Malposition Of Central Venous Catheter Research Articles

Malposition of Central Venous Catheter into Coronary Sinus throughout the Persistent Left Superior Vena Cava and Other Complications Related to Catheterization.

This case concentrates on the persistent left superior vena cava (PLSVC), a rare vascular anomaly which contributes to central venous catheter (CVC) misplacement. A 72-year-old woman with renal insufficiency presented to the hospital with recurrent bleeding from her permanent CVC device placed in the right common jugular vein. An initial attempt to replace the device was unsuccessful, necessitating the placement of a secondary catheter in the left jugular vein. Shortly after the procedure, the patient developed swelling of the face and neck. Further diagnostic imaging, including a chest radiograph and computed tomography (CT), revealed CVC misplacement in the PLSVC and coronary sinus, thrombosis of the common jugular vein, and a posterior mediastinal hematoma. Conservative therapy of the mediastinal hematoma was implemented and proved effective in this case. A temporary CVC was inserted into the left femoral vein. Two months later, the catheter underwent further dysfunction and a decision was made to place a long-term permanent CVC via the right femoral vein. The patient is currently awaiting an arteriovenous fistula for dialysis use. This case emphasizes the importance of radiological techniques for CVC procedural placement, as well as the detection of congenital abnormalities. Providers regularly placing CVCs should have an in-depth knowledge of the possible complications and potential anatomical variations, especially as seen in high-risk patients.

On the way to the azygos vein: a road of return rather than ruined

BackgroundThe malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter.Case presentationA 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications.ConclusionsCVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement.

Using central venous pressure waveform to confirm the placement of an internal jugular central venous catheter in the intensive care unit

BackgroundA mobile chest X-ray is traditionally performed to confirm the position of an internal jugular central venous catheter (CVC) after placement in the intensive care unit (ICU). Using chest radiography to confirm CVC position often results in delays in authorising the use of the CVC, requires the deployment of additional human resources, and is costly. ObjectiveThis study aimed to determine the feasibility and accuracy of using the central venous pressure (CVP) waveform to confirm the placement of internal jugular CVCs. MethodsThis retrospective study was conducted in a single quaternary ICU over a 6-month period. We included adult patients who had internal jugular CVC inserted and CVP transduced as part of their routine care in the ICU. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CVP waveform analysis in confirming the position of internal jugular CVC relative to chest radiography were calculated. ResultsA total of 241 internal jugular CVCs were inserted (in 219 patients, 35.6% female), and the CVP waveform was assessed. In 231 cases, this suggested adequate placement in a central vein, which corresponded with a correct position on subsequent chest X-ray. On six occasions, the CVP waveforms were interpreted as suboptimal; however, on chest X-rays, the CVCs were noted to be in a suitable position (sensitivity: 97.5%). Four suboptimal CVP waveforms were obtained, and they correctly identified CVC malposition on subsequent chest X-ray (specificity: 100%). The average time from CVC insertion to radiological completion was 118 minutes. ConclusionCVP waveform analysis provides a feasible and reliable method for confirming adequate internal jugular CVC position. The use of chest radiography can be limited to cases where suboptimal CVP waveforms are obtained.

Multi-task learning framework to predict the status of central venous catheter based on radiographs

Hospital patients can have catheters and lines inserted during the course of their admission to give medicines for the treatment of medical issues, especially the central venous catheter (CVC). However, malposition of CVC will lead to many complications, even death. Clinicians always detect the status of the catheter to avoid the above issues via X-ray images. To reduce the workload of clinicians and improve the efficiency of CVC status detection, a multi-task learning framework for catheter status classification based on the convolutional neural network (CNN) is proposed. The proposed framework contains three significant components which are modified HRNet, multi-task supervision including segmentation supervision and heatmap regression supervision as well as classification branch. The modified HRNet maintaining high-resolution features from the start to the end can ensure to generation of high-quality assisted information for classification. The multi-task supervision can assist in alleviating the presence of other line-like structures such as other tubes and anatomical structures shown in the X-ray image. Furthermore, during the inference, this module is also considered as an interpretation interface to show where the framework pays attention to. Eventually, the classification branch is proposed to predict the class of the status of the catheter. A public CVC dataset is utilized to evaluate the performance of the proposed method, which gains 0.823 AUC (Area under the ROC curve) and 82.6% accuracy in the test dataset. Compared with two state-of-the-art methods (ATCM method and EDMC method), the proposed method can perform best.

Catheter Misplacement Following Subclavian Vein Catheterization Under Ultrasound Guidance: An Infrequent and Unusual Malposition

The most common malposition seen during subclavian vein cannulation is to the ipsilateral internal jugular vein. We report a case of unusual malposition of a subclavian central venous catheter, where it was found to be forming a “figure of U” in the ipsilateral subclavian vein. Although the catheterization was done under ultrasound guidance, we could not visualize the course of the guidewire due to a poor ultrasound window. This report highlights the fact that although ultrasound can facilitate identification of the vessels and prevent inadvertent arterial puncture, it seldom helps in the positioning of the guidewire tip and prevention of catheter malposition.

