© 2013, Wiley Periodicals, Inc. DOI: 10.1111/echo.12397 Echocardiography Repeated Neurological Complications during Dialysis – A Case for Echo? Danja S. Groves, M.D., Ph.D.,*† Ulf Harding, M.D.,* Christian Lanckohr, M.D.,* Antje Gottschalk, M.D.,* John A. Kern, M.D.,‡ and Christoph Schmidt, M.D., Ph.D.* *Department of Anesthesiology and Intensive Care Medicine, University of Muenster, Muenster, Germany; †Departments of Anesthesiology; and ‡Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia (Echocardiography 2014;31:E35–E36) Key words: echocardiography, iatrogenic, TEE, transient ischemic attack (TIA), mobile components, carotid artery A 65-year-old woman presented with acute or chronic renal failure and signs of right heart failure. After hemofiltration over a temporary highflow catheter, a single lumen central venous dialysis catheter had been placed surgically via the left jugular vein. However, renal replacement therapy was repeatedly complicated by altered flows of the dialysis unit, impaired consciousness, new onset of seizures, and left-sided hemiparesis. An echogenic artifact appeared on transesophageal echocardiography (Vivid 7, GE Medical Systems, Milwaukee, WI, USA) in proximity to Figure 2. Transesophageal echocardiography, mid-esophageal ascending aortic short-axis view demonstrating catheter tip in ascending aorta about 2.3 cm distal to the aortic valve. Figure 1. Transesophageal echocardiography, mid-esophageal long-axis view demonstrating catheter tip in ascending aorta about 2.3 cm distal to the aortic valve. The authors declare that they sought and received written permission from the patients relative to report the case. Address for correspondence and reprint requests: Danja S. Groves, M.D., Ph.D., Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA 22908-0710. Fax: 434-982-0019; E-mail: dgroves@virginia.edu Figure 3. Supine chest radiograph demonstrating intraaortic position of hemodialysis catheter (arrow); pacemaker (device and wires), endotracheal tube, chest tubes in situ. E35 Groves, et al. Figure 4. Coronal computed tomography (CT) image demonstrating hemodialysis catheter in left common carotid artery (arrow). E36 the aortic valve within the lumen of the ascending aorta, which appeared to be the tip of the dialysis catheter (Figs. 1–3). Evaluation of the neck vessels by ultrasound (Vivid 7) and computer tomography (Philips Healthcare, Best, The Netherlands) (Fig. 4) demonstrated a primary placement of the catheter in the left common carotid artery. The intra-aortic position of the catheter explained the altered flow pattern of the dialysis unit with very low-outflow (5 mmHg) and highinflow pressures (230 mmHg) as well as the altered mental status and neurologic changes during and after renal replacement therapy. The catheter was surgically removed and the patient recovered without neurologic sequelae. This incident underscores the value of ultrasound guidance for placement of intravascular catheters.