Year : 2008 | Volume
: 52 | Issue : 3 | Page : 337--339
Malpositioning of Central Venous Catheter : Two Case Reports
MS, DNB(General Surgery), India
Department of Oncosurgery, Army Hospital, Research and Referral, Delhi Cantt , Delhi-10
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.
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Chauhan A. Malpositioning of Central Venous Catheter : Two Case Reports.Indian J Anaesth 2008;52:337-339
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Chauhan A. Malpositioning of Central Venous Catheter : Two Case Reports. Indian J Anaesth [serial online] 2008 [cited 2020 Jul 6 ];52:337-339
Available from: http://www.ijaweb.org/text.asp?2008/52/3/337/60647
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%  . When subclavian CVC placement is done, malpositioning occurs most commonly to ipsilateral internal jugular vein  . 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 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 The catheter was withdrawn 2 inches and confirmed to be in correct position subsequently.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.
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  . Other sites for malpositioning mentioned in literature include the azygos vein, left superior intercostal vein and the thymic vein  . 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 , .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  . 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  . 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  . 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  . On the other hand, other authors find that ultrasound guidance had no effect on the rate of complications or failures of subclavian-vein catheterization  . 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.
|1||Malatinsky J, Kadlic T, Majek M, Samel M. Misplacement and loop formation of central venous catheters Acta Anaesthesiol Scand 1976;20:237-47.|
|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.|
|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.|
|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.|
|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.|
|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.|
|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.|
|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.|
|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.|
|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.|