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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 337-339 Table of Contents     

Malpositioning of Central Venous Catheter : Two Case Reports


MS, DNB(General Surgery), India

Date of Acceptance16-Apr-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Ashutosh Chauhan
Department of Oncosurgery, Army Hospital, Research and Referral, Delhi Cantt , Delhi-10
India
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Source of Support: None, Conflict of Interest: None


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Malpositioning of central venous catheter inserted into subclavian vein is a known and dreaded complication. Malpositioning of catheter tip into contralateral subclavian is an extremely unusual occurrence. The author describes two cases, one of subclavian central venous catheter and another of a peripherally inserted central catheter, in which the catheter malpositioned into contralateral subclavian vein.

Keywords: Central venous catheter, Subclavian, Malpositioning


How to cite this article:
Chauhan A. Malpositioning of Central Venous Catheter : Two Case Reports. Indian J Anaesth 2008;52:337-9

How to cite this URL:
Chauhan A. Malpositioning of Central Venous Catheter : Two Case Reports. Indian J Anaesth [serial online] 2008 [cited 2019 Jun 20];52:337-9. Available from: http://www.ijaweb.org/text.asp?2008/52/3/337/60647


   Introduction Top


The placement of central venous catheters (CVC) is a technically challenging procedure with known risks and complications. Exact placement is an essential pre­requisite for long-term use of a central venous catheter. Unfortunately, malpositioning of the same is a known complication with reported incidence in an extremely wide range from less than 1% to more than 60% [1] . When subclavian CVC placement is done, malpositioning oc­curs most commonly to ipsilateral internal jugular vein [2] . Malpositioning of central line into contralateral sub­clavian vein is an extremely unusual occurrence. We report two such incidences, one through a peripherally inserted central catheter (PICC) and another through subclavian CVC.


   Case Report Top


Case 1: A 36 year old lady, diagnosed case of carcinoma ovary, required total parenteral nutrition. A PICC line was inserted through right antecubital vein. Adequate backflow of blood and free inflow of injected saline confirmed intravenous positioning. However, check X Ray chest revealed catheter tip placed in con­tralateral subclavian vein instead of expected (Rt) atrium [Figure 1]. The catheter was withdrawn 2 inches and con­firmed to be in correct position subsequently.

Case 2: A 45 year old lady, diagnosed case of carcinoma post-cricoid region, post surgery, required total parenteral nutrition (TPN). A subclavian CVC was placed in right subclavian through a conventional infraclavicular route using Seldinger technique. Ad­equate backflow of blood and free inflow of injected saline confirmed intravenous positioning. However, check X ray chest revealed catheter tip placed in con­tralateral subclavian vein [Figure 2]. This CVC was re­moved and a left side subclavian CVC line was placed subsequently.


   Discussion Top


During subclavian vein catheterization, the most common misplacement of the catheter is cephalad, into the ipsilateral internal jugular vein (IJV), accounting for 60-70 % of all malpositioning [3] . Other sites for malpositioning mentioned in literature include the azy­gos vein, left superior intercostal vein and the thymic vein [4] . Contralateral subclavian is an extremely unusual site for malpositioning. In both our cases , standard approach was used using anatomical landmarks as guid­ing factors .It is thought that the guide wire placed in (Rt) subclavian , proceeded along inside (Rt) brachio­cephalic and then ,instead of proceeding caudad to­wards (Rt) atrium , turned cephalad to move into (Lt) brachiocephalic and then (Lt) subclavian [Figure 3] . Stud­ies have hypothesized that the final position of the cath­eter tip depends on course that the guide wire takes and this itself may be influenced by the initial orienta­tions of the J-type guide wire tip during the subclavian approach [5],[6] .Indeed, in a randomized, controlled study, authors suggest that keeping the guide wire J-tip di­rected caudad increased correct placement of central venous catheters towards the right atrium [6] . Authors' personal experience dictates that it is near impossible to maintain the catheter tip in any particular orientation when doing this procedure without any fluoroscopic guidance.

Various studies have explored other possible rea­sons for malpositioning of CVC. Some authors impli­cate excessive lengths of guide wire to be the cause. They recommend that an 18 cm length should be con­sidered the upper limit of guide wire introduced during central catheter placement in adults [7] . Others consider the length of the CVC inserted itself a risk factor. These authors opine that the average safe insertion depth for a central venous catheter from the left or right subcla­vian vein is 16.5 cm for the majority of adult patients and that a central venous catheter should not be rou­tinely inserted to a depth of > 20 cm [8] . Use of ultra­sound to direct insertion of CVC is controversial .Some authors suggest that ultrasound guidance improves the success rate of subclavian venous catheterization per­formed by less experienced operators [9] . On the other hand, other authors find that ultrasound guidance had no effect on the rate of complications or failures of sub­clavian-vein catheterization [10] . Hence, insertion of CVC remains essentially a blind procedure which utilizes guid­ance of fixed bony points. This would always result in a chance of malpositioning the catheter. This can happen into unlikeliest of anatomical locations as demonstrated in our cases.

 
   References Top

1.Malatinsky J, Kadlic T, Majek M, Samel M. Misplace­ment and loop formation of central venous catheters Acta Anaesthesiol Scand 1976;20:237-47.  Back to cited text no. 1      
2.Unal AE, Bayar S, Arat M, Ilhan O. Malpositioning of Hickman catheters, left versus right sided attempts.Transfus Apher Sci 2003 ;28:9-12.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Ambesh SP, Pandey JC, Dubey PK. Internal jugular vein occlusion test for rapid diagnosis of misplaced subcla­vian vein catheter into the internal jugular vein. Anes­thesiology 2001 ;95:1377-9.  Back to cited text no. 3      
4.Currarino G. Migration of jugular or subclavian venous catheters into inferior tributaries of the brachiocephalic veins or into the azygos vein, with possible complica­tions. Pediatr Radiol 1996 ;26:439-49.  Back to cited text no. 4  [PUBMED]    
5.Hwang JW, Han SH, Bahk JH, Oh YS. Influence of orien­tations of guide wire tip on the placement of subclavian venous catheters. Acta Anaesthesiol Scand 2005;49:1460­3.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a ran­domized, controlled study. Anesth Analg 2005 ;100:21-4.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Andrews RT, Bova DA, Venbrux AC. How much guidewire is too much? Direct measurement of the dis­tance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during cen­tral venous catheter placement. Crit Care Med 2000 ;28:138-42.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V, Mallory DL. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial . Crit Care Med 1993 ;21:1118-23.  Back to cited text no. 8  [PUBMED]    
9.Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Sub­clavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med 1995 ;23:692-7.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization N Engl J Med 1994;29:1735-8.  Back to cited text no. 10      


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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