High-resolution feature based central venous catheter tip detection network in X-ray images.

Hospital patients can have catheters and lines inserted during the course of their admission to give medicines for the treatment of medical issues, especially the central venous catheter (CVC). However, malposition of CVC will lead to many complications, even death. Clinicians always detect the malposition based on position detection of CVC tip via X-ray images. To reduce the workload of the clinicians and the percentage of malposition occurrence, we propose an automatic catheter tip detection framework based on a convolutional neural network (CNN). The proposed framework contains three essential components which are modified HRNet, segmentation supervision module, and deconvolution module. The modified HRNet can retain high-resolution features from start to end, ensuring the maintenance of precise information from the X-ray images. The segmentation supervision module can alleviate the presence of other line-like structures such as the skeleton as well as other tubes and catheters used for treatment. In addition, the deconvolution module can further increase the feature resolution on the top of the highest-resolution feature maps in the modified HRNet to get a higher-resolution heatmap of the catheter tip. A public CVC Dataset is utilized to evaluate the performance of the proposed framework. The results show that the proposed algorithm offering a mean Pixel Error of 4.11 outperforms three comparative methods (Ma's method, SRPE method, and LCM method). It is demonstrated to be a promising solution to precisely detect the tip position of the catheter in X-ray images.

Comparison between ultrasound and chest X-ray to confirm central venous catheter tip position.

Mechanical central venous catheter (CVC) placement complications are mostly malposition or iatrogenic pneumothorax. Verification of catheter position by chest X-ray (CXR) is usually performed postoperatively. This prospective observational study assessed the diagnostic accuracy of peri-operative ultrasound and a 'bubble test' to detect malposition and pneumothorax. Sixty-one patients undergoing peri-operative CVC placement were included. An ultrasound protocol was used to directly visualise the CVC, perform the 'bubble test' and assess for the presence of pneumothorax. The time from agitated saline injection to visualisation of microbubbles in the right atrium was evaluated to determine the correct position of the CVC. The time required to perform the ultrasound assessment was compared to that of conducting the CXR. Chest X-ray identified 12 (19.7%) malpositions while ultrasound identified 8 (13.1%). Ultrasound showed a sensitivity of 0.85 (95% confidence interval [CI]: 0.72 to 0.93) and a specificity of 0.5 (95% CI: 0.16 to 0.84). The positive and negative predictive values were 0.92 (95% CI: 0.80 to 0.98) and 0.33 (95% CI: 0.10 to 0.65), respectively. No pneumothorax was identified on ultrasound and CXR. The median time for ultrasound assessment was significantly shorter at 4 min (interquartile range [IQR]: 3-6 min), compared to performing a CXR that required a median time of 29 min (IQR: 18-56 min) (p < 0.0001). This study showed that ultrasound produced a high sensitivity and moderate specificity in detecting CVC malposition. Ultrasound can improve efficiency when used as a rapid bedside screening test to detect CVC malposition.

A Rare Malposition of a Left Internal Jugular Central Venous Catheter into the Left Internal Mammary Vein.

We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein. Central venous access is a frequently used procedure by emergency physicians for a variety of indications. Emergency physicians must be facile with both the technical process of central venous catheter placement, as well as possible pitfalls and complications of the procedure. Common complications, such as bleeding, pneumothorax, arterial injury, infection, and hematomas, are usually well known; less frequently encountered is malposition of the catheter despite seemingly appropriate placement.

Additionally using transthoracic echocardiography during ultrasound-guided jugular central venous catheter placement and the odds of catheter misplacement in children: A before-and-after study.

