Malposition Of Central Venous Catheter Research Articles

A Case of Pleural Effusion after Malposition of Central Venous Catheter

Central venous catheterization is used to provide a large amount of fluid, total parenteral nutrition and to administer antitumor agents with few complications reported. We report an uncommon case of pleural effusion that occurred after central venous catheterization. In many cases, the mechanism for the pleural effusion after central venous catheterization occurs through an injury to the superior vena cava by the continuous mechanical force of the catheter tip, the flow of large amount of fluid and an osmotic injury to the wall of the vein. This case is somewhat different in that the central catheter was placed in an aberrant vessel resulting in the pleural effusion. A post-placement chest roentgenogram and the correct approach of catheterization are i mportant for preventing this complication. (Tuberc Respir Dis 2006; 60: 690-693)

Cardiac tamponade associated with a peripheral vein central venous catheter

We present a case of cardiac tamponade associated with placement of a central venous catheter (CVC) via a peripheral vein in a 14-year-old girl with idiopathic scoliosis undergoing corrective surgery. A number of complications have been described in association with CVC misplacement. Sporadic cases of cardiac tamponade from this have been reported, but the actual incidence is unknown. Death from cardiac tamponade attributed to CVCs ranges from 65 to 100%. In our patient, cannulation of the pericardiophrenic vein was probably the cause of cardiac tamponade, based on radiological evidence that the initial location of the catheter was near the right atrium and possibly at the outlet of the pericardiophrenic vein. The catheter could have advanced into the vein and then to the pericardial sac with postural changes. The acute clinical course of cardiac tamponade in our patient had potentially lethal hemodynamic repercussions. The main diagnostic test for this condition is echocardiography and the only effective treatment is drainage of the pericardial effusion. Echocardiography should be performed before pericardiocentesis except in life-threatening situations or high clinical suspicion. Although they are rare, it is important to be aware of the potential for CVC complications.

An under-recognised malposition of neonatal long lines

We report two cases of malposition of percutaneous central venous catheters into the left ascending lumbar vein. The level of awareness amongst clinicians of this potentially fatal complication appears to be low. The recognition of unusual patterns of contrast medium dispersal is important in the diagnosis of catheter malposition.

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

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n=147) or cephalad in Group 2 (n=148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P <0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = <0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.

Expect the unexpected: malposition of a large-bore central venous catheter in the urinary bladder

We report the case of a femoral vein cannulation in a critically ill trauma patient with the malposition of a large-bore central venous catheter in the urinary bladder. Recognition of the malposition was hampered by bloody tamponade of the bladder in the context of blunt thoraco-abdominal trauma with kidney and liver laceration. A high index of clinical suspicion and the institution of adequate therapy were the key to achieving a successful clinical outcome. We discuss the anatomy of femoral veins, including their close relation to a distended bladder. The application of ultrasound even in emergency situations is stressed.

An Unusual Case of a Malpositioned Transvenous Pacemaker Wire via a Persistent Left-Sided Superior Vena Cava

In Brief The presence of a persistent left-sided superior vena cava is a rare venous return anomaly. There have been numerous reports in the literature describing placement of central venous catheters and transvenous pacemaker wires successfully into the right side of the heart through a persistent left-sided vena cava and the coronary sinus. An 84-year-old male developed acute cardiogenic pulmonary edema resulting in respiratory failure requiring assisted ventilation. His electrocardiograms revealed findings consistent with left ventricular hypertrophy. Subsequently, he developed cardiogenic shock complicated by asystolic cardiac arrest from which he was quickly resuscitated with epinephrine and atropine. A pulmonary artery catheter was placed via the right internal jugular vein without any complications. A transvenous pacemaker was successfully inserted through the left internal jugular vein for complete heart block. The postprocedure chest radiograph demonstrated a normally placed pulmonary artery catheter and the presence of the pacemaker wire along the left side of the heart. Thoracic computed tomography (CT) confirmed that the pacemaker wire extended through a persistent left-sided superior vena cava into a superficial cardiac vein. We present an unusual and previously unreported case of malposition of a temporary transvenous pacemaker wire into a superficial cardiac vein via a persistent left-sided superior vena cava. Critical care physicians should be aware of this congenital anomaly while placing central venous catheters from the left side, particularly in patients with other congenital cardiac defects. When the position is uncertain, imaging modalities, particularly CT, will be helpful in defining the course of central venous catheter. As critical care practitioners, we routinely place central venous catheters, which are not without risk. An unusual case of malposition of a temporary transvenous pacemaker wire into a superficial cardiac vein via a persistent left-sided superior vena cava is reported. Knowledge of this congenital anomaly during placement of central venous catheters from the left side is imperative, particularly in patients with other congenital cardiac defects. Imaging modalities such as computed tomography, angiography, and echocardiography can be helpful in delineating central venous catheter malposition.

