Complication Of Placement Research Articles

Extrauterine Migration of a Displaced IUD Leading to Bladder Wall Perforation: A Case Report

Background: Uterine perforation and Intrauterine contraceptive device (IUD) migration into adjacent organs is a serious complication of IUD insertion with an incidence of 0.1% to 0.9%. Only 2% of all migrated IUD cases have included the bladder. Case Presentation: In this report we discuss the presentation and management of a 54-year-old female diagnosed with extrauterine IUD migration into the bladder with consequent stone formation. She underwent an IUD insertion 28 years ago after her third pregnancy. She presented to our clinic complaining of lower urinary tract symptoms for 2 years. An initial urinary tract ultrasound showed an intravesical echogenic structure with posterior acoustic shadowing that was initially thought to represent a stone. The patient underwent an elective open cystolithotomy under general anesthesia where the IUD was located and then removed. The patient tolerated the procedure well and had an uneventful recovery period. Conclusion: IUD migration is a rare yet serious complication of IUD placement and should be ruled out in females with chronic urinary symptoms. WHO recommends removal of any displaced IUD regardless of location and severity of symptoms.

Complications Associated with Cervical Cerclage: A Systematic Review.

Cervical cerclages are associated with improved live birth rates and have low short- and long-term risks. However, there have been reports of fistula formation or erosion of cerclage into the surrounding tissue. Those complications are uncommon and yet are serious. The risk factors associated with its development are still unclear. The purpose of our study was to evaluate the incidence of fistula formation or erosion following transvaginal cervical cerclage and the associated clinical and sociodemographic factors. We conducted a systematic search of PubMed, Medline, and Embase databases to retrieve articles related to transvaginal or transabdominal cervical cerclage. Databases were searched up to July 2021. The study protocol was registered (PROSPERO ID 243542). A total of 82 articles were identified describing cervical cerclage and erosion or fistula formation. A total of 9 full-text articles were included. There were seven case reports and series that described 11 patients who experienced late complications following cervical cerclage. Many of the cerclage procedures were done electively (66.7%). The most common type of cerclage was McDonald (80%). While all cases reported fistula formation, the main location was vesicovaginal fistulas (63.6%). One patient (9.1%) had erosion of their cerclage and another (9.1%) had bladder calculi. Of 75 patients who underwent cerclage in two retrospective case reviews, the overall incidence of fistula was 1.3% and abscess was also 1.3%. Although rare, the most common long-term complication of cervical cerclage placement is fistula formation, particularly vesicovaginal fistulas.

Successful Nonoperative Management of a Sigmoid Colon Perforation Caused by a Migrated Biliary Stent

CASE REPORT Endoscopic biliary stents have been routinely used for the treatment of various hepatobiliary diseases. Complications from biliary stent placement may include cholangitis, bleeding, stent migration, or perforation. A 94-year-old woman with a history of gallstones presented with nausea, vomiting, and abdominal pain for 1 day with markedly elevated liver enzymes. Magnetic resonance cholangiopancreatography was consistent with choledocholithiasis and biliary duct dilation. The patient underwent an uneventful endoscopic retrograde cholangiopancreatography for sphincterotomy, stone extraction, and 10 F × 7 cm common bile duct (CBD) stent placement. Repeat endoscopic retrograde cholangiopancreatography for CBD stent retrieval failed to identify the previously placed CBD stent. A computed tomography scan revealed that the stent perforated the lateral wall of the sigmoid colon. Emergent flexible sigmoidoscopy was undertaken. Endoscopically, the distal edge of the stent seemed to have perforated the sigmoid colon, as evidenced by nonvisible flanges (Figure 1). The flanges on the proximal edge were seen but seemed to have caused mild mucosal injury. The stent was retrieved endoscopically in its entirety. An over-the-scope clip was attempted for both defects; however, the proximal site injury was significantly fibrotic, which instead required 8 through-the-scope clips to ensure a high degree of closure in this elderly patient to avoid the need for surgical intervention. An over-the-scope clip at the distal injury site was successfully placed. Postendoscopic contrast examination did not show any extravasation (Figure 1). The patient was treated with empiric antibiotics and discharged the following day in stable condition.Figure 1.: Flexible sigmoidoscopy showed the stent had perforated the sigmoid colon (a). After successful retrieval of the stent (b), an over-the-scope clip was placed at the distal injury site (c). Postendoscopic contract examination showed no extravasation.Bowel injury is a rare complication of biliary stent placement occurring in less than 1% of migrated stents. Stent migration should be suspected when a previously placed stent is not identified on endoscopic examination, and a cross-sectional imaging should be promptly ordered for investigation. Multidisciplinary evaluation including surgical consultation should be pursued, yet situational awareness is critical. In select situations, endoscopic clip closure may resolve colonic perforation. Flexible sigmoidoscopy stent retreival and endocopic clip closure. Watch the video at https://links.lww.com/ACGCR/A33 and https://links.lww.com/ACGCR/A34. DISCLOSURES Author contributions: E. Kwong edited the video, collected data, and wrote the manuscript. K. Jones collected data and edited the video. S. Park and K. Kwok edited the manuscript and video. K. Kwok is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.

