	Two-step under fluoroscopy Laparotomy under DSA	Hemorrhage Hemorrhage	Antibiotic therapy Antibiotic, anticoagulation
2013 [13]	66, W	Nephrostomy tube	IVC	Two-step under fluoroscopy	Hemorrhage, pseudoaneurysm	Blood transfusion, TAE
2009 [14]	52, M 35, W	Nephrostomy tube Nephrostomy tube	RV IVC	One-step Two-step under DSA	Hemorrhage Hemorrhage	Not mentioned Not mentioned
2005 [15]	63, W	12 F Foley catheter	Right atrial	One-step under fluoroscopy	Hemorrhage, dizziness, dyspnea, palpitations	Not mentioned
2005 [16]	54, M	28 F nephrostomy tube	RV	Two-step under fluoroscopy	Hemorrhage	Antibiotic, anticoagulation

IVC, inferior vena cava; LEDVT, lower extremity deep venous thrombosis; TAE, transarterial embolization; AVF, arteriovenous fistula; DSA, digital subtraction angiography; RV, renal vein; CRV, contralateral renal vein.

Through a review of the literature mentioned above, this study analyzed the causes of fistula catheter misplacement, summarized methods for catheter removal, experiences in managing IVC thrombosis, and proposed methods for establishing a safe PCNL channel to avoid fistula catheter misplacement.

3.1. Renal vein injury

The main cause of fistula catheter misplacement into the IVC is renal vein injury. Anatomically, the renal vein and its major branches are close to the renal pelvis and posterior renal calyces, with circular branches around the calyceal neck, making renal vein injury easy during PCNL [17]. After renal vein injury, implanting a fistula tube through the puncture channel and clamping the catheter is an effective method of hemostasis [9]. However, suppose the catheter is inserted too deeply or there are operational errors, especially without ultrasound or fluoroscopy guidance during catheter placement. In that case, it may allow the catheter, damaged by the renal vein, to enter the IVC system. In this case, the left renal vein was injured during the establishment of the PCNL channel, resulting in wound bleeding. To stop the bleeding, the surgeon used a balloon catheter to compress and stop the bleeding. However, because ultrasound guidance was not used during catheter placement, the fistula catheter entered the IVC through the damaged left renal vein.

Renal vein injury is a prerequisite for fistula catheter entry into the IVC system. The causes of renal vein injury and mechanisms of catheter misplacement include: (1) Vessel injury during puncture, with the guide wire entering directly into the renal vein, leading to venous perforation during sheath dilation [2,9]. (2) When dilating to establish the cutaneous renal channel, the blood vessel was damaged due to improper operation and the dilatation sheath was inserted into the renal vein. Mazzucchi and Wang et al. suggested that deep insertion of the fascial dilator during channel establishment may cause renal parenchymal and major vein tears, leading to significant bleeding and fistula catheter misplacement into the renal vein during PCNL [13,14]. (3) Due to the adjacency of the collecting system to the renal vein, renal collecting system mucosal damage may occur during surgery or lithotripsy, affecting the renal vein. Blind manipulation during catheter insertion increases the risk of damaged catheters entering the renal vein [15,18]. Additionally, some risk factors make the renal vein prone to injury, such as urinary tract infections, solitary kidneys, and obesity [11,14,19]. Infection is one of the primary risk factors, with most reported cases of renal pelvis infections. For example, Kotb et al. [11] reported a patient with kidney stones and chronic intrarenal infection who directly penetrated the renal vein when a 12 F nephrostomy tube with balloon was implanted. They believe that severe infection can make the renal parenchymal tissue fragile, causing the relatively hard silicone tube to easily penetrate the renal parenchyma directly and enter the venous system. Therefore, patients with renal pelvis infection must receive timely and effective anti-infective treatment before PCNL operation, and gentle operation must be performed during the operation to avoid the risk of renal vessel injury. Patients with solitary kidneys are more likely to damage blood vessels during PCNL puncture due to the compensatory enlargement of the kidneys and thickening of blood vessels. Obesity patients have thicker subcutaneous fat and a longer distance from the skin to the collecting system. Therefore, establishing an excessively long fistula channel increases the possibility of accidently entering blood vessels during the expansion process.

