Inadvertent placement of left central venous catheter into left internal thoracic vein: A case report

The Editor, Central venous catheter (CVC) placement is a routine procedure in the management of patients undergoing coronary artery bypass graft (CABG). Correct placement of the CVC is an essential prerequisite for accurate monitoring of central venous pressure (CVP) and long-term use of the catheter. Malpositioning of CVC is a known complication, with the reported incidence ranging widely from less than 1% to more than 60%. [1] Malpositioning of the catheter occurs approximately 2% of the time when the subclavian or internal jugular vein (IJV) approaches are used. [2] It has been reported that the incidence of catheter malposition is 4.12% and 1.1% when the left and right IJVs are used, and it also depends on the type of material used but not on the experience of the physician who inserted the catheter. [3] We report a case of misplacement of an internal jugular catheter into the internal mammary vein before CABG. A 59-year-old obese female was scheduled for CABG. Anesthesia was induced with midazolam and fentanyl and endotracheal intubation was facilitated with vecuronium bromide and pancuronium bromide. [4] The left IJV was cannulated with a 16 cm catheter and threading of the catheter was smooth and uneventful. Return of venous blood was observed and intravenous (i.v.) fluid flowed easily into the catheter. CVP trace was normal and was measured as 13 mmHg. We connected inotropes and nitroglycerine to the other ports and started the infusion. Following median sternotomy and spreading of the sternum apart using a chest spreader, the CVP increased to 25 mmHg from 13 mmHg. When the CVC was flushed, the surgeon noticed a spurt of fluid around the internal mammary area. The surgeon observed that the catheter had entered the left internal mammary vein [Figure 1] and there was a small hematoma in the vicinity of the internal mammary artery [56] [Figures 1 and 2]. The catheter was withdrawn to a length of 10 cm. Adequate backflow was present and fluids were flowing well. After the dissection, the surgeon checked the patency of the vein, and it was found to be damaged. Proper positioning of the CVC is important to ensure optimal catheter function and to decrease complications. Many of the cases of left superior intercostal vein cannulation in the literature document the findings, with no report of patient symptoms, catheter function or management. Sekerci and colleagues [7] reported inadvertent malpositioning of a drum catheter in the left internal mammary vein following an attempt at central venous cannulation via the right antecubital fossa.Figure 1: Showing CVC in left internal thoracic veinFigure 2: Showing small tear in internal thoracic vein