Patient-reported outcomes in terms of swallowing and quality of life after prophylactic versus reactive percutaneous endoscopic gastrostomy tube placement in advanced oropharyngeal cancer patients treated with definitive chemo-radiotherapy: Swall PEG study

BackgroundPercutaneous endoscopic gastrostomy (PEG) is often used to provide nutritional support in locally advanced head and neck cancer patients undergoing multimodality treatment. However, there is little published data on the impact of prophylactic versus reactive PEG. PEG placement may affect swallowing-related physiology, function, and quality of life. The Swall PEG study is a randomized controlled phase III trial testing the impact of prophylactic versus reactive PEG on patient-reported outcomes in terms of swallowing and quality of life in oropharyngeal cancer patients.MethodsPatients with locally advanced oropharyngeal cancer receiving chemo-radiotherapy will be randomized to either the prophylactic or reactive PEG tube group. Randomization will be stratified by human papillomavirus (HPV) status and unilateral versus bilateral positive neck lymph nodes. The primary objective of the study is the patient’s reported outcome in terms of swallowing (MD Anderson Dysphagia Inventory (MDADI)) at 6 months. Secondary objectives include health-related quality of life, dosimetric parameters associated with patient-reported outcomes, chemo-radiation toxicities, PEG tube placement complications, the impact of nutritional status on survival and toxicity outcomes, loco-regional control, overall survival, the impact of HPV and tobacco smoking on survival outcomes and toxicities, and the cost-effectiveness of each treatment strategy.DiscussionFindings from this study will enhance clinical evidence regarding nutritional management in oropharyngeal cancer patients treated by concurrent chemo-radiation.Trial registrationClinicalTrials.gov NCT04019548, study protocol version 2.0_08/08/2019. Registered on 15 July 2019

Double superior vena cava and left brachiocephalic vein agenesis: a rare systemic vein anomaly and potential source of cardiac implantable electronic device and central venous catheter placement complications.

Abnormal systemic vein development produces anomalous veins, which - in the case of persistent left superior vena cava and/or left brachiocephalic vein - exhibit considerable topographic and morphometric differences in comparison with their usual anatomy. The nature and extent of those developmental anomalies - detected during intravenous procedures, such as cardiac implantable electronic device (CIED) lead insertion or central venous catheter placement - may hinder the procedure itself and/or adversely affect its outcome, both at the stage of cardiac lead advancement through an abnormally shaped vessel and lead positioning within the heart. This may lead to problems in achieving optimal sensing and pacing parameters and in ensuring that the patient cannot feel the pacing impulses. These events accompanied a de novo CIED implantation procedure in the patient with a double superior vena cava and left brachiocephalic vein agenesis, who ultimately required reoperation.

External-internal cranial expansion to treat patients with craniocerebral disproportion due to post-shunt craniosynostosis: a case series.

