Malposition of Central Venous Catheter: Presentation and Management

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1 Perspective Mlposition of Centrl Venous Ctheter: Presenttion nd Mngement Lin Wng, Zhng Suo Liu, Chng An Wng Deprtment of Nephropthy, The First Affilited Hospitl, Zhengzhou University, Zhengzhou, Henn , Chin Key words: Centrl Venous Ctheter; Complictions; Mlposition Introduction Centrl venous ctheters (CVCs) re commonly utilized to gin vsculr ccess for vried clinicl indictions. These include dministering drugs, renl replcement therpy, totl prenterl nutrition, poor peripherl venous ccess, crdic ctheteriztion, nd trnsvenous crdic pcing. [1] Centrl venous ccess involves lrge ore ctheter inserted in internl jugulr, suclvin or femorl vein in the neck, nd upper chest or groin (femorl) re. [1] The preferred vein for CVCs is the right internl jugulr vein (IJV) for its stright course to the right hert nd the lowest risk of the venous stenosis nd thromosis. [2 4] Successful ctheter plcement requires not only technicl expertise ut lso wreness of the potentil complictions. [5] Mlposition of the ctheter is reltively common compliction (5.01%), which results in the mlfunction of ctheters. [6,7] Misplcement of the superior ven cv (SVC) cn led to the perfortion of the cv or the right trium, which re ssocited with serious sequele. [4,5] Multiple litertures re in the form of isolted cse reports or smll series, which re cumersome or time consuming to ccess nd do not provide prgmtic guidnce or solutions to the prolem. This rticle outlines the norml nd norml ntomy of the centrl veins in reltion to CVCs, minly for the IJV, similr dvntges pplying t ll sites. In ddition, it presents illustrted cses of the mlposition nd discusses prcticl mngement issues, voiding the misplcement nd following complictions. Antomy of Centrl Veins CVCs re usully inserted in the internl jugulr, suclvin or femorl veins, nd re typiclly for short term or long term ccess. [8] Selection of the insertion site should e sed oth on the ese of plcement nd on the risks ssocited with Quick Response Code: Access this rticle online Wesite: DOI: / the procedure. The rnches nd triutries of SVC system re shown in Figure 1 nd 1. [6] Physicins often prefer cnnultion of the right IJV, the second est for the left IJV, to estlish centrl venous ccess since it provides more direct pth to SVC. [6] SVC lies in close ntomicl proximity to the medistinl pleur in the upper thorx. [6,9] Perfortion of the vein wll with guidewire, diltor, or ctheter my cuse uncontrolled leeding into the low pressure pleurl spce. The left rchiocephlic vein receives lymph from the thorcic duct [Figure 2]. If the guidewire goes into the orifice of the duct, the ctheter is dvnced through the wire directly into the thorcic duct. [6,10] A persistent left sided SVC (PLSVC), including duplicte SVC, my occur in up to 2.1% of the generl popultion. [6,11] The left SVC usully drins into the right trium vi the coronry sinus. [12,13] Ctheter Mlposition It is currently recommended tht the tip of CVC is positioned t the level of mid lower SVC to cvotril junction. [14] Mlposition of CVC mens ctheter lies outside of SVC, whose tip does not lie in the idel position. Misplced ctheters hve een reported in lmost every possile ntomicl position, which cn e of two types such s intr cv mlposition nd extr cv mlposition on the se of the loction of the ctheter. [6] The ltter includes vrious structures such s medistinum, pleur, pericrdium, Address for correspondence: Prof. Zhng Suo Liu, Deprtment of Nephropthy, The First Affilited Hospitl, Zhengzhou University, Zhengzhou, Henn , Chin E Mil: zhngsuoliu@sin.com This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution NonCommercil ShreAlike 3.0 License, which llows others to remix, twek, nd uild upon the work non commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com 2016 Chinese Medicl Journl Produced y Wolters Kluwer Medknow Received: Edited y: Yun Yun Ji How to cite this rticle: Wng L, Liu ZS, Wng CA. Mlposition of Centrl Venous Ctheter: Presenttion nd Mngement. Chin Med J 2016;129: Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2 227

