IMAGES FOR SURGEONS ANZJSurg.com
Unsuspected path: a central venous catheter insertion A central line is an intravascular device or catheter that terminates at or close to the heart in one of the great vessels, and is used to provide temporary or long-term vascular access for the delivery of pharmacotherapy, total parenteral nutrition and/or regular blood sampling.1 A 58-year-old woman presented to the emergency department with a 1-week history of malaise, anorexia, bilateral flank pain and decreased colostomy output, on a background of Crohn’s disease with multiple resections. On examination she appeared cachectic and distressed, but alert and orientated. She was febrile (38.4°C), normotensive (systolic 115, diastolic 63 mmHg), tachypnoeic (20/min), but saturating well (97%) on ambient air. Biochemical investigations revealed an acidosis (pH 7.10), acute kidney injury (AKI) (creatinine 247 μmol/L), a normal white cell count (9.3 × 10^9/L) and elevated C-reactive protein (182.9 mg/L). She was prepared for intensive care unit admission for ongoing management. A left internal jugular three lumen central venous catheter (CVC) was inserted utilizing ultrasound to minimize complications. Two passes were required for insertion with a note of ‘difficulties passing the wire beyond valve’. A post-insertion chest radiograph (CXR) was performed to confirm the CVC’s position (Fig. 1). This revealed that the CVC was not in the desired location (cavo-atrial junction) and that it may have entered the descending aorta. A lateral CXR was performed revealing the CVC taking a posterior course in the left hemithorax (Fig. 2). The CVC was flushed and aspirated without any documented difficulty. Blood was aspirated from the CVC for blood gas analysis and results suggested venous placement (pO2
52 mmHg, pCO2 43 mmHg) when compared with blood gas analysis from a peripheral arterial sample (pO2 116 mmHg, pCO2 42 mmhg). Connection of the CVC to a transducer produced a venous trace. Because of AKI a contrast study (computed tomography (CT) or venogram) was avoided to minimize renal insult. A non-contrast CT scan was performed, that mapped the CVC travelling through the left internal jugular vein, into the left innominate vein and down one of its inferior tributaries – the left superior intercostal vein (SIV) (Fig. 3). The left SIV is responsible for draining the superior left posterior hemithorax and is a component of the azygous venous system. It is formed by the union of the second to fourth left posterior intercostal veins and courses superiorly to the left of the midline, arches superiorly lateral to the aortic arch to drain into the left innominate vein.2 The decision was made to remove the CVC, and was performed successfully without negative sequalae. Insertion of a CVC should be within a large-calibre vein with sufficient flow to tolerate infusion for example subclavian, brachiocephalic, superior vena cava.3 However, malposition of the CVC can occur. Review of the literature resulted in three previous reports of a left internal jugular vein CVC being introduced into the left SIV.3–5 The use of a post-insertion CXR for confirmation of CVC position is routine. A properly placed internal jugular CVC should be seen to run parallel to the shadow of the superior vena cava on posteroanterior CXR.4 An upright posteroanterior CXR allows for identification of the left SIV in approximately 1.4–9.5% of the healthy patient population, as a small ‘nipple’ lateral to the aortic arch.3 In a posteroanterior or anteroposterior CXR the CVC in the left SIV will follow the aortic knob, and in a lateral CXR will be seen to occupy the posterior mediastinum.4 If the position of the CVC
Fig. 1. Chest radiograph following CVC insertion.
Fig. 2. Lateral chest radiograph following CVC insertion.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
being infectious and 2–26% being thromboembolic.7 The use of ultrasound minimizes catheter insertion complication as the maximum frequency of major complications for image-guided insertion is 3% and malpositioning up to 3.7%.6,8 This case reflects the importance of confirming the course of a newly inserted CVC to minimize local vessel complications such as phlebitis, perforation, thrombosis or occlusion related to malposition.6,9,10
References
Fig. 3. Non-contrast computed tomography showing CVC in left superior intercostal vein.
