Accidental pigtail in the inferior vena cava, a danger averted: A case report and review of literature

INTRODUCTION

Percutaneous nephrostomy (PCN) is commonly indicated for permanent or temporary drainage of the upper urinary tract due to obstruction (e.g., stones, tumors, or iatrogenic causes), with hydronephrosis or pyonephrosis, and urinary fistula. Hemorrhage and sepsis are the two most frequent and major complications after PCN, occurring in 1-9% and 1-4% of cases, respectively. Vascular injuries or hemorrhages have also been reported in 1-4% of cases. This case report highlights the rare occurrence of PCN placement in the inferior vena cava (IVC) in a patient with carcinoma prostate and its surgical management.^1,2

CASE REPORT

A 56-year-old male presented with back pain, decreased urine output, and weakness. He had a history of metastatic carcinoma of the prostate, for which he underwent bilateral orchidectomy 3 years ago, but he was lost to follow-up. On admission to the urology emergency department, his investigations showed hemoglobin levels of 9.5 g/dL, total leucocyte count of 4500 units cells per microliter, a urea/creatinine of 62/ 2.45 mg/dL, Serum Prostate Specific Antigen (PSA) of 12.5 ng/mL, and normal liver function tests. Ultrasound revealed moderate right hydronephrosis and mild left hydronephrosis. Due to moderate hydronephrosis, a right PCN was planned and performed under ultrasound guidance. While the initial puncture and guidewire insertion were uneventful with clear urine drainage, the subsequent dilatation and placement of an 8 Fr pigtail (Rusch) catheter led to bloody drainage. A non-contrast computed tomography (CT) scan revealed that the PCN had been inadvertently placed into the IVC [Figure 1-3]. Due to deranged renal function, anemia, and low blood pressure, surgical exploration was planned to remove the misplaced PCN. An exploration was performed through a right subcostal incision, and the kidney, renal vein, and IVC were dissected. After establishing vascular control, the PCN was safely removed. The renal parenchyma suffered minimal blood loss, which was controlled with pressure [Figures 4 and 5]. A new PCN was inserted through the renal parenchyma into the renal pelvis by a separate puncture. The patient recovered well, and the acute kidney injury was resolved [Figure 6]. He was started on abiraterone for newly diagnosed castration-resistant prostate cancer, postoperatively, and showed improvement. At the 3-month follow-up, he had normal serum creatinine and PSA.

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Figure 1:

Axial computed tomography scan view showing right hydronephrotic kidney (red arrow) with pigtail coil inside the inferior vena cava (yellow arrow).

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Figure 2:

Coronal computed tomography scan showing pigtail coil inside the inferior vena cava (yellow arrow).

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Figure 3:

Sagittal computed tomography scan showing Pigtail inside the inferior vena cava (yellow arrow).

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Figure 4:

Intra-operative picture showing pigtail catheter (yellow arrow) going into kidney (red arrow).

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Figure 5:

Intraoperative picture showing renal vein (purple arrow), inferior vena cava (blue arrow), ureter (orange arrow) and kidney (red arrow).

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Figure 6:

Nephrostomy tube (blue arrow) placed into right kidney (red arrow) after removal of the pigtail from the inferior vena cava.

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DISCUSSION

PCN is a common emergency procedure done in radiology and urology for managing upper urinary tract obstructions, such as hydronephrosis due to malignancies, pyonephrosis, stone disease, and strictures. The major complications include bleeding, urinary tract infections, sepsis, blockage, and accidental tube removal. Punctures in the lower pole are associated with minimal bleeding risks, through hemorrhage requiring transfusion in 4% of patients, and vascular injuries requiring intervention are seen in 1%.

PCN can be done using ultrasonography, or can be C-arm or fluoroscopy-guided. Unusual complications associated are liver injury, segmental artery injury, bleeding, pseudoaneurysm, arteriovenous fistula, and dissection of renal vessels. Rare complications involve IVC misplacements due to anatomic proximity. These are primarily reported during puncture and dilatation of the nephrostomy tract, where inadequate visualization during puncture and dilatation may contribute to vascular injury.

We have discussed important case reports of PCN insertion into the IVC and their subsequent management in Table 1.^3-8

An anatomically correct and prompt needle insertion is important, as risk increases after a first failed endoscopic or percutaneous instrumentation and delayed drainage.⁹

IVC injuries can be fatal and appear to be underreported; however, rare case reports have been published. These injuries are managed according to the mechanism of pigtail insertion, size of nephrostomy, course of nephrostomy tube, and duration of injury. The intravenous misplacement of an anatomically correct and prompt needle insertion is critical, as the risk of complications increases after the first failed endoscopic or percutaneous instrumentation and with delayed drainage. Intravenous misplacement of the PCN catheter can be managed by staged withdrawal under fluoroscopic guidance and close monitoring. Urgent laparotomy and nephrectomy are rarely needed (0.1%) after hemorrhage. In contrast, the size of the inserted needle or catheter does not correlate with the incidence of hemorrhage. Furthermore, the PCN technique (whether echo-, fluoroscopic-guided, or combined) does not significantly affect the success rate.^9-11

In our case, the patient presented with deranged renal function tests, hemodynamic instability secondary to uremia, and the inability to perform a contrast CT scan, necessitating surgical removal of the PCN. During exploration, the PCN catheter was found traversing from the renal parenchyma to the segmental vein and then into the IVC. Minimal bleeding was successfully controlled with pressure on the renal parenchyma.

We recommend delineating the pigtail’s tract and any collection around the kidney with a CT scan. If the pigtail appears to extend through the renal vein into the IVC without surrounding hemorrhage, conservative management can be performed in the intervention room or operating theater. However, if a CT scan reveals hemorrhage around the IVC or if the pigtail’s course is uncertain, surgical exploration followed by pigtail removal is warranted.

These inadvertent injuries most commonly occur during dilatation of the nephrostomy tract, highlighting the need for careful monitoring under fluoroscopy and ultrasound with special emphasis on the guidewire coil’s location. While rigid guidewires may contribute to vascular perforation, this is not well-documented in the literature. Though such complications are rare, experienced interventional radiologists or urologists should manage these cases, particularly in patients with mild hydronephrosis.

Once PCN placement into the IVC is identified, it should be clamped, and the patient should be resuscitated. CT imaging should then be performed to delineate the tract. PCN removal must be conducted in the operating theater under fluoroscopic guidance. Laparotomy and PCN removal may be required if advanced facilities are unavailable or in cases of significant bleeding or hemorrhagic shock.

CONCLUSION

IVC penetration during PCN is extremely rare. Our case provided insight into the mechanism of injury and possible ways to manage injuries to the IVC. This injury mostly occurs during dilatation of the nephrostomy tract, so dilatation should be carefully monitored under fluoroscopy and ultrasound with special emphasis on the location of the guidewire coil.