Secondary craniosynostosis subsequent to shunting is one of the late complications of ventricular shunt placement in the early childhood. Several interventions have been used to treat high intracranial pressure associated with this condition. This study aimed to evaluate the patients' clinical symptoms and head circumference before and after a method of decompressive craniotomy, coined as external-internal cranial expansion (EICE). A retrospective study was conducted, and the patients who had undergone EICE for the treatment of post-shunt craniosynostosis between 2010 and 2020 were enrolled. This approach was a combination of a hinge multiple-strut decompressive craniectomy and internal cranial flap thinning by drill. Data, extracted from medical records, were used to evaluate the patients' symptoms and head circumferences before and 12months after surgery. A total of 16 patients were enrolled in the study, of which eight were females. Before the surgery, 9 patients (56.2%) suffered from visual impairment, and all had intractable headache. Papilledema was recorded in all, with 3 cases having optic disc paleness. After cranial expansion, only two patients had headaches, diagnosed as migraine-type and psychosomatic headaches, respectively. In two patients, progressive visual impairments got worsening after surgery, which would be due to severe preoperative optic nerve atrophy. Patients' head circumferences significantly increased after the surgery (mean of 48.97 ± 4.28cm vs. 45.78 ± 4.31cm; P value < 0.0001). In lower resource countries, where newer technologies like distraction osteogenesis is not easily available, external-internal cranial expansion can be considered an effective alternative for patients with post-shunt craniosynostosis.

Single stage chest wall soft tissue reconstruction with ipsilateral pectoralis major turnover flap, rhomboid skin flap, and inferior nipple transposition

Extravasation injury is a well-known complication of central venous catheter placement, with potential for extensive soft tissue necrosis. Here, we describe the case of a patient who developed a large right chest well soft tissue defect, due to a chest wall abscess from calcium gluconate infusion via a right internal jugular central venous catheter. After multiple debridements, the chest wall defect was reconstructed with a single stage ipsilateral pectoralis major turnover flap, rhomboid skin flap, and inferior nipple transposition to match the contralateral nipple. There was no further infection, no nipple necrosis, and patient regained full range of motion of the ipsilateral shoulder.

Pancreatic duct stents.

Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.

Comparison of Open and Ultrasound-Guided Placement of Central Venous Catheter in Children Weighing Less Than Five Kilograms; A Randomized Clinical Trial

Ultrasound is currently utilized to locate the internal jugular vein (IJV), reduce the complications of catheter placement, and increase the likelihood of accessing IJV. Therefore, the aim of the present study was to evaluate the effectiveness of ultrasound in reducing complications during catheter placement in children weighing less than 5 kg. The current randomized clinical trial was performed on 111 children weighing less than 5 kg who required a central venous catheter (CVC). Children were divided into two groups: in the first group (Seldinger group; n=55), a CVC was inserted using the Seldinger wire method under ultrasound guidance, and in the second group (open surgical cutdown (OSC); n=56), the catheter was inserted via the open method. Two weeks after catheter placement, patients were evaluated for thrombosis, catheter occlusion, catheter tip migration, infection, catheter removal, and catheter dysfunction. The success rate of catheter placement in the ultrasound-guided method was 85.5%. The incidence of thrombosis (3.6% vs. 5.4%), infection (1.8% vs. 7.4%), and bleeding (zero vs. 3.6%) was lower in the Seldinger group, but the difference was not significant (p ˃ 0.05). Hematoma (7.3% vs. 3.6%) occurred less frequently in the patients of the OSC group (p=0.33). Hemothorax, pneumothorax, catheter migration, and occlusion did not occur in any of the patients. In the OSC group, two deaths (3.6%) occurred due to underlying diseases. When ultrasound is used to insert a CVC in children weighing less than 5 kg, the incidence of complications is not significantly different compared to when the open method is employed.