cannot be determined by CXR then more advanced medical imaging can be utilized for example venogram and/or CT. However, the use of advanced medical imaging is not recommended for routine use for confirmation of CVC placement because of the associated risks and limitations of each aforementioned modality that is radiation dose, contrast exposure. Several complications are associated with CVC insertion including pneumothorax, arterial puncture, arrhythmias, line fracture, migration, infection, thrombosis, fibrin sheath formation and malposition.6 Predictive risk factors for insertional complications related to CVCs include previous radiotherapy, surgery at site of insertion, prior cannulation, obesity lack of expertise and multiple attempts.6 Observational studies suggest over 15% of patients with CVC will experience complications with 5–19% being mechanical, 5–26%
1. Australian Commission on Safety and Quality in Health Care. Central line insertion and maintenance guideline. 1–20. 2012. 2. Demos TC, Posniak HV, Pierce KL et al. Venous anomalies of the thorax. AJR Am. J. Roentgenol. 2004; 182: 1139–50. 3. Padovan RS, Paar MH, Aurer I. (Mis)placed central venous catheter in left superior intercostal vein. Radiol. Oncol. 2011; 45: 27–30. 4. Ghosh S, Dewan H, Bhattacharyya S. A rare malposition of thoracic venous catheter introduced via left internal jugular vein. Indian J. Crit. Care Med. 2008; 12: 201–3. 5. Chambers NA. Left internal jugular catheter tip wedged in the left superior intercostal vein, an inferior tributary of the brachiocephalic. Paediatr. Anaesth. 2005; 15: 1022–33. 6. Nayeemuddin M, Pherwani AD, Asquith JR. Imaging and management of complications of central venous catheters. Clin. Radiol. 2013; 68: 529–44. 7. Alemohammad M. Central venous catheter insertion problem solving using intravenous catheter: technical communication. Tehran Univ. Med. J. 2013; 70: 724–8. 8. Randolph AG, Cook DJ, Gonzales CA et al. Ultrasound guidance for placement of central venous catheters; a meta-analysis of the literature. Crit. Care Med. 1996; 24: 2053–8. 9. Currarino G. Migration of jugular or subclavian venous catheters into inferior tributaries of the brachiocephalic vein or into the azygous vein, with possible complications. Pediatr. Radiol. 1996; 26: 439–49. 10. Lavandosky G, Gomez R, Montes J. Potentially lethal misplacement of femoral central venous catheters. Crit. Care Med. 1996; 24: 893–6.
Nelson Agostinho, BSc (Hons), MBBS (Hons), MS Benjamin M. Robinson, MBBS, MPhil, FRACS Tristan D. Yan, BSc (Med), MBBS, MS, MD, PhD, FRACS Cardiothoracic Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12998
© 2015 Royal Australasian College of Surgeons
Unsuspected path: a central venous catheter insertion A central line is an intravascular device or catheter that terminates at or close to the heart in one of the great vessels, and is used to provide temporary or long-term vascular access for the delivery of pharmacotherapy, total parenteral nutrition and/or regular blood sampling.1 A 58-year-old woman presented to the emergency department with a 1-week history of malaise, anorexia, bilateral flank pain and decreased colostomy output, on a background of Crohn’s disease with multiple resections. On examination she appeared cachectic and distressed, but alert and orientated. She was febrile (38.4°C), normotensive (systolic 115, diastolic 63 mmHg), tachypnoeic (20/min), but saturating well (97%) on ambient air. Biochemical investigations revealed an acidosis (pH 7.10), acute kidney injury (AKI) (creatinine 247 μmol/L), a normal white cell count (9.3 × 10^9/L) and elevated C-reactive protein (182.9 mg/L). She was prepared for intensive care unit admission for ongoing management. A left internal jugular three lumen central venous catheter (CVC) was inserted utilizing ultrasound to minimize complications. Two passes were required for insertion with a note of ‘difficulties passing the wire beyond valve’. A post-insertion chest radiograph (CXR) was performed to confirm the CVC’s position (Fig. 1). This revealed that the CVC was not in the desired location (cavo-atrial junction) and that it may have entered the descending aorta. A lateral CXR was performed revealing the CVC taking a posterior course in the left hemithorax (Fig. 2). The CVC was flushed and aspirated without any documented difficulty. Blood was aspirated from the CVC for blood gas analysis and results suggested venous placement (pO2
52 mmHg, pCO2 43 mmHg) when compared with blood gas analysis from a peripheral arterial sample (pO2 116 mmHg, pCO2 42 mmhg). Connection of the CVC to a transducer produced a venous trace. Because of AKI a contrast study (computed tomography (CT) or venogram) was avoided to minimize renal insult. A non-contrast CT scan was performed, that mapped the CVC travelling through the left internal jugular vein, into the left innominate vein and down one of its inferior tributaries – the left superior intercostal vein (SIV) (Fig. 3). The left SIV is responsible for draining the superior left posterior hemithorax and is a component of the azygous venous system. It is formed by the union of the second to fourth left posterior intercostal veins and courses superiorly to the left of the midline, arches superiorly lateral to the aortic arch to drain into the left innominate vein.2 The decision was made to remove the CVC, and was performed successfully without negative sequalae. Insertion of a CVC should be within a large-calibre vein with sufficient flow to tolerate infusion for example subclavian, brachiocephalic, superior vena cava.3 However, malposition of the CVC can occur. Review of the literature resulted in three previous reports of a left internal jugular vein CVC being introduced into the left SIV.3–5 The use of a post-insertion CXR for confirmation of CVC position is routine. A properly placed internal jugular CVC should be seen to run parallel to the shadow of the superior vena cava on posteroanterior CXR.4 An upright posteroanterior CXR allows for identification of the left SIV in approximately 1.4–9.5% of the healthy patient population, as a small ‘nipple’ lateral to the aortic arch.3 In a posteroanterior or anteroposterior CXR the CVC in the left SIV will follow the aortic knob, and in a lateral CXR will be seen to occupy the posterior mediastinum.4 If the position of the CVC
Fig. 1. Chest radiograph following CVC insertion.
