We report a case of misplacement of an internal jugular catheter into the internal mammary vein before coronary artery bypass grafting (CABG). Internal jugular vein catheterization is commonly used in anaesthesiology and critical care, but its appropriate application is unknown. Proper placement is essential for the use of central venous catheters (CVC). It has been reported that the incidence of catheter malposition depends on a number of factors including the site of insertion and the type of material used but not on the experience of the physician who inserted the catheter . Proper positioning of the catheter with the tip just above the superior vena cava (SVC) and right atrial junction is important to minimize associated complications such as dysrhythmias, thrombus formation and perforation with associated hydrothorax, pneumothorax, hydromediastinum, bleeding and tamponade. Malpositioning of the catheter occurs approximately 2% of the time when subclavian or internal jugular vein approaches are used . Malpositioning in the left mediastinum is a rare event. A case of left internal thoracic vein cannulation is described.
This 76-yr-old and obese female had a long history of effort dyspneoa and angina. At cardiac catheterization it was shown that the left anterior descending and right coronary arteries (RCx) were occluded. She was therefore scheduled for CABG.
Anaesthesia was induced with etomidate 20 mg, fentanyl 2 μg kg−1 and endotracheal intubation was facilitated with vecuronium bromide 0.01 mg kg−1. Anaesthesia was maintained with isoflurane 2%, nitrous oxide 50% in oxygen and fentanyl. Venous access in obese patients may be difficult. Initial difficulty with cannulation of the right internal jugular vein was encountered and so the left internal jugular vein was used instead. Correct cannulation using a Secalon T 16 G® (Becton Dickinson Critical Care Systems - Franklin Lakes, New Jersey, USA) cannula initially appeared to be obtained without any difficulty. Return of venous blood was observed and intravenous (i.v.) fluid flowed easily into the catheter. Central venous pressure (CVP) was measured as 4 mmHg.
Following a median sternotomy, the exact anatomical location of the catheter was seen. The surgeons informed us that the catheter had entered the left internal mammary vein (Fig. 1) and they used the catheter as a guide during dissection of the internal mammary artery. After the dissection we withdrew the catheter and inserted another catheter into the right femoral vein. Surgery was completed without any complication and the patient was transferred to the intensive care unit (ICU). One week later the patient was discharged from the hospital.
Proper positioning of CVC is important to ensure optimal catheter function and to decrease complications. Malposition can lead to inaccurate CVP evaluation, inability to aspirate blood samples, dysrhythmias, thrombus formation and perforation with associated hydrothorax, pneumothorax, hydromediastinum, bleeding and tamponade. Catheter malpositioning utilizing subclavian and internal jugular vein approaches is uncommon occurring 2% of the time. 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.
Smith described an asymptomatic patient with a normal functioning catheter . Although in our patient there was no unexpected anatomical aberration, we discovered a malpositioned catheter. A case has been reported of a pulmonary artery catheter being inserted via the left internal jugular approach without complication although it was later found to have passed through an unknown residual ventricular septal defect into the left ventricle, aorta and right carotid artery .
Although left-sided catheter malpositioning is a rare event , Şekerci and colleagues  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. Similar to this, we report misplacement of an internal jugular catheter into the internal mammary vein. Although different type of catheters had been used, we should not forget that internal mammarian vein cannulation is possible. In CABG, this can be complicated by injury to the internal mammary vein and artery thus compromising an important graft source. To use X-ray imaging to assist correct replacement would be an alternative. Intraoperative trans-oesophageal echocardiography is gaining acceptance as a diagnostic tool for controlling the proper placement of catheters. Fortunately, our patient was undergoing open heart surgery and we had a chance to see the placement of it directly during the operation.
A. H. Karagöz
1Department of Anaesthesiology and Reanimation, Hacettepe University Faculty of Medicine, Ankara, Turkey
2Department of Cardiovascular and Thoracic Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
1. Muhm M, Sunder-Plassmann G, Apsner R, et al
. Malposition of central venous catheters. Incidence, management and preventive practices. Wien Klin Wochenschr
2. Kaufman JL, Rodriquez JL, McFadden JA, et al
. Clinical experience with the multiple lumen central venous catheter. J Parenteral Enteral Nutr
3. Smith DC, Pop PM. Malposition of a total parenteral nutrition catheter in the accessory hemiazygous vein. J Parenteral Enteral Nutr
4. Kanbak M, Öcal T. Inadvertent placement of pulmonary artery catheter into right carotid artery. Inadvertent placement of pulmonary artery catheter into right carotid artery. Can J Anaesth
5. Moskal TL, Ray Jr CE. Left mediastinal central line malposition: a case report. Angiology
6. Şekerci S, Mercan Ş, Dönmez A, et al
. Malpositioning of the central venous catheter necessitating sternotomy. Eur J Anaesthesiol