Emergent Large-Bore Central Venous Catheter Placement in Severely Thrombocytopenic Patients with Suspected Immune-Mediated Thrombotic Thrombocytopenic Purpura Is Safe and Effective

Introduction: Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a progressive and nearly uniformly fatal disease if not suspected and managed with plasma exchange (PLEX). Initiation of PLEX requires placement of a large-bore central venous catheter (CVC) in a patient with severe thrombocytopenia where platelet transfusion is contraindicated except in the setting of life-threatening hemorrhage. We sought to determine the safety and complication rates of large-bore CVC placement in patients with suspected iTTP. Methods: The Parkland Health and Hospital System electronic medical record system was queried for ADAMTS13 labs from 7/2011 to 7/2021, identifying 1,371 ordered tests with 465 being ordered in the emergency department, observation, or inpatient setting. Sixty-eight patients had a large-bore CVC placed for PLEX with suspicion for iTTP. Characteristics of providers performing CVC placement were obtained via chart review. Records were reviewed for complications, including death, infection, thrombosis, bleeding, pneumothorax, or pressure ulcers. Minor bleeding complications were procedure site hematomas and self-limited episodes of bleeding requiring manual pressure. The only major complication was a hematoma that required intubation for airway protection. Categorical variables were compared using the chi-square test, while continuous variables were compared using the Wilcox rank sum test. Results: Of the 68 patients, the majority were Black or Hispanic (84%). Central venous catheter placement was most often performed by General Surgery (68%) followed by the Medical Intensive Care Unit (MICU; 12%), Emergency Medicine (7%), and Nephrology (7%). Surgery and Emergency Medicine placed significantly more catheters in patients who ultimately had iTTP (P = 0.03). Resident physicians placed the majority of CVCs (79%) with no prophylactic blood products used in over 90% of cases. There was a 12% (8 out of 68) complication rate predominantly related to bleeding (n=7), although one patient had a pressure ulcer due to a lack of mobility after a femoral vein CVC placement. There was only one severe complication with the development of a rapidly expanding hematoma during an internal jugular (IJ) line placement causing airway compromise and requiring intubation. There were no differences in complication rates between line placement by General Surgery versus other services (P = 0.91) or with prophylactic platelet (P = 0.81), cryoprecipitate (P = 0.59), or FFP (P = 0.70) transfusions. A significant association was observed between the number of line attempts (median [IQR]) and complications (2 [2-4] v patients without complications: 1 [1-1], P < 0.001). In patients with iTTP, pre-procedural coagulation parameters had significantly lower platelets, lower INR, lower PT, and higher fibrinogen, suggesting a level of coagulopathy and/or disseminated intravascular coagulation in patients who were ultimately not found to have iTTP. Discussion: In a tertiary hospital, there was only one severe complication of large-bore CVC placement was observed in a cohort of 68 patients-most of whom had severe thrombocytopenia and did not receive prophylactic platelet or cryoprecipitate transfusions. Furthermore, resident physicians placed 79% of these CVCs without a significant increase in complication rate. Given that iTTP is a severe and progressive disease requiring emergent intervention, our findings suggest that CVC insertion for PLEX should not be delayed due to concerns regarding thrombocytopenia or bleeding complications. Most complications were minor bleeding or hematomas that resolved with pressure and observation. No significant difference in the rate of complications was observed when comparing surgical and non-surgical services. Conversely, there was an association between the number of CVC placement attempts and complications, suggesting that the line should be placed by whomever is qualified and available to expedite treatment. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 12376: Is Supraventricular Tachycardia a Potential Complication of Bronchoscopic Lung Volume Reduction

