An interesting case of central venous catheter misplacement.

Sir,

The misplacement of the central venous catheters happens routinely in our practice. The subclavian vein (SCV) catheters are often misplaced into internal jugular veins (IJV), contralateral SCV or brachiocephalic veins, and internal mammary veins. Here, we describe a case of SCV catheter misplacement into the axillary vein. A 60-year-old obese male, who had sustained polytrauma was posted for fixation of the acetabular fracture. He had a fracture of the odontoid process. General anesthesia was administered with fentanyl, propofol, and atracurium. He was intubated maintaining the head in a neutral position with the help of a c-MAC video laryngoscope. Since his peripheral access was poor, it was decided to place a catheter into the SCV by the ultrasound-guided infraclavicular approach. The right neck and upper chest were draped and a high-frequency linear probe was placed parallel to the clavicle. In the short-axis view, the vein was seen at a depth of 2.5 cm. The needle was inserted in an in-plane technique and a free flow was ensured. The guidewire was passed easily without any resistance on which the catheter was threaded. After confirming backflow in all three lumens, the catheter was fixed at a depth of 13 cm. Postoperatively, the chest X-ray showed the catheter tip in the axillary vein [Figure. 1]. A bedside repeat ultrasound examination showed a superficial vein communicating with the SCV. The SCV was at a depth of 4 cm. The catheter was seen in the lumen of this communicating vein and passing into the SCV [Figure 2]. We speculate that we had primarily punctured this communicating vein. The guidewire must have passed into the SCV and then retrograded into the axillary vein. Since the patient needed the catheter for fluid and antibiotic administration only and all three lumens had good backflow, it was decided to maintain the catheter in the same place. The patient did not consent to further imaging studies to study the course of the catheter and further confirmation could not be done. At the time of discharge from the hospital, the catheter was removed uneventfully.

Figure 1

Chest X-ray of the patient showing the catheter

Figure 2

The vein communicating with the subclavian vein and the catheter in situ

A CVC tip which is not at the 'ideal’ position is termed a misplaced catheter. The ideal position is described as inside a large central vein, outside the pericardium, and without abutting the vessel wall at an acute angle.[1] The SCV catheters are most often misplaced into ipsilateral IJV. The axillary vein misplacement is very rarely reported.[2] The SCV can be accessed via the supraclavicular or infraclavicular approach. A recent study demonstrated a shorter procedural time and higher first-chance success rates in the supraclavicular approach.[3] Since our patient had an odontoid process fracture and needed to wear a hard collar, the infraclavicular approach was chosen. The position of the catheter can be confirmed with an X-ray, point-of-care ultrasound, and transthoracic or transoesophageal echocardiogram. Misplacement of the SCV catheter into the IJV can be detected by the IJV occlusion test.[4] The ultrasound has shown good diagnostic accuracy in detecting misplaced catheters.[5] Various formulae have also been studied to predict the ideal depth of the catheter insertion to avoid misplacements.[6] The management of the misplaced catheters depends on the position of the tip, the clinical status of the patient, and the indications for the CVC. The CVCs are placed for multiple purposes and the importance of the ideal tip position varies depending on the indication. While the placement of the catheter tip in a large vein is enough for the administration of the fluids and measuring the venous pressure, the infusion of chemotherapeutic and sclerosant agents requires the catheter tip to be near the right atrium. In patients with poor venous access, misplaced catheters may be maintained after discussing the risks and benefits.[1]

Declaration of patient consent

The consent for publication was obtained from the patient.

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Conflicts of interest

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