Central venous catheter (CVC) misplacement is a major complication.1 To avoid CVC misplacement, real-time ultrasound (US) guidance is recommended for CVC placement in children.2, 3 Transthoracic echocardiography (TTE) can be additionally used to confirm correct CVC tip position.4, 5 Whether additionally using TTE during US-guided jugular CVC placement reduces the incidence of catheter misplacement remains scarcely described. We thus sought to test the hypothesis that additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children. After approval by the ethics committee with waiver of informed consent, we performed a retrospective before-and-after study in children aged 0–6 years who received a jugular CVC during anesthetic induction for congenital heart disease surgery at the University Medical Center Hamburg-Eppendorf (Hamburg, Germany) between March 2015 and April 2020. In our institution, jugular CVCs in children having cardiac surgery are routinely placed using real-time US guidance since 2013. In October 2017, routine use of additional TTE during US-guided jugular CVC placement was implemented. In the 31-month “before period” (March 2015 to September 2017), anesthesiologists did not use TTE but chose the CVC insertion depth considering patient height (no-TTE-group). In the 31-month “after period” (October 2017 to April 2020), additional TTE (subcostal long-axis view) was routinely used during US-guided jugular CVC placement to confirm the correct position of the guidewire and the CVC tip (rapid saline flush test) (TTE-group) (Figure S1). During both study periods, chest x-ray was used to confirm correct CVC tip position after surgery. We categorized CVCs as misplaced when the CVC tip ended above the level of the superior vena cava in a noncentral vein or deep in the right atrium (Figure S2). We investigated the associations between CVC misplacement and TTE use by logistic regression for all patients including age as covariate—and separately for patients aged <1 year and 1–6 years. We report the odds ratios (OR) with 95% confidence intervals. We included 373 patients (156 no-TTE-group and 217 TTE-group) (Table S1). CVC misplacement occurred in 15/156 no-TTE-group patients (9.6%) and in 5/217 TTE-group patients (2.3%). The odds for CVC misplacement were 371% lower when TTE was used compared to when it was not used (p = .004, OR = 0.21 [0.067–0.57]) (Figure 1). Of all 373 patients, 229 (61%) were younger than 1 year. In these patients, CVC misplacement occurred in 8/76 no-TTE-group patients (11%) and in 4/153 TTE-group patients (2.6%). The odds for CVC misplacement were 319% lower when TTE was used (p = .023, OR = 0.24 [0.062–0.79]). Of all 373 patients, 144 (39%) were between 1 and 6 years old. In these patients, CVC misplacement occurred in 7/80 no-TTE-group patients (8.8%) and in 1/64 TTE-group patients (1.6%). The odds for CVC misplacement were 480% lower when TTE was used (p = .107, OR = 0.17 [0.0090–1.0]). In our study, additionally using TTE during US-guided jugular CVC placement in children reduced the odds for CVC misplacement by more than 300%—which obviously is clinically meaningful. In only about 1% of children, the subcostal long-axis view could not be obtained—and TTE could thus not be used to confirm the CVC tip position. In general, children provide an excellent acoustic window for TTE examination of the right atrium and the superior vena cava. Nevertheless, TTE requires technical skills and operator experience. Our results need to be interpreted in light of the inherent limitations of retrospective before-and-after studies. Additionally, we only included children with congenital heart disease, whose anatomy may differ from healthy children. However, as we excluded patients with irregular venous conformations, we assume that our findings can be transferred to pediatric patients in general. Additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children aged 0–6 years. Clinicians should consider additionally using TTE during US-guided jugular CVC placement to increase patient safety. This work was supported solely from institutional and/or department sources. There are no conflicts of interest to declare. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

Central Venous Catheter Malposition into the Left Internal Mammary Vein in Patient with Coagulation Disorder and Safe Removal: A Case Report

A 61-year-old male patient with underlying diseases of hypertension and alcoholic liver cirrhosis was hospitalized for liver transplantation due to advanced liver cirrhosis. In preparation for liver transplant surgery, a multi-lumen access catheter and Swan-ganz catheter are inserted into the right internal jugular vein. And another central venous catheter is inserted into the subclavian vein for central venous pressure measurement and drug administration. There was no abnormal resistance of the guide wire or catheter that the operator could feel during the insertion process, and there was no abnormality in the function of the catheter. But the postoperative chest image showed that the left subclavian central vein catheter was malpositioned. Through venography at the angiography room, it was confirmed that the central venous catheter was inserted into the left internal mammary vein. Since the patient with coagulation disorder, special attention was required to remove the catheter. In addition, due to the location of the internal mammary vein, it was expected that it would be difficult to compress for hemostasis after removal of the catheter. Therefore, it was necessary to check the patient's coagulation test to determine the appropriate time of the catheter removal and cooperation of the radiologist.

Vascular anomaly diagnosis by central venous catheter misplacement: a case report

BackgroundCongenital heart diseases rarely have a primary manifestation in adulthood. They are a rare cause of pulmonary hypertension in adults.Case presentationA 70-year-old woman of Eurasian descent underwent emergency surgery for bowel ischemia. Her history of mild pulmonary hypertension likely correlates with a peculiar diagnosis of an anatomic anomaly on the postoperative x-ray and computed tomography scan. The central venous catheter was misplaced. Initial management consisted of removal of the catheter. The diagnosis, partial anomalous pulmonary venous return, may pose a clinical therapeutic dilemma.ConclusionsPartial anomalous pulmonary venous return is a potentially treatable cause of pulmonary hypertension. With the current trend toward more medical imaging, we expect this diagnosis to be made more often in the future.

Echocardiographic Determination of Percutaneous Central Venous Catheters in the Superior Vena Cava: A Prospective Cohort Study.

