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Contamination of Transvenous Pacemaker Leads Due to Tunneled

Hemodialysis Catheter Infection: A Report of 2 Cases

Roger G. Carrillo, MD,

1

Juan D. Garisto, MD,

1

Loay Salman, MD,

2

Donna Merrill, RN,

2

and

Arif Asif, MD

2

Catheter-related bacteremia is a frequent complication associated with the use of tunneled hemodialy-sis catheters. Catheter-related bacteremia can lead to metastahemodialy-sis of infection to other sites. This article presents 2 patients with transvenous pacemakers (placed2 years ago) who were receiving long-term hemodialysis therapy using tunneled hemodialysis catheters. Both were admitted to the hospital with catheter-related bacteremia. Blood cultures showed methicillin-resistantStaphylococcus aureus(MRSA) in both cases. Transesophageal echocardiography was negative for the presence of valvular endocardi-tis, but showed lead-associated vegetation in both cases. Intravenous antibiotic therapy was initiated, and both the tunneled hemodialysis catheters and cardiac devices were removed by a cardiothoracic surgeon. The catheter tip and leads cultures showed MRSA in both cases. After resolution of bacteremia, both patients received an epicardial cardiac device. Antibiotic therapy was continued for 6 weeks. Renal physicians providing dialysis therapy should be aware that catheter-related bacteremia could cause contamination of transvenous pacemaker leads. Because catheter-related bacteremia is a frequent complication, epicardial leads might be considered as an alternative route to provide cardiac support to catheter-consigned patients. Epicardial leads do not navigate through the central veins, lie in the path of blood flow, or cause central venous stenosis.

Am J Kidney Dis55:1097-1101.©2010 by the National Kidney Foundation, Inc.

INDEX WORDS:Hemodialysis; pacemaker; tunneled dialysis catheter; catheter-related bacteremia.

T

unneled hemodialysis catheters can lead to

the hematogenous spread of infection to

distant sites, such as cardiac valves

(endocardi-tis), vertebral column (disci(endocardi-tis), or joints (septic

arthritis).

1

This report presents 2 cases of

tun-neled dialysis catheter–related bacteremia that

showed contamination of the transvenous

pace-maker leads of these patients.

CASE REPORTS

Case 1

A 72-year-old long-term hemodialysis patient was admit-ted with fever, chills, and hypotension. His medical history included hypertension, diabetes, and left ventricular dysfunc-tion. Surgical history was remarkable for multiple failed arteriovenous accesses, right internal jugular catheter (single body, step tip) insertion (6 months ago), and transvenous pacemaker and cardiac resynchronization therapy device placement 4 years previous. There have been no episodes of cardiac device–related infection. Physical examination of the catheter site showed warmth, tenderness, and minimal drainage through the exit site. The rest of the examination findings were unremarkable, including the pacemaker pocket site. The emergency department physician inserted a central catheter in the left internal jugular vein. After withdrawing blood culture specimens, intravenous antibiotics (vancomy-cin and ceftazidime) and fluids were administered. The initial attempt at catheter removal by an interventionalist failed. Because the patient had a pacemaker, the intervention-alist did not put excessive traction to pull the catheter out for

fear that the catheter might be stuck to the cardiac device leads. A cardiothoracic surgeon was consulted, and com-puted tomography was performed that showed tethering of the catheter and leads to the vascular wall (Fig 1). This was considered to be the cause of the stuck catheter. The cardio-thoracic surgeon documented lead involvement (vegetation) on transesophageal echocardiography (TEE) and removed the 2 devices simultaneously (Fig 2). The cardiac valves were free of vegetation. Both the catheter and pacemaker were removed. A laser sheath device (Spectranetics Corp, www.spectranetics.com/) was used to remove the leads and catheter. Open thoracotomy was not required. The leads were found to be infected upon gross examination at the time of extraction. Temporary pacing was provided in the interim. Blood culture results were positive before catheter and lead removal. After resolution of fever at 24 hours, a new tunneled catheter was inserted. Bacteremia resolved at 48

From the1

Division of Cardiothoracic Surgery and2

Sec-tion of IntervenSec-tional Nephrology, University of Miami Miller School of Medicine, Miami, FL.

Received September 13, 2009. Accepted in revised form January 8, 2010. Originally published online asdoi:10.1053/ j.ajkd.2010.01.009on April 5, 2010.

