Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction

Abstract

Despite the level of skill of the operator and the use of ultrasound guidance, central venous catheter (CVC) placement can result in CVC malpositioning, an unintended placement of the catheter tip in an inadequate vessel. CVC malpositioning is not a complication of central line insertion; however, undiagnosed CVC malpositioning can be associated with significant morbidity and mortality. The objectives of this review were to describe factors associated with intravascular malpositioning of CVCs inserted via the neck and chest and to offer ways of preventing, identifying, and correcting such malpositioning. A literature search of PubMed, Cochrane Library, and MD Consult was performed in June 2014. By searching for "Central line malposition" and then for "Central venous catheters intravascular malposition," we found 178 articles written in English. Of those, we found that 39 were relevant to our objectives and included them in our review. According to those articles, intravascular CVC malpositioning is associated with the presence of congenital and acquired anatomical variants, catheter insertion in left thoracic venous system, inappropriate bevel orientation upon needle insertion, and patient's body habitus variants. Although plain chest radiography is the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC malpositioning even in presence of normal or inconclusive conventional radiography findings should prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning. With very few exceptions, the recommendation in cases of intravascular CVC malpositioning is to remove and relocate the catheter. Knowing the mechanisms of CVC malpositioning and how to prevent, identify, and correct CVC malpositioning could decrease harm to patients with this condition.

Figure 1

Common variants of clinical significance in the central venous anatomy, the congenital persistent left-sided superior vena cava.

Figure 2

Portable chest radiograph showing a central line inserted in the left subclavian vein, catheter located at persistent left-sided superior vena cava (arrow). Patient was unaware of his congenital variant. He was always asymptomatic during line placement.

Figure 3

Portable chest radiograph showing a central line catheter placed on the right subclavian vein. The catheter migrated to the right internal jugular vein despite proper procedural technique. Mild resistance was experienced during the wire threading. The patient had history of chronic renal disease. A hemodialysis catheter had been placed in the right subclavian vein for several months and had been removed recently.

Figure 4

Portable chest radiography, limited by the patient’s body habitus, showing bilateral retrocardiac opacities and mild cardiomegaly. A left internal jugular central venous catheter extends through the hemiazygos vein; the catheter tip is most likely located in a left intercostal vein (arrow). A chart review revealed that the same malpositioning was present two months earlier. The patient experienced burning pain in the chest during a crystalloid bolus infusion.

Figure 5

Portable chest radiograph showing mild cardiomegaly and bilateral basal lung opacities. A right internal jugular central venous catheter is shown with its tip apparently located at the superior vena cava. The emergency physician initially read the radiograph as showing the catheter as “adequately positioned.” Poor blood return was observed from the ports during placement. Chest burning pain was present during a normal saline infusion.

Figure 6

Lateral chest radiograph of patient in Figure 5 showing catheter (arrows) malposition coursing anteriorly along right internal mammary vein.