3.2. Catheter removal

The fistula catheter withdrawal methods reported in the literature include open surgery, gradually withdrawn, and one or two step tube withdrawal method (Table 1). Although surgical intervention is an effective method for catheter removal and was used in early reported cases [[9], [10], [11], [12]], with the widespread use of minimally invasive interventional techniques, most patients no longer require open repair. Instead, the general approach is to clamp the renal fistula catheter for 2−4 weeks and observe the patient's vital signs. If stable, the catheter can be removed without further treatment. The currently accepted method is stepwise withdrawal, selecting withdrawal steps based on the location of the catheter's distal end: (1) when the distal end is near the renal vein orifice, the catheter can be withdrawn directly into the collecting system after clamping and observation for 7 days; (2) when the distal end is in the main renal vein, IVC, or even the right atrium, it should be immediately withdrawn under fluoroscopic guidance to the vicinity of the renal vein orifice. After 7 days of observation, it can be withdrawn into the collecting system. If the above steps are successful, the catheter can be completely removed from the body one week later.

Liu et al. reported a case of renal vein injury treated by clamping the renal fistula catheter and gradually withdrawing the distal end to the proximal renal vein and then into the collecting system under X-ray guidance [8]. Similarly, most cases of renal vein injury reported in the literature were successfully treated by similar methods without the need for open surgery (Table 1). In this case, based on these experiences, the patient's catheter was removed gradually and step by step without surgical intervention. The patient's bleeding was effectively controlled, and there were no complications such as renal vein fistula or perinephric bleeding, nor were there severe kidney infections or renal dysfunction. Hemoglobin levels gradually returned to normal during follow-up 1−3 months postoperatively.

3.3. Inferior vena cava thrombosis and treatment strategies

When the fistula catheter enters the IVC, the catheter or balloon may interfere with venous return, triggering venous thrombosis, and unstable thrombi can lead to fatal pulmonary embolism (PE). Previous literature reported a mortality rate of 1.1 % due to PE after PCNL, but the detailed causes of PE were not mentioned [20]. IVC thrombosis severely affects pelvic and lower limb venous return, causing pelvic congestion and lower limb swelling. More importantly, thrombi may dislodge and cause fatal PE. Therefore, thrombus should be removed promptly, and timely initiation of anticoagulation or thrombolysis [21]. For situations where anticoagulation or thrombolysis is contraindicated, implanting a filter in IVC and using catheter thrombus aspiration is a rapid and effective method for thrombus removal [22]. The filter is a protective device designed to prevent PE caused by the detachment of thrombus in the deep veins of the lower limbs or the IVC, which can reduce the incidence of fatal PE [19]. Inserting a retrievable filter into the IVC above the thrombosis site, and then using the method of CDT or thrombus aspiration to eliminate the thrombus can minimize the serious consequences of thrombus detachment when removing the nephrostomy tube. More importantly, when the thrombus is completely cleared, the filter can be pulled out in time to ensure that no foreign matter remains in the IVC. Simultaneously, gradually withdrawing the renal fistula catheter under fluoroscopy monitoring allows for clear and dynamic observation of the catheter's position, thrombus, and bleeding, facilitating the timely detection and management of unexpected events.

Among the 20 cases we reviewed, 3 were complicated by IVC thrombosis [6,7,11]. Among them, Song et al. reported a case where a fistula catheter misplacement into the IVC led to extensive thrombosis in the IVC and lower limb veins. They removed the catheter after placing a filter in the IVC and the patient was successfully discharged after anticoagulation and thrombolysis treatment [6]. Li et al. reported a case where a water-filled balloon catheter misplacement into the IVC blocked venous return, causing thrombosis. They also placed a filter into the patient's IVC before removing the catheter to prevent PE. After anti-bacterial and anticoagulation therapy, they successfully managed this complication [7]. Kotb et al. reported a case where a fistula catheter traversed the renal parenchyma and terminated in the inferior vena cava, with thrombus extending from the catheter to the proximal ends of the two common iliac veins. After the surgical removal of the catheter and the kidney stone, the patient was transferred to the cardiovascular department for continued anticoagulation therapy and monitoring. Finally, the patient recovered and was discharged after active treatment [11]. Although thrombus aspiration was not used, the thrombus in the IVC were eventually absorbed completely in these three patients after continuous anticoagulation.