2 Figure 1: () The trunk of the superior ven cv system. It shows tht left internl jugulr vein negotites two 90 turns. () Triutries of the superior ven cv system. It shows tht the superior ven cv drins venous lood from the upper hlf of the ody in which there would e vrile nd complicted considerly. Figure 2: A ntomic illustrtion of the jugulr lymphtic trunk. It indictes tht the thorcic duct is medil close to the internl jugulr vein in front of the internl jugulr vein. trche, esophgus, surchnoid spce, nd other errnt sites. Ctheter mlposition is usully ssocited with serious consequences while some of them remin unrecognized resulting in incorrect dignosis nd delyed tretment. Recent methodologicl dvnces, incresed vilility of imging, guidewire mnipultion, nd experience in the mngement of complictions hve huge impct on moridity nd mortlity in this re. We collected different cse reports, discussed the clinicl presenttion nd mngement of some of the more common sites for ctheter misplcements in ptients [Tles 1 nd 2]. Some rre computed tomogrphy (CT) or chest rdiogrphy imges lter in the text re presented to guide how to del with different misplcements. Mechnisms of Mlposition Methodologicl inccurcy, ntomicl vrition, nd inter opertor vriility re predisposed to ctheter misplcement. [15,16] Fctors such s rnches of the vein, vein tortuosity, cute ngultions of vessels, congenitl ntomicl vrition, nd vein stenosis my result in misplcement. [9] For exmple, the zygos vein would ct s the ypss collterl to the right trium during the insertion under the condition tht SVC ostruction lies elow the zygos vein. [17,18] On the other side, the guidewire leds to n importnt role in steering the successful plcement of the ctheter. [19,20] If the wire is unexpected to kink, entering into other vein indvertently, the 228 ctheter would tend to e misplced or ostructed following the guidnce, even to the other venous system, y following n norml pth to neck, rm, thorx, or contrlterl side. [21] Furthermore, excessive force, which is used improperly s the guidewire run out of the veins, mkes the ctheter pss into the pleur, medistinum, or other structures, which will ring out severe nd ftl outcomes. [22,23] Therefore, ny resistnce to pssge should rise suspicion of prolem, nd further imging will e required. The following text illustrtes cliniclly mlpositioned cses with ttched pictures for detiled descriptions nd puts forwrd the corresponding mngements s well. Crotid rtery Artery cnnultion during ctheter insertion is one serious compliction. It is elieved tht rtery puncture is more common when plcing CVC in jugulr vein (14.28%) for veins run in close pproximtion to right crotid rtery. [24,25] When indvertent puncture of the rtery hppens, the lood drwn from the lines is pulstile, right red, nd high pressed. However, none of these is entirely relile. Sometimes, the signs listed ove re too miguous to give us ccurte discrimintion. [24,26,27] A frontl chest rdiogrph shows the ctheter tip projected to the left of the verterl column [Figure 3]. CT exmintion revels the ctheter position to e in the crotid rtery [Figure 3]. [9] Once ctheter is indwelled into the crotid rtery, there will e continuous errhysis round the ctheter port or hypotension occurs which results in hemorrhgic shock, while some symptomtic. [28] If the ctheter is removed immeditely, leeding could not e stopped. Immedite removl of the misplced ctheter might not e the est choice. It is suggested to leve the misplced ctheter in rtery until further intervention in considertion of complictions nd repir ccess. The routine use of ultrsound needle guidnce should drmticlly reduce the risk of these complictions. [28,29] Azygos veins Azygos veins system is quite vrile in terms of ntomicl course nd dringe pttern. Sometimes, the ccessory hemizygos vein my drin either directly or fter forming Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2

