Misplaced tunneled catheter into azygos vein.

Tunneled cuffed internal jugular vein catheters (TCC) are frequently used for hemodialysis. The procedure should ideally be undertaken under fluoroscopic image guidance, but many nephrology units do not have access to such facility. Anatomical landmark guided blind insertion is carried out in such a situation.

A 36-year-old man was initiated on maintenance HD. Under local anesthesia with aseptic precautions, a TCC was introduced into right internal jugular vein by anatomical landmark guidance. A check chest X-ray revealed that the tip of the TCC was unusually curved [Figure 1]. In a fluoroscopy suite, contrast was injected into the venous limb of the TCC. It showed that the catheter tip was in the azygos vein at the posterior mediastinum [Figure 2]. The TCC was pulled up into superior vena cava (SVC). A guidewire was inserted through the catheter. After confirming the position of the guidewire in the inferior vena cava, TCC was positioned at mid right atrium [Figure 3]. Adequate blood flow could be achieved for HD.

Figure 1

Arrows follow the curved tip of tunneled cuffed catheter

Figure 2

Lateral fluoroscopic view. Black arrow shows tunneled cuffed catheter in posterior mediastinum. White arrow shows dye entering Azygos vein

Figure 3

Arrow shows tip of repositioned tunneled cuffed catheter at junction of superior vena cava and right atrium

Azygos vein courses in the posterior mediastinum from abdomen to empty into SVC with wide variation in its anatomical position, tributaries, and course.[1] The size of its opening into SVC can vary between of 4 and 16 mm. The vein enlarges in state of venous congestion as in chronic kidney disease with cardiac failure.[2] This may permit the tip of TCC to enter the vein. Lateral chest X-ray will reveal the catheter to be placed in the posterior mediastinum.[3] Serious hemorrhage and hemothorax have been encountered due to such misplacement.[4] Use of fluoroscopy could have prevented this occurrence.