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

Purpose: The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy. Methods: This was a retrospective review of the charts of all patients at Children’s Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed. Results: There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray. Conclusions: The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.

Elective and emergent endovascular treatment of subclavian artery aneurysms and injuries.

To demonstrate our short and long-term results after transbrachial treatment of subclavian artery aneurysms and injuries with stent-grafts in elective and emergency settings. Ten of 12 consecutive patients (6 men; mean age 63.8 years, range 38-80) were treated electively with commercially prepared endografts delivered via a transbrachial access to repair a subclavian artery aneurysm (n=3) or an injury from a misplaced central venous catheter (n=7). Two patients required emergency treatment for a ruptured atherosclerotic aneurysm in one and an unintentional arterial puncture during placement of a central venous access in the other. Stent-graft patency during follow-up was assessed by physical examination with comparison of brachial blood pressures in all patients; computed tomography angiography (CTA) was performed in available patients. Successful deployment of stent-grafts with sealing of the lesion was achieved in all cases. There were 2 (17%) procedural complications. One patient developed an access-site hematoma that required surgical revision. The second patient, who had a right subclavian injury, suffered an embolic cerebral infarction. The primary stent-graft patency during follow-up (mean 11.6 months) was 100%. CTA examinations in 7 patients at a mean 18 months showed strut dislocation at the thoracic outlet without luminal narrowing in 1 patient. A 50% intraluminal narrowing due to compression between the clavicle and the first rib occurred in another patient. Six patients with a mean follow-up of 23 months (range 0.3-4.5 years) are still alive with patent stent-grafts. Endovascular stent-graft treatment of subclavian artery aneurysms and injuries is a less invasive alternative to surgical repair. Long-term results must still be confirmed in further studies.

Central venous catheter malposition in the azygos arch

Central venous catheter malposition in the azygos arch

Life-threatening vascular complications after central venous catheter placement.

The purpose of this retrospective study was to report 11 cases of severe vascular complications after central venous catheter misplacement. For each patient, data collection included body mass index, the diagnosis at admission, the site of the procedure, the type of catheter, coagulation parameters, the imaging modalities performed and the applied treatment. Eight patients had a lesion of the subclavian artery. Brachiocephalic vein perforations were assessed in three more patients. All patients had a chest roentgenogram after the procedure, six a CT examination, and four an angiographic procedure. Seven patients had a body mass index above 30, and 5 patients had coagulation disorders prior to the procedure. Seven patients were conservatively managed, 2 patients died despite resuscitation, 1 patient was treated with a stent graft, and one by superselective embolization. Subclavian or jugular vein temporary catheter positioning is a practical approach. Identification of any iatrogenic perforation of the subclavian artery or central veins urges obtaining a chest roentgenogram and, when required, a chest CT, selective angiograms or venograms. Body mass index superior to 30, previous unsuccessful catheterization attempts, and coagulation factor depletion seemed to account for risk factors. Recognition of clinical and radiological complications is mandatory.

Radiologic placement of implantable chest ports in pediatric patients.

We evaluated the technical success and complications associated with radiologic placement of implantable chest ports in children for long-term central venous access. Between May 1, 1996 and January 11, 2000, 29 chest ports were placed in 28 children (15 girls, 13 boys; age range, 2-17 years; mean, 11.7 years). The patient's right internal jugular vein was used for access in 93% (27/29) of the procedures, and a collateral neck vein was used as a conduit to recanalize the central veins in two procedures because of bilateral jugular and subclavian vein occlusion. All procedures were performed in interventional radiology suites. Both real-time sonography and fluoroscopy were used to guide venipuncture and port insertion. Follow-up data were obtained through the clinical examination and electronic review of charts. Technical success was 100%. Fourteen percent of the catheters were removed prematurely, including one catheter removed 17 days after placement because the patient's blood cultures were positive for Candida albicans. No patients experienced hematoma, symptomatic air embolism, symptomatic central venous thrombosis, catheter malposition, or pneumothorax. The median number of days for catheter use by patients was 280 days (total, 9043 days; range, 17-869 days). The rate of confirmed catheter-related infection was 14% or 0.04 per 100 venous access days. One catheter occluded after 132 days. In pediatric patients, radiologists can insert implantable chest ports using real-time sonographic and fluoroscopic guidance with high rates of technical success and low rates of complication.