Address correspondence to Arif Asif, MD, Interventional Nephrology, University of Miami Miller School of Medicine, 1600 NW 10th Ave (Ste 7168), Miami, FL 33136. E-mail:

aasif@med.miami.edu

©2010 by the National Kidney Foundation, Inc. 0272-6386/10/5506-0017$36.00/0

doi:10.1053/j.ajkd.2010.01.009

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hours, and a permanent subcutaneous epicardial system replaced the transvenous pacemaker at day 4 of admission. The catheter tip and leads showed methicillin-resistant Staphylococcus aureus(MRSA). The patient was treated for 6 weeks with 1 g of vancomycin after each dialysis session. Although the patient has had 2 episodes of catheter-related infection, there has been no infection of the epicardial system during follow-up of 11 months.

Case 2

A 75-year-old Hispanic woman was admitted with fever and chills during hemodialysis therapy. She had been dialyz-ing with a right internal jugular Tesio hemodialysis twin catheter system (Medcomp, Harleysville, PA) that was placed 7 months ago. Her medical history included hypertension, coronary artery disease, and diabetes. Surgical history was remarkable for insertion of a transvenous pacemaker 2 years ago and multiple failed arteriovenous accesses. Physical examination of the catheter site showed warmth and tender-ness without drainage through the exit sites. The rest of the examination findings were unremarkable, including the pace-maker site. After withdrawing blood culture specimens, intravenous vancomycin therapy was initiated. As in case 1, the initial attempt at catheter removal by an interventionalist failed, and a cardiothoracic surgeon was consulted. Com-puted tomography showed tethering of the catheter and leads to the vascular wall, which was considered to be the cause of

the stuck catheter. The cardiothoracic surgeon documented lead involvement (vegetation) using TEE and removed the 2 devices simultaneously. The cardiac valves were free of vegetation. The leads and Tesio catheter were removed using the laser sheath device. As in case 1, the leads were found to be infected at the time of extraction. Temporary pacing was provided in the interim. Blood culture results were positive before catheter and lead removal. After resolution of fever at 12 hours, a new tunneled catheter was inserted. A subcutane-ous epicardial system was placed on day 3 of admission after resolution of bacteremia (at 24 hours). The catheter tip and pacemaker leads were positive for MRSA. The patient was treated for 6 weeks with 1 g of vancomycin after each dialysis session. The patient has had 1 episode of tunneled dialysis catheter infection, and the epicardial system has been infection free for the past 18 months.

DISCUSSION

The present cases show that catheter-related

bacteremia can lead to contamination of cardiac

device leads. In general, the incidence of

pace-maker infection ranges from 0.8%-5.7%.

2,3

How-ever, many reports have highlighted that patients

with chronic kidney disease are at increased risk

of infection.

3-5

Although the incidence of

pace-maker infection in hemodialysis patients has not

been well studied, a recent case-control study (n

152) by Bloom et al

6

found that moderate to

severe kidney disease (glomerular filtration rate

60 mL/min/1.73 m

2

[

1 mL/s/1.73 m

2

]) was

the most potent risk factor for infection of a

pacemaker, with a prevalence of 42% in infected

patients compared with 13% in the control group

(odds ratio, 4.8).

Cardiac device infection can be a potentially

life-threatening complication.

2,7-9

Lead infection

can occur alone or in association with the

involve-ment of cardiac valves.

2,10,11

Both are managed as

endocarditis and require lead removal.

2,7-9

Cardiac

device lead infection can be confirmed if TEE

shows lead vegetation.

2,10,11

TEE can identify lead

vegetation in 90%-96% of cases.

2,10,11

Lead-associated endocarditis, a major contributor to high

mortality, is not uncommon and has been known to

occur in approximately 50% of patients presenting

with device-related infection.

8

Staphylococcus

spe-cies continue to be a major culprit, causing 60% of

cases of lead-induced endocarditis.

9

In 1 study of

lead-induced endocarditis caused by staphylococci,

60% were MRSA.

9

The 2 patients presented in

this report had MRSA. Fortunately, neither

pa-tient presented here had valvular vegetation or

dysfunction.

Figure 1. Three-dimensional color computed tomo-graphic scan of patient 1. A tunneled dialysis catheter (TDC) is seen in the right internal jugular vein. A central venous line (CVL) is seen in the left internal jugular vein; this was placed by the emergency department physician at the time of admis-sion. A pacemaker (PM)-chronic resynchronization therapy (CRT) device is seen on the left side of the chest. Leads of the PM-CRT device are seen traversing through the subclavian and brachiocephalic veins and superior vena cava. Notice the intimate proximity and intertwining of the catheter with the PM-CRT leads (arrow). Fibrous tissue wrapping these struc-tures also is seen (arrow).