3 Tle 1: Anlysis for the intr cv misplcements during the ctheteriztion Sites Cuse Chest X ry Consequence Mngement Crotid rtery Azygos vein Persistent left sided SVC Internl mmmry vein Verterl vein Other veins Inccurcy, penetrtion, ntomicl vrition Diltion of the zygos vein, high CVP, IVC, or SVC is locked Anorml vrition Blocked IVC or SVC Excessive rottion of the ptient s hed Nrrowing IVC with split tipped ctheter, ent wire The ctheter s tip projected to the left of the verterl column Superior intercostl vein is to e cnnulted with contrst filling the ccessory hemizygos vein The ctheter is pssing down the left side of the medistinum The ctheter descends in the region of the medistinum The ctheter psses the trnsverse processes of the 6 th nd the 7 th cervicl vertere One or oth of lumens lose their routes to other veins SVC: Superior ven cv; IVC: Inferior ven cv; CVP: Centrl venous pressure. Asymptomtic, errhysis, hypotension, nd hemorrhgic shock Ctheter s dysfunction, pleurl effusion, pulmonry edem, dyspne, chest pin, ck pin, nd crdic tmponde Dyspne, chest pin, nd crdic tmponde Ctheter s dysfunction, shoulder or rm pin Trpping ctheter, thromosis, endothelil dmge, nd fluid lekge Ctheter s dysfunction Leve the ctheter until further intervention Reposition under rdiologicl guidnce Surgicl removl Remove the ctheter under rdiogrphic monitor Remove the ctheter modertely Cutious removl, or using step tipped ctheter Tle 2: Anlysis for the extr cv misplcements during the ctheteriztion Sites Cuse Chest X ry Consequence Mngement Extrdurl spce Too deep penetrtion The line hd penetrted the jugulr vein nd reched the spinl epidurl spce Pericrdium Pleurl spce Erosion of ctheters through the lower SVC or right trium Indvertent to zygos, hemizygos, nd internl thorcic veins Much fluid is in the pericrdium The ctheter tip lies in the pleurl cvity Severe ck pin Hemopericrdium, ftl, ventriculr firilltion Dyspne, chest pin, nd ck pin Penetrte in the lighter depth Urgent pericrdiocentesis, surgicl repir Removl referrl to rdiology Medistinum Too deep penetrtion Diltion of medistinum Chest pin Removl referrl to rdiology Thorcic duct SVC is locked The ctheter follows the course of the duct downwrd on level with the cistern chyli Infusion medistinum nd chylothorx, cler yellow fluid is spired Susequent surgicl removl SVC: Superior ven cv. Figure 3: Ctheter misplcement to intr rtery. () Chest film shows the tip of the ctheter pssing close to the ortic rch (rrow). () Further imging indictes the tip of the ctheter lying in the position of the rteril system (rrow). common trunk with the left superior intercostls vein into the left rchiocephlic vein. [7] The frequency of ccidentl zygos vein cnnultion during centrl venous ccess through IJV is %. [18] When misplcement to zygos veins, the insertion goes smoothly during the opertion ut fterwrd, lood cnnot e spirted from the ctheter. It shows tht the guidewire enters to zygos veins system through the left IJV during ctheteriztion [Figure 4]. Complictions of the misplcement include pleurl effusion, pulmonry edem, chest wll scess, dyspne, chest pin, ck pin, nd crdic tmponde depending on the site of the ctheter. The ctheter will e pulled nd repositioned under rdiologicl guidnce fter confirmtion. [30] Contrst enhnced CT, mgnetic resonnce imging studies, nd venogrphy lone or in comintion will provide definitive informtion out the loction of the ctheter. Persistent left sided superior ven cv A PLSVC is due to n norml development of the sinus venosus in the erly stges of fetl life, seen in % of the norml popultion. [6] PLSVC is usully not recognized until left superior pproch to the hert is required s one ntomic finding. [12] In fct, it complictes the plcement of left sided plcement of centrl venous lines. [31] Technicl difficulties ssocited with PLSVC my led to misplcement of the ctheter nd injury to the vessel wll. There is good flow in oth rteril nd venous lumens of Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2 229

