Quiz Page May 2008: Why Doesn't This Hemodialysis Catheter Work?

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

		Insertion Site
		Right Internal Jugular Vein	Left Internal Jugular Vein	Right Subclavian Vein	Left Subclavian Vein
	Contralateral innominate vein (%)	0.5	2.4	1.9	1.7
	Omolateral innominate vein (%)	0.5	1.4	4.3	0.6
	Right subclavian vein (%)	0.7	0.7	1.2	—
	Left subclavian vein (%)	—	1.4	0.6	0.6
	Omolateral external jugular vein (%)	0.2	0.3	—	—
	Omolateral axillary vein (%)	—	—	—	—
	Omolateral thyroid vein (%)	—	—	—	—
	Omolateral internal thoracic vein (%)	—	1.0	—	0.6
	Pericardiacophrenic vein (%)	—	—	—	—
	Azygos vein (%)	0.7	1.2	—	1.1

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.