Medical Image of the Week: Malposition of Central Venous Catheter

Figure 1. Portable anterior-posterior chest x-ray showing the tip of the catheter projecting on the left lung filed instead of crossing the midline.

Figure 2. Coronal images of computed tomography of head, neck, and upper chest. Yellow arrows showing the anatomical course of the left internal jugular catheter. Left upper image showing the catheter entering the internal jugular vein. Right lower image showing the tip of the catheter in the left inferior pulmonary vein.

A 66-year-old man a with history of systolic heart failure and end-stage renal disease on hemodialysis was admitted to the intensive care unit due to cardiogenic shock requiring inotropes. As left arm fistula was clotted, left internal jugular vein triple-lumen catheter (IJC) was placed to obtain a hemodialysis access. Central line placement was performed under ultrasound guidance with no complications. A confirmatory chest x-ray revealed central venous catheter malposition; the catheter tip did not cross the midline; instead, it projected over the left lung field which was concerning for arterial puncture of the carotid artery (Figure 1). Bedside ultrasonography showed an appropriate catheter placement in the left internal jugular vein, but the final catheter tip location was unclear. The transduced pressure was low; approximately 5mmHg. A blood gas sample from the catheter was compatible with arterial blood; pH 7.42, pCO2 34, and pO2 92. Computed tomography scan of the head and neck showed the IJC entering the left jugular vein, coursing within an anomalous left pulmonary vein, and terminating within the left inferior pulmonary vein (Figure 2). The catheter was not used and was withdrawn without complications.

One of the notable complications of central venous catheter (CVC) placement is malposition, with an approximate rate of 6,7 % (1). Catheter malposition indicates that the catheter tip lies outside the recommended position (within the mid lower part of the superior vein cava (SVC) above its junction with the right atrium and parallel to the vessel walls). Possible sites of central catheter malposition include the carotid artery, azygos vein, persistent left‑sided SVC, internal mammary vein, vertebral vein, pericardium, pleural space, thoracic duct and mediastinum (2). As artery puncture in the carotid artery can lead to serious complications, malposition of the catheter should be addressed in a stepwise approach. Initially bedside ultrasound should be performed to determine the anatomical catheter course and the position of the tip. A pressure transducer is also helpful in differentiating venous versus arterial waveform and measuring the transduced pressure, obtaining arterial blood gases and eventually confirming the catheter position with CT scan or CT angiography. Malposition of the jugular catheterization incidentally revealing partial anomalous of pulmonary venous return was described in a very few cases in literature, the catheter was used for seven days for continuous veno-venous hemofiltration in one of these cases (3). At this time there is insufficient literature to determine the safety of using CVC inserted in an anomalous pulmonary vein.

Mohamad Muhailan, MD and Muhamad Alhaj Moustafa, MD

Department of Internal Medicine

MedStar Washington Hospital Center

Washington, DC USA

References

1. Schummer W, Schummer C, Rose N, Niesen WD, Sakka SG. Mechanical complications and malposition of central venous cannulations by experienced operators. A prospective study of 1794 catheterizations in critically ill patients. Intensive Care Med. 2007 Jun;33(6):1055-9. [CrossRef] [PubMed]
2. Wang L, Liu ZS, Wang CA. Malposition of central venous catheter: Presentation and management. Chin Med J (Engl). 2016 Jan 20;129(2):227-34. [CrossRef] [PubMed]
3. Grillot N, Figueiredo S, Aubry A, Leblanc PE, Duranteau J. Unusual dialysis catheter position due to partial anomalous pulmonary venous return: Diagnosis and management. Anaesth Crit Care Pain Med. 2016 Jun;35(3):233-5. [CrossRef] [PubMed]

Cite as: Muhailan M, Moustafa MA. Medical image of the week: Malposition of central venous catheter. Southwest J Pulm Crit Care. 2018;17(1):30-1. doi: https://doi.org/10.13175/swjpcc084-18 PDF 

Medical Image of the Week: Central Venous Access with Dextrocardia

Figure 1. Post CVC placement chest X-ray. Catheter traced with arrows.

An 88-year old man, with known dextrocardia, was admitted with a diagnosis of septic shock. A right sided internal jugular central venous catheter was placed uneventfully using ultrasound guidance. Chest X-ray obtained after the catheter placement is shown (Figure 1). Although the utility of a chest X-ray after every ultrasound guided central line placement is questionable, it continues to be “routine practice” in many centers. In dextrocardia, a right sided central line is expected to cross the midline as in this patient. When in doubt, the catheter may not be used unless venous placement is confirmed.

Venous placement of the catheter can be confirmed by:

1. Transducing the catheter and confirming venous waveform;
2. Blood gas analysis consistent with venous gas;
3. Imaging X-ray or cross sectional (1).

Bhupinder Natt MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson, AZ USA

Reference

1. Morton PG. Arterial puncture during central venous catheter insertion. Crit Care Med. 1999 May;27(5):878-9. [CrossRef] [PubMed] 

Cite as: Natt B. Medical image of the week: central venous access with dextrocardia. Southwest J Pulm Crit Care. 2017;15(6):296. doi: https://doi.org/10.13175/swjpcc148-17 PDF 

Medical Image of the Week: Persistent Left Superior Vena Cava

Figure 1. Left subclavian central line courses in a left paramediastinal location.

Figure 2. Axial CT image of the chest shows a vessel coursing lateral to the aortic arch consistent with a persistent left superior vena cava.

A 19 year old man with acute lymphocytic leukemia was admitted to the ICU with septic shock. Due to areas of cellulitis on the right side of the chest and neck and femoral venous thrombi, a left subclavian central access was attempted. The chest x-ray obtained after line placement is shown below (Figure 1). Blood gas done from the line was consistent with venous blood and venous tranduction was seen. A CT of the chest (Figure 2) confirmed the diagnosis of persistent left superior vena cava (PLSVC).

A persistent left superior vena cava is the most common congenital thoracic venous anomaly, seen in 0.3-0.5% of the population (1). Incidence is increased in patients with congenital heart disease to 5%. In most patients a right sided SVC is also present; hence the term SVC duplication has also been used. Embryologically a PLSVC is formed when the left anterior cardinal vein is not obliterated during fetal development to form the ‘Ligament of Marshall’. It usually drains in to the coronary sinus.

Diagnosis is usually made incidentally on CT scan, echocardiography or,like in our case, after a left sided central access. Practically, its presence may complicate left sided central access including Swan Ganz Catheter placement, implantable cardioverter defibrillator (ICD) placement and during cardiac surgery including during administration of retrograde cardioplegia or cardiac transplant.

Emad Hammode MD¹, Khaled Hamed MD¹, Mohammad Hudeeb MD¹, Veronica Arteaga MD²

¹Department of Internal Medicine

²Department of Thoracic Imaging

University of Arizona Medical Canter

Tucson, AZ

Reference

1. Povoski SP, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol. 2011;9:173. [CrossRef] [PubMed]

Reference as: Hammode E, Hamed K, Hudeeb M, Arteaga V. Medical image of the week: persistent left superior vena cava. Southwest J Pulm Crit Care. 2014;9(4):242-3. doi: http://dx.doi.org/10.13175/swjpcc132-14 PDF