Carrillo et al 1098

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Instead of navigating through the central veins

and tricuspid valve, epicardial leads traverse

through the subcutaneous tissue and are inserted

into the epicardium.

12-20

Transvenous leads can

cause central venous stenosis by causing

endothe-lial injury.

21-23

The leads and fibrous tissue that

cover them also can augment stenosis by

occ-upying the available space in the central veins

(

Fig 1

).

21,24

Because catheter-related bacteremia

is a frequent occurrence that imposes the risk of

spread of infection to the transvenous leads, and

on account of the previously mentioned factors,

it is not unreasonable to consider epicardial leads

as the preferred system in hemodialysis patients

using tunneled hemodialysis catheters. These

leads are not directly exposed to blood flow or

the infected catheter and do not cause central

venous stenosis. Some differences between the

transvenous endocardial and subcutaneous

epicar-dial leads are listed in

Table 1

.

In both cases, laser sheaths were used to

remove the leads. It is worth mentioning that

fibrotic tissue develops on the leads over time

and binds the leads to the vascular wall and in the

Figure 2. Multiplanar transesophageal echocardiogram of patient 1 at 119° rotation shows the pacemaker lead, superior vena cava (SVC), and right (RA) and left atrium (LA). Lead-associated vegetation (Veg) is observed.

Table 1. Advantages and Disadvantages of Subcutaneous Epicardial and Transvenous Endocardial Cardiac Devices

Subcutaneous Epicardial Cardiac Devices Transvenous Endocardial Cardiac Devices

Central venous stenosis Not observed Common

Infection Uncommona Not uncommona

Placement Easily accomplished Easily accomplished

Placed by CT surgeon CT surgeons & cardiologists

Effectiveness Very effective Very effective

Surgical complications Minimal Minimal

Major vascular injury Rare Rare

Anesthesia General Sedation & local anesthesia

Length of hospitalization (d) 1-2 1

Procedure setting Inpatient Generally outpatient

Preservation of central veins Available Compromised

Abbreviation: CT, cardiothoracic.

aInfection in a transvenous endocardial system ranges from 0.8%-5.6%.5In contrast, 9 studies12-20evaluating 253

epicardial leads failed to show a single episode of infection. To the best of our knowledge, no specific information exists in the literature regarding infection in long-term hemodialysis patients who harbor epicardial cardiac devices.

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endocardium.

24

Removal of these leads requires

freeing the lead body from the fibrotic tissue. A

variety of tools, including telescoping sheaths,

have been used to remove cardiac leads.

25,26

However, application of excessive force to

de-tach the leads carries the risk of vascular or

endocardial avulsion. In contrast, the laser sheath

delivers the laser energy to the distal end of the

sheath to release the lead. This technique offers a

low complication rate, high success rate of

com-plete lead removal, and efficient procedural time

compared with nonlaser techniques.

2,27,28

In the present report, the catheter and leads

were removed simultaneously because the leads

were found to be infected using TEE. However,

in the absence of lead involvement, the catheter

should be removed first, antibiotic therapy should

be continued, and the patient should be observed

closely. The leads should be considered for

re-moval if the patient remains bacteremic after

catheter removal. The duration of antibiotic

therapy with lead vegetation is the same as for

endocarditis (ie, 6 weeks).

2

Catheter-related bacteremia can lead to

con-tamination of transvenous pacemaker leads. The

catheter and leads should be removed

simulta-neously if the leads are found to be infected (lead

or cardiac valve vegetation). The epicardial route

instead of a transvenous pacemaker might be a

better option for such patients.

ACKNOWLEDGEMENTS

Support:None.

Financial Disclosure:The authors declare that they have no relevant financial interests.

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J Intervent Card Electrophysiol. 2004;11:149-154. 13. Cannon BC, Friedman RA, Fenrich AL, Fraser CD, McKenzie ED, Kertesz NJ. Innovative techniques for place-ment of implantable cardioverter-defibrillator leads in pa-tients with limited venous access to the heart.Pacing Clin Electrophysiol.2006;29:181-187.

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27. Wilkoff BL, Byrd CL, Love CJ, et al. Pacemaker lead extraction with the laser sheath: results of the Pacing Lead Extraction with Excimer Sheath (PLEXES) Trial.J Am Coll Cardiol.1999;33:1671-1676.

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www.spectranetics.com/) http://www.uptodateonline.com

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