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Article Outline

• Clinical Presentation
• Discussion
  • Why Doesn't This Catheter Work?
• Final Diagnosis
• References
• Copyright

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Clinical Presentation 

A 66-year-old man with end-stage renal disease secondary to focal and segmental glomerulosclerosis was admitted after thrombosis of his dialysis fistula. A 15-cm double-lumen right internal jugular catheter was placed by using real-time ultrasound–guided puncture. During the procedure, mild resistance was encountered while pushing the wire into the introduction needle, but this was overcome and the guidewire was advanced without further difficulty. Nonpulsatile blood was aspirated, and the hemodialysis catheter was placed without difficulty by using the Seldinger technique. Saline was injected and aspirated through both the arterial and venous lumens with ease. Anteroposterior chest radiograph showed the catheter tip at the height of the fourth vertebral body.

Hemodialysis was scheduled for the following day. However, at that time, blood could not be aspirated from the arterial side. Injection of saline through the catheter caused the patient retrosternal discomfort. A computed tomographic (CT) scan was obtained (Fig 1).

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• Figure 1. 

  Anteroposterior reformatted multidetector computed tomographic scan image.

■ Why doesn't this catheter work?

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Discussion 

Why Doesn't This Catheter Work? 

Cannulation of the central veins and placement of catheters for temporary hemodialysis is a common procedure in the management of patients with end-stage renal disease. The internal jugular vein is the most common site for central venous catheter (CVC) placement, being associated with the lowest complication rate. Nevertheless, this procedure can result in a variety of malpositions of the catheter (2% to 2.5% of cases¹, ²) and, rarely, can lead to significant morbidity and even death, if not recognized and corrected promptly. Given the anatomy and possible variations of the venous drainage system, the most common sites of CVC malposition include the azygos-hemiazygos vein, homolateral/contralateral jugular veins, and cross in the innominate and/or subclavian contralateral veins (Table 1; Fig 2). Malposition in the azygos arch occurs in about 1.2% of central venous cannulations.² Nevertheless, there are fewer catheter malpositions using the internal jugular approach than the subclavian approach.³ In this case, laterolateral multidetector CT scan showed misplacement of the CV in the right internal thoracic vein (Fig 3). Anatomically, cannulation of the right internal thoracic vein may be explained because it frequently arises 1 cm before the confluence in the superior vena cava.

Table 1. Central Venous Catheters: Most Common Reported Sites of Malposition

Adapted from Townley et al.²

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• Figure 2. 

  Diagram showing the central veins where catheter malpositioning occurs. Abbreviations: A, azygos vein; AJ, anterior jugular vein; BC, brachiocephalic vein; EJ, external jugular vein; I, intervertebral vein; IJ, internal jugular vein; IT, internal thoracic vein; S, subclavian vein; SVC, superior vena cava.

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• Figure 3. 

  Laterolateral reformatted multidetector computer tomographic scan image shows the central venous catheter positioned behind the anterior chest wall (white arrow).

Difficulty advancing a guidewire or catheter is a clue that misplacement may be occurring. Furthermore, catheter dysfunction associated with worsening chest or back pain requires additional investigation by means of imaging (anteroposterior and laterolateral chest radiography or CT scan).

In conclusion, we recommend that an anteroposterior and lateral chest radiogram be performed following placement of CVCs in which there is difficulty in catheter placement, because the aspiration of a small amount of blood from the catheter lumen does not confirm an in situ catheter.

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Final Diagnosis 

Right internal thoracic cannulation by CVC for hemodialysis therapy.

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References 

1. Koroglu M, Demir M, Koroglu BK, et al. Percutaneous placement of central venous catheters: Comparing the anatomical landmark method with the radiologically guided technique for central venous catheterization through the internal jugular vein in emergent hemodialysis patients. Acta Radiol. 2006;1:43–47
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2. Townley SA. Central venous catheter malposition in an anomalous pulmonary vein. Eur J Anaesthesiol. 2003;20:985–986
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3. Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters (Internal jugular versus subclavian access—A systematic review). Crit Care Med. 2002;30:454–460
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