Fig. 2. Lateral chest radiograph following CVC insertion.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
being infectious and 2–26% being thromboembolic.7 The use of ultrasound minimizes catheter insertion complication as the maximum frequency of major complications for image-guided insertion is 3% and malpositioning up to 3.7%.6,8 This case reflects the importance of confirming the course of a newly inserted CVC to minimize local vessel complications such as phlebitis, perforation, thrombosis or occlusion related to malposition.6,9,10
References
Fig. 3. Non-contrast computed tomography showing CVC in left superior intercostal vein.
cannot be determined by CXR then more advanced medical imaging can be utilized for example venogram and/or CT. However, the use of advanced medical imaging is not recommended for routine use for confirmation of CVC placement because of the associated risks and limitations of each aforementioned modality that is radiation dose, contrast exposure. Several complications are associated with CVC insertion including pneumothorax, arterial puncture, arrhythmias, line fracture, migration, infection, thrombosis, fibrin sheath formation and malposition.6 Predictive risk factors for insertional complications related to CVCs include previous radiotherapy, surgery at site of insertion, prior cannulation, obesity lack of expertise and multiple attempts.6 Observational studies suggest over 15% of patients with CVC will experience complications with 5–19% being mechanical, 5–26%
1. Australian Commission on Safety and Quality in Health Care. Central line insertion and maintenance guideline. 1–20. 2012. 2. Demos TC, Posniak HV, Pierce KL et al. Venous anomalies of the thorax. AJR Am. J. Roentgenol. 2004; 182: 1139–50. 3. Padovan RS, Paar MH, Aurer I. (Mis)placed central venous catheter in left superior intercostal vein. Radiol. Oncol. 2011; 45: 27–30. 4. Ghosh S, Dewan H, Bhattacharyya S. A rare malposition of thoracic venous catheter introduced via left internal jugular vein. Indian J. Crit. Care Med. 2008; 12: 201–3. 5. Chambers NA. Left internal jugular catheter tip wedged in the left superior intercostal vein, an inferior tributary of the brachiocephalic. Paediatr. Anaesth. 2005; 15: 1022–33. 6. Nayeemuddin M, Pherwani AD, Asquith JR. Imaging and management of complications of central venous catheters. Clin. Radiol. 2013; 68: 529–44. 7. Alemohammad M. Central venous catheter insertion problem solving using intravenous catheter: technical communication. Tehran Univ. Med. J. 2013; 70: 724–8. 8. Randolph AG, Cook DJ, Gonzales CA et al. Ultrasound guidance for placement of central venous catheters; a meta-analysis of the literature. Crit. Care Med. 1996; 24: 2053–8. 9. Currarino G. Migration of jugular or subclavian venous catheters into inferior tributaries of the brachiocephalic vein or into the azygous vein, with possible complications. Pediatr. Radiol. 1996; 26: 439–49. 10. Lavandosky G, Gomez R, Montes J. Potentially lethal misplacement of femoral central venous catheters. Crit. Care Med. 1996; 24: 893–6.
Nelson Agostinho, BSc (Hons), MBBS (Hons), MS Benjamin M. Robinson, MBBS, MPhil, FRACS Tristan D. Yan, BSc (Med), MBBS, MS, MD, PhD, FRACS Cardiothoracic Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12998
© 2015 Royal Australasian College of Surgeons