4 the dilysis ctheter when indwelling in PLSVC. A routine postline insertion chest X ry is performed [Figure 5]. [32] The chest X ry showed tht the dilysis ctheter is pssing down the left side of the medistinum rther thn crossing the midline vi the rchiocephlic vein to enter SVC on the right side. The CT exmintions show tht the ptient hs PLSVC, nd the dilysis ctheter tip is in the distl prt of the left sided SVC [Figure 5 nd 5c]. [32] Misplcement to the vein will ring out serious complictions such s pericrdil nd pleurl effusion. Once the misplcement hppens, the ctheter needs to e removed y crdiothorcic surgeon. [30] Internl mmmry vein The internl mmmry vein origintes from the rchiocephlic vein. The mmmry (internl thorcic) vein trvels long the order to drin into the rchiocephlic vein. The insertion of the right mmmry is often more proximl on the rchiocephlic vein on the left side thn the right side. [9] Becuse the right internl thorcic vein is often close to the origin, it cn e y ctheter coming from either rchiocephlic vein. [33] When inserting into the right internl mmmry vein, no lood is spirted from the line nd the cnnultin produce shoulder or rm pin with spirtion nd flushing of the ctheter. [34] X ry or CT exmintion to confirm the plce of ctheter indictes Figure 4: Chest film shows tht the guide wire enters to zygos veins system through the left internl jugulr vein during ctheteriztion (rrow). the ctheter descends in the region of the medistinum nd plces in the internl mmmry vein [Figure 6 nd 6]. [33] The ctheter should e removed under rdiogrphic monitor with the moderte force. Verterl vein The verterl vein, posterior to the IJV, psses through the trnsverse formin from the tls to the 6 th cervicl verter. [35] After exiting the trnsverse formen of the 6 th verter, the vein drins the rchiocephlic vein. The misplcement of CVC into the verterl vein is reltively rre, which might occur from excessive rottion of the ptient s hed, nd from deep insertion of the puncture needle. [36] Chest X ry revels tht CVC is closely pssing the right wll of the IJV nd proceeding deep. Then, it psses the trnsverse processes of the 6 th nd the 7 th cervicl vertere, inserting the verterl vein [Figure 7]. [37] In the cse, nonpulstile drk colored lood flow is oserved in the line, which is not different from the norml insertion, while the misinsertion increses the possiility of complictions, including trpping of the ctheter, thromosis, endothelil dmge, nd lekge of infused fluid. Therefore, it is dvised, for sfe CVC insertion, to minimize ptient s hed rottion nd to mke use of ultrsound when the ntomicl structures cnnot e clerly identified. Plin chest rdiogrph is lso considered the proper method for confirming the loction of the ctheter tip. [37,38] Other veins The misinsertion of the ctheter into other veins cnnot e esily distinguished from successful CVC insertion, ecuse it is rre occurrence, nd there is no difference in the color nd pulstion of the regurgitted lood flow sometimes. A dul lumen dilysis ctheter with split distl tip is inserted vi the left IJV to the contrlterl IJV with one or oth of the lumens to the right side [Figure 8 nd 8]. Similr to the ove finding, nother cse shows lumens indvertent insertion into the suclvin vein vi the right IJV [Figure 9]. [39] As presented in previous reports, the tpe of the ctheter should e tken into ccount to void the lumen s ifurction or offsetting during dvncing ctheter. [40] The dul lumen ctheter is ssocited with higher incidence of the divriction in comprison with the single lumen Figure 5: Ctheter misplcement to the persistent left sided SVC. [32] () The chest X ry demonstrtes tht dilysis ctheter psses down the left side of the medistinum with pleurl effusion nd sucutneous emphysem over the left clvicle (rrow). () Computed tomogrphy chest demonstrtes the ctheter in the persistent left sided SVC, pericrdil nd pleurl effusion from coronl view (rrow). (c) The rrow indictes the ctheter in the persistent left sided SVC from conventionl view. SVC: Superior ven cv. c 230 Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2