Introduction: Endobronchial valve (EBV) placement is one technique to attain bronchoscopic lung volume reduction (BLVR). This procedure has shown clinical benefits in terms of lung function, symptoms, and quality of life. A few complications have been reported including pneumothorax, dislocation or migration of the valve, hemoptysis, COPD exacerbation, and pneumonia. However, supraventricular tachycardia (SVT) was not seen as a potential complication within 45 days of the procedure. Hypothesis: SVT is a complication of EBV placement to attain BLVR. Methods: We conducted a retrospective chart review of consecutive patients who underwent EBV placement between January 2018 and December 2021. Patients who developed SVT were compared to patient who did not get SVT. Results: A total of 94 cases were identified. The incidence of SVT was 18 (19.15%) cases post EBV placement. The patients who developed SVT were older (median [IQR]: 74 [69-76], 72.2% males and all were whites (100%). The time to develop SVT ranged between 2.5 hours and 118 hours with median 40.5 hours. 13 (72.2%, P= 0.007) of patients who developed SVT had an electrolyte imbalance post EBV placement. Electrolyte imbalance was an independent factor for predicting SVT on multiple regression after controlling for age, BMI, gender, and location of valve placement (adjusted OR, [CI 95%] 4.64, [1.41 - 15.29], P = 0.012). Placement of EBV in the lingula and left upper lobe (LUL) have higher incidence of SVT (5 (27.8%, P = 0.049) and 12 (66.7%, P = 0.071), respectively). Table 1 and Table 2 further summarizes the result from the study. Conclusion: Given the results, SVT can be recognized as a potential complication of BLVR. Additional caution must be paid to patients who have EBV placed in the LUL and patients with electrolyte imbalance post procedure. Electrolyte imbalance post procedure was the only statistically significant independent predicting factor for SVT. A larger study is needed to determine the level of association.

Hysteroscopic Removal of Deeply Embedded IUD

<h3>Study Objective</h3> Highlight deeply embedded IUD as a potential complication of IUD placement and review surgical techniques for hysteroscopic removal of malpositioned IUD. <h3>Design</h3> N/A. <h3>Setting</h3> Main operating room suite, lithotomy position. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> Operative hysteroscopy to remove deeply embedded IUD. <h3>Measurements and Main Results</h3> Successful recognition and removal of deeply embedded IUD via hysteroscopy including pre-operative ultrasound and MRI to localize IUD position. <h3>Conclusion</h3> Malpositioned IUD is a common complication of IUD use. A hysteroscopic approach is a safe and effective tool in removal of malpositioned or embedded IUD, including those deeply or completely embedded in the myometrium.

7491 Laparoscopic Removal of a Perforated Adnexal Copper IUD

<h3>Study Objective</h3> The objectives of this video are to review the 1) inflammatory sequelae of a perforated intra-abdominal copper intrauterine device (IUD) 2) surgical technique to safely and effectively remove a perforated copper IUD from the adnexa and 3) considerations for management of the affected adnexa. <h3>Design</h3> This is an educational video. Institutional review board approval was not required for this video as the video describes a de-identified clinical case. <h3>Setting</h3> The procedure was performed in a gynecologic operating room with the patient in dorsal lithotomy position with steep Trendelenburg. <h3>Patients or Participants</h3> This video reviews a clinical scenario involving a de-identified patient. <h3>Interventions</h3> A copper IUD was found to have perforated through the uterus and into the left adnexa with a subsequent inflammatory reaction. The foreign object was removed from the patient's adnexa using blunt dissection and electrosurgery. This video describes the sequalae of a perforated Copper IUD, surgical technique used to remove the copper IUD, and considerations for removal or retention of the adnexa. <h3>Measurements and Main Results</h3> The video can serve as a resource for gynecologists to understand the sequalae and surgical management of a perforated copper IUD. <h3>Conclusion</h3> A possible complication of IUD placement is uterine perforation. Migration of the foreign object into an unlikely location must be considered when a patient presents with pelvic pain following placement. Copper IUDs generate an inflammatory reaction and may require advanced surgical technique for effective surgical management.

Complications in Prepectoral Tissue Expander Placement: A Single Institution Study

Complications in Prepectoral Tissue Expander Placement: A Single Institution Study

PITFALLS OF PERCUTANEOUS TRACHEOSTOMY PLACEMENT

PITFALLS OF PERCUTANEOUS TRACHEOSTOMY PLACEMENT

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

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME

S2590 Endoscopic Sengstaken-Blakemore Tube Placement for Variceal Hemorrhage: A Case Series

