Malposition of right internal jugular vein cannulation into left brachiocephalic vein

Sir,

The catheter malpositioning into contralateral brachiocephalic vein is a rare presentation. So far to our knowledge, this has not been reported. Hence, we report this catheter misinsertion into other veins which cannot be easily identified from a successful central venous cannula (CVC) insertion as there is no difference in the colour and pulsation of the regurgitated blood flow (Wang et al. 2016). The patient in her sixties was admitted to the ICU for immunoglobulin infusion after being diagnosed with Guillain barre syndrome. Right internal jugular vein (IJV) cannulation was performed under strict aseptic conditions using Selinger’s technique. With ultrasound assistance, the IJV was punctured and the guide wire location was confirmed with ultrasound. Guide wire insertion was smooth without any resistance. Backflow was present in all three lumens. A chest X-ray was taken after catheter insertion to establish its position (Fig. 1). The catheter tip was found to be in the contralateral brachiocephalic vein (confirmed by the radiologist). It was partially removed and then under strict aseptic precaution, the guidewire was once again inserted and adjusted. The possible course of the catheter is shown in Fig. 2.

Fig. 1

Right IJV misposition into left brachiocephalic vein

Fig. 2

Course of right IJV catheter (shown in red)

The ipsilateral and contralateral internal jugular veins, as well as the opposite subclavian vein (SCV), are popular sites for misplaced catheters. A study by Maddali et al. found that 4% of the patients had the central venous catheter tip in a malposition in the right IJV group and in the left IJV group 22.3% of patients had malposition (Maddali et al. 2022). On radiography, Pikwer et al. showed a 3.3% overall incidence of catheter tip mispositioning (Pikwer et al. 2008). Right IJV cannulation with a figure of eight appearances that is not in the proper place has been reported (Solanki et al. 2015).

Catheter malpositioning into contralateral brachiocephalic vein is a rare presentation. The longer the left brachiocephalic vessel, the more oblique path to the heart, and the location of the small tributaries is thought to be the causes of the elevated risk of malpositioning left IJV (Gibson and Bodenham 2013). Following CVC placement, congenital variants are frequently found by chance during imaging. Even though they do not cause any symptoms, they can make it challenging to determine the CVC tip’s radiologic location.

The correct placement of the CVC tip is important in obtaining accurate central venous pressure (CVP) measurements. Inaccurate CVP measurements and inability to obtain an ideal waveform tracing are suggestive of a misplaced location of the catheter tip (Agrawal et al. 2010).

Ambesh and colleagues found that during SCV cannulation, manual compression of the IJV resulted in a clear increase in transduced pressure if the catheter tip was misplaced into the IJV and successfully prevented the passage of the guide wire into the IJV (Ambesh et al. 2002).

The take-home message from this case is that although routine use of ultrasound-guided insertion of CVC and training in ultrasound-guided insertion will reduce failure and complications, such techniques do not eliminate the risk of malposition altogether. Sound clinical judgement and radiological assessment are still necessary to confirm the correct placement of the central venous catheter tip.