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Clinical Images

Aberrant Line Placement in a Septic Patient

Avital O’Glasser, MD, FACP, Elly Karamooz, MD, Claire Zeigler, MD MPH

February 19, 2016

A 41-year old woman with end-stage renal disease on dialysis and difficult vascular access was transferred from another hospital for management of sepsis.  She arrived with a right subclavian central line.  Chest radiograph showed that the catheter appeared to be extravascular and penetrating a subclavian vein stent (figure 1).  Easy return of blood was consistent with venous origin with pCO2 44 mmHg and pO2 40 mmHg.  Chart review confirmed prior subclavian stent stenosis with documented collateral veins.  Non-contrast CT suggested the catheter was in an enlarged collateral vein (figure 2), and angiography confirmed its location in such off the occluded subclavian vein (figure 3). 

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Figure 1: Chest radiograph revealing right subclavian center venous catheter apparently extravascular and penetrating through existing subclavian vein stent

 

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Figure 2: non-contrast chest CT suggesting catheter was located in a large collateral vein anterior to the subclavian vein stent

 

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Figure 3: Angiography revealing an occluded subclavian vein stent, well-developed collateral veins, and the catheter tip in a large collateral vein. 

 



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References:

1. Kilbourne MJ, Bochicchio GV, Scalea T, et al. Avoiding common technical errors in subclavian central venous catheter placement. J Am Coll Surg. 2009; 208:104-109. 

2. Puls LE, Twedt CA, Hunter JE, et al. Confirmatory chest radiographs after central line placement: Are they warranted? South Med J. 2003; 96:1138-1141. 

3. Crozier JE and McKee RF. Is the landmark technique safe for the insertion of subclavian venous lines? Surgeon. 2005; 3:277-279.

4. Moskal TL and Ray CE. Left mediastinal central line malposition- A case report. Angiology. 1999; 50:349-353.

 

Author Bios:

Avital O’Glasser, MD, FACP - Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University

Elly Karamooz, MD - Division of Pulmonology and Critical Care Medicine, Department of Medicine, Oregon Health & Science University

Claire Zeigler, MD MPH - Division of Hospital and Specialty Medicine, Portland VA Medical Center, and Department of Medicine, Oregon Health & Science University

 



 

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