Introduction: Management of brisk variceal bleeding is challenging and nerve-racking for both gastroenterologists and intensivists. When visibility is hampered, a Sengstaken-Blakemore (SB) tube is used to tamponade as a temporary bridge to Transjugular intrahepatic portosystemic shunt (TIPS). Traditionally, the SB tube is placed blindly, or with the help of radiography to confirm gastric balloon location. Catastrophic complications are reported with blind approach including distension of the esophagus or trachea leading to rupture. Endoscopic SB placement has been described in literature as a successful technique. We report 3 cases with successful placement of SB tubes in massive variceal hemorrhage as a bridge to TIPS. Case Description/Methods: Case 1: A 36-year-old gentleman with alcoholic cirrhosis presented with hematemesis 2 days after undergoing variceal banding. Bleeding post-banding ulcers were confirmed with endoscopy and treated with hemoclips and epinephrine. Despite the intervention, the patient had recurrence of bleeding the following day with hematemesis. Repeat endoscopic intervention was limited due to poor visibility from brisk bleeding. An SB tube was placed endoscopically, and he underwent emergent TIPS that same day. The SB tube was removed 24 hours later with no recurrence of bleeding, and he was discharged to home. Case 2: A 68-year-old gentleman with alcoholic cirrhosis and history of variceal bleeding presented with hematemesis. Emergency endoscopy found massive bleeding, however the source of bleeding could not be located. An SB tube was endoscopically placed and an emergent TIPS was performed on the same day. The SB tube was removed 24 hours later with no recurrence of bleeding. After a 10-day hospital stay, he was ultimately discharged to hospice. Case 3: A middle-aged woman presented to the hospital with active variceal bleeding. She underwent successful endoscopic SB tube placement as a bridge to TIPS. Although she also had successful placement and no rebleeding, she ultimately succumbed to her disease. Discussion: Endoscopic SB tube placement is an effective bridge to emergent TIPS due to the improved hemostasis and decreased likelihood of rebleeding. This technique also limits the complications of blind placement, such as inadvertently distending the gastric balloon in the wrong location. Therefore, gastroenterologists should consider endoscopic placement of a SB tube when other endoscopic interventions fail to achieve hemostasis in variceal hemorrhage (Figure 1).Figure 1.: Endoscopic placement of a SB tube, confirming correct placement for hemostasis.

Safety of Percutaneous Endoscopic Gastrostomy Placement in Patients With SARS-CoV-2 Infection.

Coronavirus disease 2019 (COVID-19) can lead to ventilator-dependent chronic respiratory failure and a need for tube feeding. Percutaneous endoscopic gastrostomy (PEG) placement provides more sustainable longer-term enteral access with fewer side effects compared to the long-term nasogastric tube placement. Bleeding is a recognized complication of PEG placement, and many COVID-19 patients are on antiplatelets/anticoagulants, yet minimal data exist on the safety of PEG tube placement in this context. A retrospective chart review identified patients who underwent PEG placement between January 2020 and January 2021 at a single institution. Success was defined as PEG placement and use to provide enteral nutrition with no complications requiring removal within 4 weeks. Thirty-six patients with and 104 age- and sex-matched patients without COVID-19 infection were included. More COVID-19 patients were obese, on anticoagulants, had low serum albumin levels and had a tracheostomy in place. Of those patients, 8.3% with COVID-19 developed PEG-related complications compared to 16.3% without (P = 0.28). PEG success rates in patients with and without COVID-19 were similar at 97.2% and 92.3%, respectively (P = 0.44). PEG tube placement is comparatively safe in COVID-19 patients who need long-term enteral access.

Lymphorrhea following Tunneled Femoral Central Venous Catheter Placement: Avoidance and Management of a Rare Complication.

Lymphatic injury and chylothorax are known, albeit rare, complications of both right and left internal jugular central venous catheter placement.[1] [2] Some reports suggest that these complications occur more frequently when lines are placed in the presence of other complicating factors such as infection or thrombosis.[3] [4] [5] [6] [7] [8] Although rare, the potential for a peripheral lymphatic injury is present during vascular access adjacent to the inguinal nodal cluster. A case of iatrogenic peripheral lymphatic injury during placement of a femoral tunneled central venous catheter (TCVC) is described. We review peripheral lymphatic anatomy, suggest approaches to avoid inadvertent lymphatic injury, and discuss management strategies of a peripheral lymphatic injury.