CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 AFRICA 321 Very rare malposition of central venous catheter in cardiac surgery patients Nursen Tanrikulu, Ali Haspolat, Ali Sefik Koprulu Abstract Malposition of a catheter is found in approximately 7% of cases after central venous catheterisation. This may result in haemorrhage, venous thrombosis and functional impairment, depending on the injury to the vessel wall. Uncomplicated catheterisation, easy aspiration of blood and monitoring of catheterisation do not guarantee correct placement of the catheter. In our rare case series, we share our experience of four cases of malposition into the left internal mammary vein (LIMV) that we experienced in a three-year period. The thinness and fragility of the vessel wall, particularly, increases the probability of complications in malposition into the LIMV. Administration of a catheter through the right jugular vein is associated with the lowest incidence of malposition. Performing the procedure under the guidance of ultrasonography (USG) and confirmation of the catheter position after puncture using one of the USG techniques will minimise the probability of malposition. In addition, a lung X-ray should immediately be taken, and venography and fluoroscopy should be considered in the presence of suspicion. Keywords: malposition, left internal mammary vein, central venous catheter, complications Submitted 25/11/21, accepted 14/11/22 Published online 6/2/23 Cardiovasc J Afr 2023; 34: 321–324 www.cvja.co.za DOI: 10.5830/CVJA-2022-062 Open-heart surgery is one of the procedures in which central venous catheterisation (CVC) is routinely performed. Although it is a simple and safe intervention, various complications may occur during and after the procedure, even when performed by the most experienced surgeons. The rate of these complications is estimated to be approximately 20%, alhough it varies in different studies.1 Successful catheterisation requires not only technical expertise but also awareness of potential complications and timely intervention. One of the frequently seen complications in the early term is malposition.2 The tip of the catheter ideally should be placed out of the pericardial sac and as wide as possible, parallel to the long axis of a central vein.3 The vessel most used in cardiac surgery is the superior vena cava (SVC). In this study, we aimed to increase the awareness of such complications and emphasise possible action to be taken to minimise complications by sharing our experience of four cases of malposition of the central venous catheter inserted into the left internal mammary vein (LIMV) during coronary artery bypass grafting (CABG) surgery performed between 1 January 2018 and 31 December 2020. Case report 1 A 61-year-old male patient scheduled for CABG had an uncomplicated puncture through the right internal jugular vein (RIJV) after anaesthetic induction. The guide-wire could not be forwarded further than 10 cm. So as not to put the patient, who had partial stenosis in the right carotid artery, at risk, the left side was attempted. A triple-lumen 7-F catheter was inserted through the LIJV without complication. Free flow of blood was confirmed through all three ports and the catheter was fixed at 16 cm. The central venous pressure (CVP) was high (16–17 cm H2O) and the trace was irregular. During dissection of the left internal mammary artery (LIMA), the surgical team found the catheter to be inserted into the LIMV (Fig. 1). No rupture or haemorrhage was present and vascular integrity was intact. However, leakage of fluid out of the catheter was observed after treatment with pressurised fluid. The catheter was withdrawn and repositioned intra-operatively. The operation was continued with a CVP of 8 cmH2O. No other peri-operative or postoperative complication was found. Case report 2 LIJV catheterisation was performed after anaesthetic induction since cannulation of the RIJV was secheduled for cardiopulmonary bypass in a 64-year-old male patient who would undergo minimal invasive CABG through a left anterior thoracotomy. The CVP trace could not be monitored although blood could be aspirated easily through the catheter and the CVP was inconsistent. The catheter was found to be malpositioned in the LIMV by the surgeon during dissection of the LIMA. The catheter was withdrawn under surgical supervision and catheterisation was repeated. Case report 3 The LIJV catheterisation procedure was completed without complications in a 57-year-old female patient since the cardiovascular anaesthesiologist was highly experienced in paediatric SVC cases. The trace was monitored, but the CVP was low. The patient was haemodynamically stable. The surgeon Department of Anesthesiology and Reanimation, Kolan International Hospital, Istanbul, Turkey Nursen Tanrikulu, MD, nursentanrikulu1@gmail.com Ali Haspolat, MD, alihaspolat@kolanhastanesi.com.tr Department of Anaesthesiology and Reanimation, Yeni Yüzyıl University Medical Faculty, Istanbul, Turkey Ali Sefik Koprulu, MD
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