Similar to these reported cases, this patient was accidently implanted a nephrostomy catheter with a balloon in the IVC. The balloon happened to block the IVC upon inflation, leading to thrombus formation. Since the thrombus is close to the catheter and has a large load, directly removing the catheter will inevitably cause the thrombus to fall off. Therefore, a filter must be implanted in the IVC above the catheter to prevent PE. However, unlike previously reported cases, the distal end of the fistula catheter in this patient was already located in the IVC behind the hepatic vein, so the filter must be placed higher than the hepatic vein, and the anatomical distance of the IVC above the hepatic vein is shorter, making it challenging to place an IVC filter. Additionally, considering the short time since thrombus formation, CDT therapy was initiated, but it was discontinued due to hematuria. Therefore, a large-lumen catheter aspiration was chosen to effectively remove the thrombus. Fortunately, the IVC thrombus were removed effectively through thrombus aspiration, and the filter was promptly removed. After subsequent standard anticoagulation treatment, the patient's thrombosis did not recur.

Based on the review of the literature, we also summarized some experiences in managing catheter misplacement into the IVC: (1) Catheter misplacement into the IVC is prone to secondary retrograde infection, so broad-spectrum antibiotics may be considered for infection prophylaxis. (2) After catheter misplacement, the patient needs strict bed rest to prevent thrombus dislodgment causing PE or catheter loosening inducing severe bleeding and other serious complications. (3) After IVC thrombosis, thrombus dislodgment can lead to PE. Therefore, it is recommended to implant a retrievable filter in the IVC above the renal vein. (4) In cases of massive bleeding during PCNL operation suspected of renal vein injury, renal fistula catheterography can be performed for confirmation, and if arterial bleeding cannot be excluded, renal artery angiography can be performed postoperatively.

3.4. Establishing a safe PCNL channel

Misplacement of the nephrostomy catheter into the IVC during PCNL brings additional trauma and risk of thrombogenesis to patients, as well as considerable psychological pressure on surgeons. Therefore, establishing a safe puncture channel during PCNL surgery is crucial.

Adequate preoperative preparation, accurate intraoperative positioning, precise puncture, and the establishment of an effective channel are key factors for the success of PCNL operation. Ultrasound and X-ray fluoroscopy guidance are the two most commonly used imaging positioning methods [23]. Ultrasound can clearly and dynamically display the internal blood vessels and renal pelvis structures, effectively reducing the risk of vascular injury caused by puncture. Therefore, we believe that real-time ultrasound guidance during the puncture process is of great practical value and recommend its routine application. X-ray fluoroscopy, with the ability to display lesions at different angles through the rotation of the C-arm, has significant advantages in determining the relationship between the puncture needle and the lesion's position. However, it is often difficult to distinguish between blood vessels and the collecting system under plain X-ray fluoroscopy, and the use of contrast agents is often needed to effectively distinguish between the two. Therefore, puncture needles during the puncture process often unavoidably cause vascular damage. Thus, if conditions permit, the combination of ultrasound and X-ray fluoroscopy in PCNL can not only significantly improve the accuracy of puncture but also greatly reduce the risk of vascular injury, effectively preventing the misplacement of the nephrostomy catheter into the renal vein and IVC.

4. Conclusion

The occurrence of nephrostomy catheter misplacement into the IVC during PCNL has become increasingly rare with the development of imaging technology, especially ultrasound technology. In a few cases, errors in the operation or lack of imaging equipment guidance can easily lead to renal vein injury and subsequent catheter misplacement into the renal vein or IVC. Therefore, emphasis on early imaging examination to promptly detect and remove the catheter to restore normal venous blood flow is crucial. In this case, the catheter was discovered to be misplaced into the IVC on the 5th postoperative day, resulting in prolonged interference with venous blood flow and thrombus formation. Although the patient did not experience severe complications after timely treatment, the patient still faced the inconvenience of prolonged hospitalization and increased medical burden. Therefore, proficient use of ultrasound or X-ray guidance to establish a safe and effective puncture channel during PCNL operation is fundamental to preventing catheter misplacement into the renal vein or IVC and thrombus formation.

Ethics statement

This study was reviewed and approved by the local ethics committee of The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed written consent was obtained from the patient for the publication of this case report and the accompanying images.

Funding

This study received no specific grant from any funding agency.

Consent for publication

Consent for publication was obtained for every individual person's data included in the study.

CRediT authorship contribution statement

Wang Xiong: Conceptualization, Data curation. Wei Wei: Conceptualization, Data curation. Xinqiang Ju: Conceptualization, Investigation, Writing – original draft. Wei Hu: Resources, Validation, Visualization. Yanneng Xu: Validation, Visualization, Writing – original draft. Guangyan Si: Conceptualization, Supervision, Writing – review & editing. Gang Yuan: Conceptualization, Data curation, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.