Malposition of percutaneous central venous catheters (PCVCs) in the superior vena cava (SVC) is common. We previously showed that real-time sonography was safer and faster than radiography in identifying PCVC tip location in the inferior vena cava (IVC). However, in preterm infants, determining PCVC tip location in the SVC is complicated by endotracheal or nasogastric tubes in situ and emphysematous lung conditions. We aimed to find an appropriate sonographic view by which to assess PCVC tip location in the SVC compared to the sonographic examination of PCVC in the IVC. Neonates (n = 50) with PCVCs in the SVC were enrolled and their data (gestational age, gender, birth weight, body weight at intervention, repositioning rate, and duration of tip assessment) were compared with retrospective data of 50 neonates with PCVCs in the IVC. The mean gestational age in the groups of IVC and SVC was 31.43 weeks and 32.16 weeks, respectively. The mean birth weight in the groups of IVC and SVC was 1642.18 g and 1792.00 g, respectively. Placement of an S12-4 ultrasound sector transducer to obtain clear parasternal views of the aorta allows visualization of PCVC tips in the SVC and near the cavoatrial junction. PCVC repositioning rates were not significantly different between the two groups (p = 0.092). Sonography examinations in the SVC had a longer duration than those in the IVC (p < 0.001). Sonography provides an accurate method for determining PCVC tip location in the SVC.

"To See is to Believe? A Misplaced Central Venous Catheter in Normal Position on Chest Radiograph"

Yu-Fu Lee and Yao-Chuan Hsiao* Author Affiliations Department of emergency and critical care medicine, Changhua Cristian Hospital, Taiwan Received: April 01, 2022 | Published: April 08, 2022 Corresponding author: Yao-Chuan Hsiao, Department of emergency and critical care medicine, Changhua Cristian Hospital, Taiwan DOI: 10.26717/BJSTR.2022.43.006860

Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients.

The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. Single-center retrospective cohort study. Quaternary academic PICU. Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. None. The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.

Viabahn Stent Graft for Inadvertent Insertion of a Central Venous Catheter in the Subclavian Artery

Subclavian artery (SCA) injuries associated with central venous catheter (CVC) insertion are uncommon yet lethal complications that typically require surgical treatment. This case report presents the case of a 94-year-old man with an iatrogenic right SCA injury resulting from a misplaced CVC. Computed tomography revealed the catheter piercing the right internal jugular vein to enter the right SCA and then reaching the aortic arch. Emergent endovascular treatment was performed, and a 13-mm × 50-mm self-expanding Viabahn stent graft (W.L. Gore & Associates, Flagstaff, AZ, USA) was placed via the right brachial artery. The misplaced catheter was successfully removed under simultaneous postdeployment balloon dilatation. This case highlights the utility of the Viabahn stent graft for iatrogenic right SCA injury caused by a misplaced CVC and presents some insights and tips for a safer procedure.

An interesting case of central venous catheter misplacement

An interesting case of central venous catheter misplacement

Supradiaphragmatic central venous catheter malposition detection using the parasternal long-axis echocardiographic view and dextrose 50% contrast solution: A pilot study.

Contrast-enhanced ultrasonography (CEUS) using saline was studied to detect supradiaphragmatic central venous catheter malposition. Commonly used echocardiographic views are apical 4-chamber (A4c) and subcostal views. However, this standard method is not feasible in certain situations. We explored the feasibility of the right ventricle inflow parasternal long axis (RVI-PLAX) echocardiographic view and dextrose 50% (D50%) contrast solution for detecting supradiaphragmatic central venous catheter malposition. This pilot study screened 60 patients who underwent ultrasound-guided supradiaphragmatic central venous catheter insertion. We compared the investigators' guidewire's J-tip detection, D50% rapid atrial swirl sign (RASS) findings on the RVI-PLAX view and the central venous catheter tip on chest radiograph. We also compared the mean capillary blood sugar level before and after the 5 ml D50% flush. No guidewire J-tips were detected from the RVI-PLAX view. The first and second investigators' diagnosis of central venous catheter malposition detected on RVI-PLAX CEUS achieved an almost perfect agreement (κ = 1.0 (95% confidence interval (CI): 0.90 to 1.0), p < .0001). The RVI-PLAX CEUS was not able to detect two central venous catheter malpositions (one atrial malposition and one left brachiocephalic vein venous catheter malposition). The capillary blood sugar was significantly elevated (8.96 mmol/L vs. 9.75 mmol/L) after D50% flush (p < 0.005) with no complications reported within 30 minutes after the D50% flush. RVI-PLAX view should not be used for guidewire detection. CEUS using D50% and RVI-PLAX view are potentially useful tools in detecting central venous catheter malposition. Further studies comparing them with conventional methods are needed.

Advocacy for the Patient’s Voice

Advocacy for the Patient’s Voice