5 throughout the procedure. Cutious removl gives rise to no grve consequence usully. Roentgenogrphy must e performed with or without contrst mteril to identify the position of the CVC. [41] Extrdurl spce Spinl epidurl hemtom s compliction of CVC cnnultion is very rre. It is reported tht mrked swelling round the right side of the ptient s neck grdully worsened fter the CVC vi the right IJV uneventfully. Cervicl CT demonstrted tht the ctheter tip of the centrl venous line hd penetrted the jugulr vein nd reched the spinl epidurl spce [Figure 10 10d]. [41] The ctheter is crefully extrcted immeditely under fluoroscopy in operting room. While severl minutes fter the ctheter removl, the ptient complined of sudden severe ck pin. Urgent imging of the spine reveled lrge spinl epidurl hemtom extending compressing the dorsl spinl cord. The ptient showed full recovery undergoing emergency surgicl removl of the epidurl hemtom. The possile reson is tht the guidewire hd penetrted the side wll of the IJV, nd the following ctheter is mlpositioned to the extrdurl spce. Any nery structure is potentilly t risk from needle puncture, guidewire, diltor, nd ctheter plcement. [42] It is generlly sfer to mke confirmtion to the loction of the ctheter rther thn hsty removl with pressure pplied to the ccess site. Pericrdium The rre ut often ftl compliction of crdic tmponde occurs in the context of CVC when there is perfortion of the right trium or lower SVC. This cn occur fter period due to erosion y the ctheter tip. Immedite postopertive chest rdiogrph shows tht the tip of the ctheter is seen to lie within the right trium [Figure 11]. [6] Reported cses suggest tht it is typiclly pressurized fluid infusion. If the tmponde is confirmed on echocrdiogrphy fter clinicl suspicion, timely tretment is indicted. [15] Aspirtion of the infused fluid should e ttempted through the ctheter, followed y urgent pericrdiocentesis nd stenting or surgicl repir if required. Pleurl spce The right order of SVC, zygos, hemizygos, nd internl thorcic veins re immeditely djcent to the pleur. Dmge to these or djcent rteries cn cuse significnt leeding into the low pressure pleurl spce. In Figure 6: Ctheter misplcement to the right internl mmmry vein. [33] () Chest X ry: Anterior posterior demonstrting wht ppers to e good position of ctheter in the superior ven cv. () Computed tomogrphy (xil imge): Ctheter mlposition to the right of the sternum. Figure 7: Ctheter misplcement to the verterl vein. [37] Chest X ry shows tht the centrl venous ctheter psses the trnsverse processes of the 6 th nd the 7 th cervicl vertere (rrow). Figure 8: The misplcement of left internl jugulr vein ctheter. () The chest film shows oth of lumens indvertent insertion into the right internl jugulr vein (rrow). () The chest film shows one of lumen dwelling into the right internl jugulr vein (rrow). Figure 9: Ctheter misplcement to the suclvin vein. [39] Chest rdiogrph shows tht the ctheter is inserted vi the right internl jugulr vein nd loops in the suclvin vein. Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2 231

6 Figure 10: Ctheter misplcement to the extrdurl spce. [41] Cervicl computed tomogrphy scns demonstrte tht the centrl venous ctheter hs penetrted the posterior spect of the internl jugulr vein. () Chest rdiogrph revels tht the tip of the centrl venous line (rrows) runs inside the norml route of the internl jugulr vein nd ppers to overlp with the cervicl spine (rrows). () The cervicl computed tomogrphy scn demonstrtes tht the ctheter trvels posterior to the crotid rtery (rrows). (c) The cervicl computed tomogrphy scn shows tht the ctheter penetrtes the preverterl fsci (rrow). (d) The imge indictes tht the ctheter enters the interverterl formen (rrow). c d Figure 11: Ctheter misplcement to the pericrdium. [6] Chest rdiogrph revels tht the tip of the ctheter is seen to lie within the right trium (rrow). Figure 12: Ctheter misplcement to the pleurl spce. [6] () The left sided dilysis ctheter hs