Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
Year : 2017  |  Volume : 20  |  Issue : 4  |  Page : 477-478
Accidental placement of central venous catheter into internal mammary vein: A rare catheter malposition

Department of Cardiac Anesthesia, Seven Hills Hospital, Andheri, Mumbai, Maharashtra, India

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Date of Web Publication9-Oct-2017

How to cite this article:
Kela M, Munde H, Raut S. Accidental placement of central venous catheter into internal mammary vein: A rare catheter malposition. Ann Card Anaesth 2017;20:477-8

How to cite this URL:
Kela M, Munde H, Raut S. Accidental placement of central venous catheter into internal mammary vein: A rare catheter malposition. Ann Card Anaesth [serial online] 2017 [cited 2020 Jul 7];20:477-8. Available from:

The Editor,

Central venous catheterization plays important roles in cardiac surgery. Although a relatively safe procedure, it is associated with multiple complications. Malposition of the catheter tip is one of them. This report presents a rare malposition of a catheter into left internal mammary vein (IMV). It also emphasizes the need for routine use of ultrasound to minimize such complication by locating the exact position of catheter in superior vena cava (SVC) and right atrium junction.

We present a case of a 45-year-old male, for coronary bypass graft surgery. Postinduction right internal jugular vein (IJV) cannulation was attempted with Arrow 7 French (F) triple lumen but failed due to inability to pass the guidewire in spite of free flow of blood.

Left IJV cannulation was then done successfully with Arrow 7 F triple lumen without difficulty and catheter was fixed at 14 cm after confirming free flow of blood through all three ports. Continuous pressure monitoring showed persistently high central venous pressure (18–22 cm of H2O) throughout surgery. During left internal mammary artery dissection it was found that the catheter had entered into the left IMV [Figure 1] - in figure it looks like the catheter had perforated the vein as it was very thin walled but lumen was intact and there was no bleeding]. This was confirmed in postoperative period by chest X-ray [Figure 2]. Repositioning of catheter was not done intraoperatively to prevent any possible trauma to mammary vein. Catheter was finally removed smoothly without any resistance at the end of surgery.
Figure 1: Catheter in left internal mammary vein

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Figure 2: Chest X-ray showing catheter in left internal mammary vein

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The ideal position of catheter for measuring central venous pressure is at the level of mid-lower SVC to cavoatrial junction.[1] Malposition means a catheter lies outside of SVC. The incidence of malposition during IJV cannulation is around 2%.[2] Malposition can be of two types, intracaval and extracaval on the base of the location of the catheter.[3] The latter includes various structures such as mediastinum, pleura, pericardium, trachea, esophagus, and subarachnoid space. Catheter malposition is usually associated with serious consequences resulting in incorrect diagnosis and delayed treatment. Complication related to IMV placement includes laceration of IMV with massive hemothorax and altered patency of the vein.[4]

Various factors responsible for malposition are variable venous anatomy, tortuosity, acute angulations, congenital anatomical variation, and vein stenosis.

Malposition can be identified by the absence of bloody aspirate from the ports, chest radiograph, and central venous pressure tracing.

Turi reported a case of catheter placement at the anterior mediastinum, following SVC perforation. Trunjillo described two cases of accidental placement of a catheter in the left pericardiophrenic vein.[5] Leang reported a case of accidental placement of the catheter in the plural cavity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hsu JH, Wang CK, Chu KS, Cheng KI, Chuang HY, Jaw TS, et al. Comparison of radiographic landmarks and the echocardiographic SVC/RA junction in the positioning of long-term central venous catheters. Acta Anaesthesiol Scand 2006;50:731-5.  Back to cited text no. 1
Zaman MH, Mitra P, Bondi E, Gintautas J, Abadir AR. A rare malposition of the central venous catheter. Chest 1990;98:768-70.  Back to cited text no. 2
Gibson F, Bodenham A. Misplaced central venous catheters: Applied anatomy and practical management. Br J Anaesth 2013;110:333-46.  Back to cited text no. 3
Eulmesekian PG, Pérez A, Minces PG, Lobos P, Moldes J, García Mónaco R. Internal mammary artery injury after central venous catheterization. Pediatr Crit Care Med 2007;8:489-91.  Back to cited text no. 4
Trujillo MH, Arai K. Hydrothorax after inadvertent placement of a central venous catheter in the left pericardiophrenic vein. J Intensive Care Med 1994;9:257.  Back to cited text no. 5

Correspondence Address:
Manish Kela
A/14 Saiprasad Apartments, Telli Gulli Crosslane, Andheri, Mumbai - 400 069, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_106_17

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  [Figure 1], [Figure 2]