Central line complication…

April 14, 2014

Chest XR, Devices, Non-Trauma, XR


Central line mishap 1

Central line mishap 2 Central line mishap 3 Central line mishap 4

Central lines are often necessary and performed quite frequently.  With frequent procedures sometimes we get comfortable performing them and we minimize possible dangers.  This case demonstrates, however, that there are real complications that can occur from our invasive procedures.  Thus it is important to weigh the risks and benefits.

This central line decided to go through the caudal portion of the brachiocephalic vein and into the mediastinum.  The first xray shows the end of the catheter kinked near the aortic root.  CT of the chest shows the distal tip of the catheter puncturing through the vein and into the mediastinum.  Obviously this is a very rare complication!

Image Contributor:  Aaron Hougham, MD

Author:  Russell Jones, MD

 

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2 Comments on “Central line complication…”

  1. G Miller (@ORpocus) Says:

    Cool image.

    There is a remote possibility that the catheter is intravascular, as both the cardiophrenic vein and a persistent left SVC would be in about this position. Any additional info on whether this position was confirmed as extravascular (contrast, surgical exploration)?

    I’ve seen this on both sides during fluoroscopic guidance. On the right the catheter appeared to be advancing in the SVC but halted. Contrast showed retrograde filling to the origin of the SVC and we eventually were able to bypass this. As I recall the SVC was partially scarred. Since this was part of a minimally invasive surgical procedure with direct visualization of the right pericardial surface (including SVC origin to RA) there was no apparent extravasation.

    In another instance a highly flexible catheter (consistency of cooked spaghetti) repeatedly tracked along the left border of the mediastinum. Was disconcerting, but eventually tracked into the left brachiocephalic vein and into its final destination of the common PA.

    An autopsy study at Mayo clinic several decades ago showed coexistence of both a left brachiocephalic and persistent left SVC in 2/3 patients with a left SVC. The relative ratios varied. I’ve observed small PLSVCs where the coronary sinus as normal size on TEE and fluoro (confirmed by contrast spreading to left brachiocepalic from CS occlusive venography.)

    While it requires “favorable” alignment, there are instances where a normal catheter and/or guidewire can track intravascularly where “there aren’t any vessels.”

    Skepticism includes not assuming that you messed up.

    In this case, however, the sharp angle at the end is interesting. Any additional info that is shareable?

    Reply

    • emrems411 Says:

      Thanks for the comment! I can reveal further pictures of the line passing just lateral to the aorta with a tip ending up near an area of pleural effusion. See next post.

      Reply

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