Coiling of Central Venous Catheter: A Rare and Preventable Complication.

Central venous catheter (CVC) placement is not only restricted to Intensive Care Units and operation theaters but its horizon has also expanded to the bedside placements. Meticulous care and aids such as ultrasound and fluoroscopy dramatically increase the successful placement of needles, guidewires, and catheters, but still a large number of catheter misplacements can occur. The formation of a loop in CVC is a rare complication occurring mostly during right-sided catheterization. We report a rare complication of coiling of left subclavian CVC.

INTRODUCTION

Central venous catheterization (CVC) is an essential component of modern-day critical care practice.[1] Subclavian vein (SV) central line placement is done commonly by landmark-guided technique followed by ultrasound-guided method. Despite careful placement using proper landmarks and technique, it might be associated with acute mechanical complications such as catheter malposition, hematoma formation at insertion site, inadvertent arterial puncture, pneumothorax, hemothorax, nerve injury, and thoracic duct injury. The formation of a loop in CVC is a rare complication occurring mostly during right-sided catheterization.[2] We report a rare complication of coiling of left subclavian CVC.

CASE REPORT

A 20-year-old female, a postoperative case of perforation peritonitis with ileostomy and fecal fistula, was advised bedside placement of CVC for administration of parenteral nutrition. After confirming the normal coagulation profile and platelet count, with all aseptic precautions under local anesthesia, left SV (as right internal jugular vein (IJV) and right SV were previously cannulated) was cannulated with triple lumen heparin saline flushed CVC (16–18-18G, 7 Fr, 20 cm, triple lumen; certofix, B Braun®) using standard Seldinger method[1] through infraclavicular approach by landmark technique. The procedure of CVC insertion was uneventful. Central line was inserted till 15 cm mark. The guidewire was withdrawn without any resistance. It was found that middle port had no free aspiration of blood, but all ports could be flushed with heparinized saline. A chest X ray (CXR) was performed to confirm the position of catheter, which revealed that it was coiled in a C-shaped pattern in the left brachiocephalic vein region [Figure 1]. It was removed without resistance, and a new left IJV catheter was placed using landmark technique, all ports had free aspiration of blood. CXR was done, which showed the normal placement of CVC [Figure 2].

Figure 1

Coiled central venous catheter

Figure 2

Correct position after removal of earlier central venous catheter

DISCUSSION

Incidence of mechanical complication in SV cannulation is 6%–10%.[3] The formation of a loop is mostly reported during pulmonary artery catheterization or right-sided SV catheterization,[2] suggesting that left-sided CVC coiling is a rare complication.

Various theories have been postulated for these rare incidences of coiling or looping such as extra length of insertion of guidewire and catheter.[4] In our case as it was a left SV catheterization, 15 cm of insertion was adequate. Excessive force might lead to coiling,[5] but in our case, the guidewire and CVC were passed easily and there was no kinking of the guidewire. Direction of J-type guidewire tip during insertion[4] and its locking with catheter tip during removal both may cause looping of CVC.[6] In our case, J-tip was in caudal direction as it should be and no resistance was felt during guidewire removal. There was no manufacturing defect in CVC[6] as catheter was inspected and flushed before insertion. A bottleneck exists between the clavicle and first rib, which can impede the threading of the wire and might contribute to looping and knotting;[5] this was overcome by placement of sandbag between the scapulas along the axis of spine which opens up the space between the two. There was no mass in the thoracic region and no lung disease to distort the vascular anatomy.[4] We cannulated left SV as it was not perforated or cannulated even once so it decreases the chances of it being stenosed or thrombosed which may increase the chance of coiling.[1] There was no anatomical vascular abnormality as left subclavian CVC tip was not lying in any aberrant tributary and it fells back on itself in the same vein,[7] and left IJV catheter was not in left paramedian position on chest X-radiograph as would have been in persistent left superior vena cava (SVC).[1] The acute angle formed by left brachiocephalic vein with SVC may cause abutting of the guidewire and the catheter, leading to falling back of the catheter on itself.[7] This might be the cause of the coiling in our case.

Coiled or knotted intravascular catheters may lead to catheter breakage and embolization, no free aspiration of blood from port, and central venous pressure (CVP) readings may be falsely elevated.[28] They are more likely to traumatize the vein, resulting in perforation or thrombosis.[8] Therefore, coiled catheter should ideally be removed, and new line from a different route should be inserted. Negative aspiration of blood from middle port may be due to acute coiling of CVC occluding the distal end of middle port or its lumen.[2]

Different landmarks, Peres formula (height [cm]/10), CXR, CVP waveform, right atrial electrocardiography (ECG), ultrasonography, and fluoroscopy have been used to ensure the correct placement of CVC.[9] USG only helps in safe and visible venous puncture but not in detecting malposition of the tip of the CVP catheter.[10] C-arm fluoroscopy cannot be used as a bedside procedure. ECG monitoring is routinely done throughout the procedure. It should be modified into right atrial ECG using wire provided with the CVC set [Figure 3] and an adapter, as it does not increase the financial burden and is more accurate in securing correct position within the SVC even when used as a bedside tool.[11] CXR radiograph remains the gold standard to confirm the tip of catheter.[12]

Figure 3

Electrocardiography lead with central venous catheter

CONCLUSION

Negative aspiration of blood from any of the port must raise an alarm for the malposition of the CVC tip. Right atrial ECG which is readily available in central line set should be used. Chest radiography should to be done immediately after insertion of every CVC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.