An Enigmatic Discovery - Accidental Insertion of Internal Jugular Haemodialysis Catheter into the Vertebral Vein

Abstract

A 40-year-old male was admitted to the medical ward with chronic kidney disease with uremic symptoms and a decision was made to initiate the patient on haemodialysis. It was decided to catheterize the right internal jugular vein directly as the patient would require an A-V fistula in the near future which would be created in the left arm subsequently.
 Procedure
 During the time of right internal jugular vein catheterization using the anterior landmark technique, the right carotid artery was punctured leading to hematoma formation on the right side of the neck, despite adequate haemostatic measures.
 It was decided to catheterize the left internal jugular vein subsequently. Using the anterior landmark technique again, venipuncture was performed on the left side of the neck and in the first attempt itself the guide wire was inserted without any difficulty or resistance.
 Safe back-flow of venous blood was achieved through all ports of the catheter; that is, the catheter tip was presumed to be well positioned in the left internal jugular vein (IJV), as seen on the chest X-ray taken following the procedure.
 Clinical Course
 The patient complained of numbness over the left shoulder and weakness of the left upper limb following the procedure and was evaluated for the same. Under the clinical suspicion of left vertebral artery catheterization, a vascular surgeon opinion was sought and a CT angiogram of the neck was advised.
 The CT angiogram revealed the catheter entering the left vertebral vein at the level of C6 vertebra, coursing anteroinferiorly reaching the left brachiocephalic vein with its tip noted at the confluence of subclavian vein with internal jugular vein.
 After the CT angiogram, the misplaced catheter was promptly extracted to prevent the onset of additional complications.
 No excessive resistance was encountered during the catheter removal, and there were no signs of hematoma formation.
 Over the next few days, the patient’s symptoms of numbness and weakness resolved spontaneously.
 The patient had no neurological complaints and deficits on examination during follow-up in the outpatient department.