Unexpected Sudden Death from Coronary Sinus Thrombosis. An Unsual Complication of Central Venous Catheterization

Coronary sinus thrombosis is an unusual but potentially serious complication of the use of central venous devices. We report a fatal case of coronary sinus thrombosis in relation to a malpositioned central venous catheter. The death occurred very soon following the beginning of symptoms and the cause could not be suspected. Direct trauma of the catheter on the coronary sinus endothelium seems the most probable cause of the thrombosis.

Paravertebral and intraspinal malposition of transfemoral central venous catheters in newborns

Paravertebral and intraspinal malposition of transfemoral central venous catheters in newborns

Paravertebral and intraspinal malposition of transfemoral central venous catheters in newborns

We report permanent tetraplegia in a newborn resulting from intraspinal malposition of a transfemoral catheter. In 2 other neonates paravertebral malposition of indwelling Silastic lines was detected. We suggest that left-sided transfemoral catheterization and conditions enhancing collateral flow through the vertebrolumbar pathway may predispose to inadvertent paravertebral catheter placement.

Thoracic venous anatomy delineated by malpositioned central venous catheters on plain chest films.

The aim of this essay was to demonstrate the thoracic venous anatomy as delineated by malpositioned central venous catheters on plain chest radiographs. We therefore used the didactic advantage of clinically inadvertent catheter positions. This approach was chosen to illustrate venous anatomy with plain chest radiographs, and, thereby, to recognize malpositions promptly on the modality with which positions of central venous catheters is routinely performed.

ECG GUIDED PLACEMENT OF CENTRAL VENOUS CATHETER

Recording RA-electrocardiography, we inserted central venous catheters in a series of 68 patients. In patients with normal sinus rhythm, whenever a P wave enlargement was observed, the catheters were properly inserted. In three patients, initially there were no changes on elctrocardiography. But after withdrawal and re-insertion of the catheters, the P wave enlargement was observed in them and the catheters were properly inserted. In two patients, no changes on electrocardiography were seen to the last, and catheters were malpositioned. We think that this technique is handily available at bed-side, and useful to reduce the malposition of central venous catheters.

Azygos arch cannulation by central venous catheters: radiographic detection of malposition and subsequent complications.

The aim of this study was to determine the frequency of radiographically evident central venous catheter misplacement in the azygos arch and to analyze whether the frequency of azygos arch cannulation is dependent on the anatomical site of catheter insertion. We reviewed 1,287 postprocedural examinations and 3,441 follow-up examinations. Catheters had been inserted through the left (6%) or right (15%) internal jugular veins and through the left (32%) or right (46%) subclavin veins. Radiographs were analyzed for possible catheter malposition in the azygos arch and for complications related to this malposition. Catheter malposition in the azygos arch was seen on 16/1,287 (1.2%) postprocedural radiographic examinations. Of the 16 malpositioned catheters, 11 (69%) had been inserted in the left subclavian vein, three (19%) in the left jugular vein, two (12%) in the right subclavian vein, and none (0%) in the right jugular vein. There was a statistically significant difference in the frequency of azygos arch cannulation between left- and right-sided catheters (p = 0.001). All complications consisted of venous perforations and were seen in three of 16 cases (19%). Azygos arch cannulation is a rare but hazardous central venous catheter malposition that occurs early after catheter insertion and carries a substantial risk for complication. The risk for azygos arch cannulation is substantially increased if catheters are inserted in left-sided veins. Because of the severity of subsequent complications, radiologists should be vigilant in the detection of this rare malposition.

Transfemoral repositioning of malpositioned central venous catheters.

To determine the efficacy of the transfemoral vein approach to repositioning malpositioned central venous catheters. During a 4(1/2)-year period, malpositioned central venous catheters were repositioned 91 times in 83 patients via the transfemoral vein approach. All repositioning was initially attempted with a Grollman catheter or other pigtail catheter and a tip-deflecting wire. If these techniques failed or the venous anatomy was unfavorable, gooseneck or long loop snares were used. During 48 repositionings, rotating a pigtail-type catheter alone was used successfully in 39 (81%). In 6 of 9 failures, the addition of a tip-deflecting wire also failed. A Grollman catheter and tip-deflecting wire were used initially in 39 repositionings (6 failures; 85% success). Successful repositioning required a snare in 8 (4 as the primary repositioning technique) and a long-loop technique in 5. All repositionings were ultimately successful and there were no complications. Central venous catheters can be repositioned consistently by the transfemoral route. Pigtail catheters or tip-deflecting wires alone are successful in over 80% of cases.

Transfemoral Repositioning of Malpositioned Central Venous Catheters

Transfemoral Repositioning of Malpositioned Central Venous Catheters

The Misplaced Central Venous Catheter: A Long Loop Technique for Repositioning

The Misplaced Central Venous Catheter: A Long Loop Technique for Repositioning