Unusual positioning of a central venous catheter

Posterior wall penetration of the internal jugular vein during central venous catheter insertion using real-time ultrasound: Two case reports

RATIONALE

Because central venous catheters (CVCs) are placed at the great vessels, mechanical complications can be fatal. Using the landmark method alone can make CVC difficult to access, depending on the skill of the operator and various patient conditions, such as anatomical variations of the vessels, young age, hypovolemic state, obesity, and short neck. Therefore, ultrasound (US)-guided techniques, including visualization of the vein and needle in the lumen of the vessel, are recommended. Nevertheless, our experience demonstrated that CVC malposition or vascular penetration cannot be prevented completely, even with real-time US guidance.

PATIENT CONCERNS

The first patient was a 19-year-old woman (weight = 58 kg, height = 155 cm) who underwent CVC cannulation in the right internal jugular vein (IJV) under general anesthesia using real-time US. The second patient, a 50-year-old woman (weight = 51.6 kg, height = 155.7 cm), underwent CVC insertion in the right IJV using real-time US.

DIAGNOSES

During guidewire insertion in the first case, the posterior wall of IJV was penetrated, and a break in the core body of the guidewire was detected. In the case of second patient, CVC was embedded in the posterior wall of IJV and misplaced in the interpleural space in the right thorax. In both cases, an out-of-plane US approach was used.

INTERVENTIONS

In the first case, the broken guidewire was completely removed with real-time US guidance. In the second case, all fluid injected through CVC was aspirated, and then CVC was removed.

OUTCOMES

In both cases, surgeries were completed successfully and all the patients were discharged without any complications.

LESSONS

Even if the needle tip is located in the lumen of IJV and blood aspiration is confirmed on real-time US, vascular penetration or CVC malposition during the procedure cannot be completely prevented because of the limitation of the US imaging field. These results suggest that care must be exercised even during US-guided CVC placement and that alternative US-guided techniques or supplementary monitoring should be considered to confirm proper CVC position.

The malposition of a central venous catheter through a sheath introducer via the left internal jugular vein: A case report

RATIONALE

The misplacement of central venous catheter (CVC) can occur more often at the left jugular vein than the right side due to anatomic differences. And many of the previously reported cases are about catheter misplacement resulting from vessel penetration associated with guidewire. This case differs that the catheter itself through the sheath introducer can cause venous injury that may lead to the malposition of CVC particularly through an approach to the left internal jugular vein.

PATIENT CONCERNS, DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

We cannulated a large-bore CVC with a sheath introducer, namely mult-lumen access catheter (MAC) in the left jugular vein of patient under anesthesia using ultrasound and inserted the additional central venous oximetry catheter through the sheath introducer of MAC and confirmed aspiration of blood. However, the postoperative imaging study revealed malposition of the tip of the oximetry catheter in the mediastinum.

MAIN LESSON

The insertion of additional catheter through the sheath introducer needs to be carried out as carefully as the insertion of guidewire and should be confirmed with imaging study after the procedure.

Rare central venous catheter malposition - an ultrasound-guided approach would be helpful: a case report

Background

A central venous catheter enables the measurement of hemodynamic variations, such as accurate central venous pressure; catheter malposition may induce potentially fatal complications. This case report describes a rare central venous catheter tip malposition in the right internal mammary artery.

Case presentation

A 56-year-old Japanese woman who presented with severe pneumonia secondary to scleroderma was treated under ventilator support because of acute respiratory failure. A right central venous catheter was inserted using a landmark technique to monitor central venous pressure and administer medications. However, central venous waveforms detected by the catheter using a pressure lot transducer were later found to be absent. Further imaging studies, including plain radiography, computed tomography, and angiography, confirmed central venous catheter malposition in the internal mammary artery. Her right internal mammary artery was embolized using two interlocking detachable coils, and the central venous catheter was removed from her internal mammary artery without further complications.

Conclusions

Internal mammary artery malposition is a rare but potentially lethal complication of central venous catheter catheterization; however, caution should be taken regarding the assessment of risk factors and management of a severe complication. An ultrasound-guided approach would be helpful.

Noncardiac entrapment of a pulmonary artery catheter during heart transplantation: inadvertent cannulation and perforation of the internal thoracic vein

Placement of a central venous catheter into an internal thoracic vein occurs in approximately 2% of all catheterizations. A case in which a pulmonary artery catheter was trapped within the internal thoracic vein during orthotopic heart transplantation is presented.

Rare malposition of a central venous catheter into the left internal mammary vein in a liver transplantation patient

We report a rare malposition of a central venous catheter in a liver transplantation patient which occurred during an intensive care period. The waveform of central venous pressure was aberrant after connecting the catheter to the pressure kit transducer. It was misplaced into left internal mammary vein confirmed by thoracic computed tomography. Significant engorgement of the left internal mammary vein may have been the cause of this rare malposition.