Percutaneous peritoneal dialysis catheter making its way to the prevertebral space: A rare occurrence

Percutaneous peritoneal dialysis (PD) catheter insertion is widely performed by nephrologists and is generally safe; however, a lack of direct visualization may predispose to mechanical complications, including catheter malposition. We report a rare case of PD catheter migration into the retroperitoneal prevertebral space. A 33-year-old woman with chronic kidney disease stage 5 secondary to chronic glomerulonephritis underwent ultrasound-guided percutaneous Tenckhoff catheter insertion for initiation of continuous ambulatory PD. Although inflow was adequate, persistent outflow dysfunction prompted further evaluation. Imaging revealed that the catheter had traversed the posterior peritoneal wall and entered the prevertebral space anterior to the L5 vertebra. Laparoscopy confirmed the finding, and the catheter was successfully repositioned into the pelvis with closure of the peritoneal defect. The patient subsequently initiated PD with satisfactory catheter function. This case highlights an extremely rare catheter malposition and underscores the importance of early imaging and multidisciplinary management to salvage catheter function.