perforted through the right wll of SVC, nd the tip hs entered the right pleurl spce (rrow). () The left sided dilysis ctheter hs perforted through the right wll of SVC nd kink in the right pleurl spce (rrow). CVC: Centrl venous ctheter; SVC: Superior ven cv. Figure 13: Ctheter misplcement to the medistinum. [6] The computed tomogrphy imge shows the medistinum grows for the huge hemtom. SVC: Superior ven cv. Figure 12 nd 12, [6] left sided dilysis ctheter hs perforted through the right wll of SVC nd entered the pleurl spce. [6] If the ctheter tip lies in the pleurl cvity, hemothorx or pleurl effusions my result from the infusion of lood or fluids through the ctheter. It is 232 Figure 14: Ctheter misplcement to the thorcic duct. [44] () Scout view of the chest computed tomogrphy shows the guidewire (rrows) tkes stright crniocudl course projecting on the verterl column reching cudl to the diphrgm. () Computed tomogrphy cross sectionl imge t the level of the middle medistinum. The guidewire (rrow) cn e seen in preverterl position djcent to the descending ort nd posterior to the esophgus. dngerous to remove ctheter for leeding risk. The ctheter should e removed referrl to rdiology. [42] Medistinum A CVC my perforte through vessel wll entering the medistinum. There is prticulr risk if excessive force hs een used to dvnce the guidewire, diltor, or ctheter. It shows n exmple of CVC pssing into the medistinum Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2

7 s confirmed with contrst injection [Figure 13]. [6] Infusion of pressurized fluid through such n opening will led to extrvstion with risk of swelling, compression of medistinl or neck structures, or tissue necrosis. [31] During next insertion fter the ctheter s extrction, it is s well under the rel time screening or other ids. [43] Thorcic duct The thorcic duct drins into the distl portion of the left rchiocephlic vein. If the needle punctures the thorcic duct directly t the orifice of the duct into the left rchiocephlic vein, the guidewire is dvnced through the needle directly into the thorcic duct nd then followed the course of the duct downwrd on level with the cistern chili. [43] If mlposition of CVC in the thorcic duct is not recognized nd CVC is used for infusion, the potentil compliction would e n infusion medistinum [Figure 14 nd 14]. [44] In ddition, lcertion of the thorcic duct cn lso result in chronic chylothorx even fter the removl of the centrl venous line. This lcertion my require susequent surgicl removl. [45 47] In conclusion, there re multiple resons for the procedurl mlposition of CVC, opertors should mke intensive nlysis of ctheter s loction through much of ntomicl cknowledgment. Correct dignoses nd timely mngements, under the supervision of chest rdiogrphy or CT exmintion, cn often prevent permnent or severe dmge. Acknowledgments We would like to thnk the uthors of references 6,32,33,37,39,41,44 for the permission for using their pulished figures in the present study. Finncil support nd sponsorship This study ws supported y grnts from the Ntionl Key Technology Reserch nd Development (R nd D) Progrm of the Ministry of Science nd Technology of Chin (No. 2013BAI09B04), nd Ntionl Bsic Reserch Progrm of Chin 973 Progrm (No. 2012CB517606). Conflicts of interest There re no conflicts of interest. References 1. Tn PL, Gison M. Centrl venous ctheters: The role of rdiology. 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Imging nd mngement of complictions of centrl venous ctheters. Clin Rdiol 2013;68: doi: /j.crd Pikwer A, Bååth L, Dvidson B, Perstoft I, Akeson J. The incidence nd risk of centrl venous ctheter mlpositioning: A prospective cohort study in 1619 ptients. Anesth Intensive Cre 2008;36: Wu A, Helo N, Moon E, Tm M, Kpoor B, Wng W. Strtegies for prevention of itrogenic inferior ven cv filter entrpment nd dislodgement during centrl venous ctheter plcement. J Vsc Surg 2014;59: doi: /j.jvs Gllieni M, Mrtin V, Rizzo MA, Grvellone L, Moili F, Giordno A, et l. Centrl venous ctheters: Legl issues. J