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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 177-178

From subclavian vein to contralateral internal jugular vein: Central venous catheter malposition is still not uncommon


Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission05-Feb-2021
Date of Decision31-Mar-2021
Date of Acceptance01-Apr-2021
Date of Web Publication18-May-2021

Correspondence Address:
Dr. Ashutosh Kaushal
Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_260_20

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How to cite this article:
Pathak S, Kaushal A, Gupta P, Singh S. From subclavian vein to contralateral internal jugular vein: Central venous catheter malposition is still not uncommon. Int J Health Allied Sci 2021;10:177-8

How to cite this URL:
Pathak S, Kaushal A, Gupta P, Singh S. From subclavian vein to contralateral internal jugular vein: Central venous catheter malposition is still not uncommon. Int J Health Allied Sci [serial online] 2021 [cited 2021 Jun 17];10:177-8. Available from: https://www.ijhas.in/text.asp?2021/10/2/177/316290



Sir,

Central venous catheters (CVC) are routinely placed in both perioperative and intensive care environment. Even in the most experienced hands, CVC insertion still remains a procedure with many complications, one of them being catheter malpositioning.[1] We report an unusual case of CVC malposition, wherein catheter inserted through the right subclavian vein migrated toward the contralateral internal jugular vein (IJV).

A 28-year-old female with torcular meningioma was posted for craniotomy and excision of the tumor. Under general anesthesia, a 7 Fr triple lumen CVC placement was attempted on the right subclavian vein using Seldinger technique. One assistant was asked to place pressure on the ipsilateral IJV when the guidewire was being threaded in the subclavian vein in order to prevent migration to ipsilateral IJV. Guidewire went in smoothly without any resistance, and backflow of blood was confirmed in all three ports of CVC, but as during the guidewire insertion, there was no electrocardiogram change, we suspected possible malpositioning of the catheter. We tried visualizing common sites of catheter tip malposition like such as ipsilateral IJV and contralateral subclavian vein using high frequency linear probe of ultrasound with no luck. On ultrasound screening further, the catheter tip was found in the contralateral IJV, an extremely rare site of malposition. This was further confirmed by ultrasonography (USG) saline flush test[2] and C-arm radiography inside operating room [Figure 1].
Figure 1: Chest radiograph showing the migration of catheter from subclavian vein to ipsilateral internal jugular vein Central venous catheter malposition is still not uncommon

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In order to correct this malposition, the catheter was pulled up to 6–7 cm and reinserted over the guidewire maintaining proper asepsis. This time assistant was asked to provide transient bilateral manual compression of IJV. Repeat ultrasound and chest radiography by C-arm confirmed correct position of CVC tip in the superior vena cava. Malpositioning is a very common complication related to subclavian vein catheterization, with the rate going as high as 9.1%,[3] and the most common site of malposition is to ipsilateral IJV.[2] Malpositioning to other sites such as azygous vein, hemiazygous vein, pericardium, pleura, and peritoneum are also reported, but misplacement into the contralateral IJV is a very rare event. From previous literatures, it seems that CVC tip can go anywhere depending on anatomical variations among individuals. We assume that, in our case, this unusual misplacement is also explained by anatomical variations among individuals.[2]

Misplaced CVC in smaller vein is usually associated with a few complications such as inaccurate measurement of CVP, catheter blockade due to clotting, thrombophlebitis, and vein perforation.[4] Although these complications are expected to occur mainly after long time in postoperative period, it is the catastrophic complications such as hemothorax, pneumothorax, and cardiac tamponade which require radiographic confirmation following the procedure. However, in this case, in order to effectively optimize cerebral perfusion pressure and possible venous air embolism management, we required correct CVC positioning before beginning of surgery. Hence, CVC malposition was diagnosed as well as corrected before beginning of craniotomy. Chest radiography is the most recommended and commonly used method to identify the position of CVC tip following the procedure in postoperative period.

Although USG is frequently used for jugular vein cannulation, its applicability to subclavian vein is limited because of bony obstacle in the form of clavicle. Noting a rise in CVP on manual compression of the ipsilateral IJV,[3] bedside echo after CVC saline flush and bubble contrast enhanced echo[2],[5] are other methods described in literature to detect CVC malposition. These techniques may not possible always due to unavailability of logistics and time constraint inside operating room.

We recommend that anesthesiologist should be aware of this rare complication, and at least ultrasound screening should be done routinely to identify CVC misplacement early, especially in the case where there is a need of air embolism management as well as accurate CVP measurement. Furthermore, bilateral transient IJV compression should be considered during insertion of guidewire.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Central line catheters and associated complications: A review. Cureus 2019;11:e4717.  Back to cited text no. 1
    
2.
Kumar N, Kaushal A, Dev Soni K, Tomar GS. A rare case of malposition of central venous catheter detected by ultrasonography-guided saline flush test. BMJ Case Rep 2017;2017:1-3.  Back to cited text no. 2
    
3.
Tomar GS, Tiwari AK, Jain DG, Chawla S, Sinha R. Central venous catheter rotation malposition: An unusual presentation. Indian J Anaesth 2012;56:415-7.  Back to cited text no. 3
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4.
Abbas H, Arshad Z, Saxena S, Bogra J, Kazim A. Unusual malposition of central venous catheter. A case report. Natl J Med Res 2013;3:96-7.  Back to cited text no. 4
    
5.
Blans MJ, Endeman H, Bosch FH. The use of ultrasound during and after central venous catheter insertion versus conventional chest X-ray after insertion of a central venous catheter. Neth J Med 2016;74:353-7.  Back to cited text no. 5
    


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