Vsc Access 2011;12: doi: /JVA Hodzic S, Golic D, Smjic J, Sijercic S, Umihnic S, Umihnic S. Complictions relted to insertion nd use of centrl venous ctheters (CVC). Med Arch 2014;68: doi: /medrh Powers CJ, Zomorodi AR, Britz GW, Enterline DS, Miller MJ, Smith TP. Endovsculr mngement of indvertent rchiocephlic rteril ctheteriztion. J Neurosurg 2011;114: doi: / JNS Ho L, Spnger M, Hywrd P, McNicol L, Weinerg L. Missed crotid rtery cnnultion: A line crossed nd lessons lernt. Anesth Intensive Cre 2014;42: Chirinos JC, Neyr JA, Ptel J, Rodn AR. Hemodilysis ctheter insertion: Is incresed PO 2 sign of rteril cnnultion? A cse report. BMC Nephrol 2014;15:127. doi: / Akkn K, Cindil E, Kilic K, Ilgit E, Onl B, Ers G. Misplced centrl venous ctheter in the verterl rtery: Endovsculr tretment Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2 233

8 of foreseen hemorrhge during ctheter withdrwl. J Vsc Access 2014;15: doi: /jv Kitzis DG, Blits AG, Skndlos IK, Htziloglou AK. Crotid rtery repir fter erroneous insertion of hemodilysis ctheter: Cse report. J Vsc Access 2006;7: Vrghese A, Pienr W, Vndervelde C, Rnkin S. RE: CT ppernces of congenitl nd cquired normlities of the superior ven cv. Clin Rdiol 2008;63: doi: /j.crd Sheikh AS, Mzhr S. Persistent left superior ven cv with sent right superior ven cv: Review of the literture nd clinicl implictions. Echocrdiogrphy 2014;31: doi: / echo Blsurmnin S, Gupt S, Nicholls M, Loi P. Rre compliction of dilysis ctheter insertion. Clin Kidney J 2014;7: doi: /ckj/sfu Stone PA, Hss SM, Knckstedt KS, Jgnnth P. Mlposition of centrl venous ctheter into the right internl mmmry vein: Review of complictions of ctheter misplcement. Vsc Endovsculr Surg 2012;46: doi: / Ghfoor H, Ftimi Sh, Ali M. Unusul mlposition of dilysis ctheter in the left internl mmmry vein A cse report. Middle Est J Anesthesiol 2011;21: Gu X, Pulsen W, Tisndo J, He Y, Li Z, Nixon JV. Mlposition of centrl venous ctheter in the right min pulmonry rtery detected y trnsesophgel echocrdiogrphy. J Am Soc Echocrdiogr 2009;22:1420.e5 7. doi: /j.echo de Bucourt M, Brum L, Teichgräer U, Hmm B. Centrl venous ctheter insertion vi the verterl vein nd the sixth trnsverse formen. J Vsc Interv Rdiol 2011;22: doi: /j. jvir Yng SH, Jung SM, Prk SJ. Misinsertion of centrl venous ctheter into the suspected verterl vein: A cse report. J Vsc Access 2014;15: doi: /kje Ide S, Kwmt T, Imi N, Ando A, Kwmt M. Misplcement of guidewire into the verterl vein through the internl jugulr vein. J Crdiothorc Vsc Anesth 2012;26:e17 8. doi: /j. jvc Bhti P, Sied NN, Comunle ME. Mngement of n unusul compliction during plcement of pulmonry rtery ctheter. Anesth Anlg 2004;99: Lee HJ, Prk SW, Chng IS, Jo YI, Prk JH, Lee JH, et l. A comprison of stndrd dul tip hemodilysis ctheter split lumen hemodilysis ctheter. Clin Imging 2013;37: doi: /j. clinimg Yokoym K, Kwnishi M, Ymd M, Tnk H, Ito Y, Kuroiw T. Spinl epidurl hemtom following removl of incorrectly plced jugulr centrl venous ctheter. J Neurosurg Spine 2011;15: doi: / SPINE Thomopoulos T, Meyer J, Stszewicz W, Bgetkos I, Scheffler M, Lomessy A, et l. Routine chest X ry is not mndtory fter fluoroscopy guided totlly implntle venous ccess device insertion. Ann Vsc Surg 2014;28: doi: /j. vsg Avil JO, Smith BC, Seerg DC. Use of echocrdiogrphy to identify pproprite plcement of centrl venous ctheter wire in the ven cv prior to cnnultion. Acd Emerg Med 2014;21:E1 2. doi: /cem Teichgrer UK, Nie L, Geuer B, Wgner HJ. Indvertent puncture of the thorcic duct during ttempted centrl venous ctheter plcement. Crdiovsc Intervent Rdiol 2003;26: Kwshim S, Itgki T, Adchi Y, Ishii Y, Tniguchi M, Doi M, et l. Indvertent thorcic duct puncture during right xilly centrl venous cnnultion. Msui 2010;59: Hughes ME. Periphlly inserted centrl ctheters A serious compliction. Br J Nurs 2013;22:S4, S Jdhv AP, Sthlheer C, Hofmnn H. Trumtic chyle lek: A rre compliction of left internl jugulr venous cnnultion. Am J Med Sci 2011;341: doi: /MAJ.0013e cf Chinese Medicl Journl Jnury 20, 2016 Volume 129 Issue 2