Straight to the back: Femoral triple lumen catheter misplaced in a lumbar vein

Abstract

Central venous catheters are devices inserted into large central veins, usually internal jugular, femoral, or subclavian and serve multiple purposes including administration of vasoactive medications, dialysis, plasmapheresis, total parenteral nutrition, among others. It is considered a relatively safe procedure when performed by experienced clinicians, especially under ultrasound guidance. However, complications are not uncommon and include arterial puncture, injury to nearby structures such as lung puncture leading to pneumothorax, bleeding, infection, and line misplacement. We present a case of a triple lumen catheter which was misplaced in a small lumbar vein side-branch while attempting a left groin approach. This finding was discovered on CT scan of the abdomen and pelvis, after which the catheter was repositioned with proper placement.

Introduction

Central venous catheters are devices inserted into large central veins, usually internal jugular, femoral, or subclavian, and serve multiple purposes including administration of vasoactive medications, dialysis, plasmapheresis, and total parenteral nutrition [1]. Common and known complications include arterial puncture, injury to nearby structures such as lung puncture causing pneumothorax, bleeding, infection, and air embolism [1]. Although uncommon given availability of ultrasound guidance, misplacement of catheters can occur and has been reported [2,3]. Follow-up imaging to confirm proper placement is typically recommended, especially after internal jugular or subclavian vein placement to ensure absence of pneumothorax. However, confirmation for femoral vein placement can be challenging given that the catheter travels vertically, and the inferior vena cava can overlap other veins or structures. In cases where there is doubt about the proper position of a central venous catheter, a CT scan should be considered for verification.

Case report

The patient is an 81-year-old female with a past medical history of hypertension, dyslipidemia, heart failure with preserved ejection fraction, end-stage renal disease on hemodialysis, atrial fibrillation, multiple strokes, and hypothyroidism who presented to our hospital with complaints of cough and progressively worsening shortness of breath for 1 week. Her initial workup was remarkable for a respiratory viral panel which was positive for respiratory syncytial virus and elevated lactic acid level of 3.9. Her vitals were: temperature 38.3 degrees Celsius, heart rate 156 beats/minute, respiratory rate 30 breaths/minute, oxygen saturation 90% on room air, and blood pressure 96/60 mmHg. Physical examination notable for an elderly lady, obtunded and in respiratory distress with bilateral crackles on lung exam. Chest X-ray showed bilateral infiltrates. She was intubated for acute hypoxic respiratory failure and admitted to the intensive care unit for treatment of respiratory failure secondary to pneumonia. Soon thereafter she became hypotensive with no response to fluids and required placement of a triple lumen catheter (TLC) for administration of vasopressors and decision was made to place the TLC in the left femoral vein under ultrasound guidance. During the procedure, the operator met resistance while advancing the guidewire through the needle but eventually was able to do so and subsequently advanced the catheter over the guidewire; adequate venous return was noted in all ports. X-ray of the abdomen was done and showed a left femoral catheter terminating on the left side parallel to the spine (Fig. 1). As part of her sepsis workup and concern for intraabdominal source of infection, a computed tomography (CT) scan of her abdomen and pelvis was obtained. This showed the left groin approach vascular catheter terminating in a small lumbar vein side-branch (Fig. 2). Sagittal and coronal views on CT (Fig. 3, Fig. 4, Fig. 5) more clearly demonstrate the distal end of the catheter appearing as a radio-opaque linear structure terminating adjacent to the spine rather than in the IVC. The catheter was then repositioned and adjusted successfully, and the patient tolerated it without any issues.

Fig. 1.

Antero-posterior supine x-ray of the abdomen showing the left central venous catheter in the left groin and terminating parallel to the spine on the left side (arrow).

Fig. 2.

CT of the lower abdomen in axial view showing the end of the TLC adjacent to the lumbar vertebrae.

Fig. 3.

CT in sagittal view showing the terminal end of the TLC.

Fig. 4.

CT in coronal view demonstrating the ascending portion of the TLC.

Fig. 5.

Continuation of Figure 3, demonstrating the TLC tip ending in a lumbar vein branch.

Discussion

Central venous catheters (CVC) are devices inserted into large central veins, usually internal jugular, femoral, or subclavian, and serve multiple purposes including administration of vasopressors, dialysis, plasmapheresis, and total parenteral nutrition [1]. Common and known complications include arterial puncture, injury to nearby structures such as lung puncture and pneumothorax, bleeding, infection, air embolism, and CVC malposition [1]. The risks from CVC insertion varies based on patient anatomy, insertion site, operator experience, and ultrasound guidance. A recent study revealed the events of complications per 1000 catheters around 2.8 for arterial cannulation, 16.2 for arterial puncture, and 4.4 for pneumothorax [4]. Another important yet less commonly described complication is catheter malpositioning, which can occur in approximately 5%-7% of cases [5,6], with lumbar vein misplacement being a rare but known occurrence [[7], [8], [9], [10]]. Malpositioning can occur in the external iliac, ipsilateral deep pelvic veins, contralateral femoral vein, or ascending lumbar veins. Risks for catheter malposition include anatomical variation in venous structure, improper insertion technique or excessive guidewire manipulation, and retrograde flow into collateral veins or vein tributaries that offer low-resistance routes for the catheter tip to enter. Difficulty threading the wire during insertion and meeting resistance can be a sign of improper position; pain or insufficient blood return is another clue of malpositioning [5]. If a CVC was found malpositioned, it is important to reposition to avoid complications such hematomas, unrecognized arterial placement, or extravasation of infusate [5]. Some corrective actions involve gently flushing the catheter to dislodge it from a tributary vein, withdrawing the line and reattempting aspiration to confirm adequate blood return, readvancing a guidewire under ultrasound guidance and repositioning the catheter, or if malposition persists, removing the catheter and reinserting it either at an ipsilateral or contralateral location. Ways to confirm proper placement of a central line include obtaining central venous pressure, venous blood gas, transducing venous pressures, and x-ray or ultrasound imaging [1]. The adjunct use of ultrasound guidance has now become the standard of care for CVC insertion procedures and has resulted in a decrease in complications and increase in first-pass success [11]. However, complications are inevitable. In our case, the femoral vein was visualized using ultrasound. The needle was then inserted until blood was aspirated, followed by advancing the guidewire over the needle. Some resistance was met while inserting the wire however there was successful dilation, and the triple lumen catheter (TLC) was advanced over the guidewire with ease. X-ray of the abdomen was done and showed a left femoral catheter terminating on the left side parallel to the spine (Fig. 1). Subsequently, a computed tomography (CT) scan of the abdomen and pelvis which was obtained to rule out an intraabdominal source of infection showed misplacement of the TLC adjacent to the spine in a lumbar vein side-branch rather than in the IVC (Fig. 2, Fig. 3, Fig. 4, Fig. 5). To avoid any complications with administering vasoactive medications into the lumbar vein, the catheter was adjusted and repositioned, and the patient tolerated the procedure well with no complications noted thereafter. Plain radiographs such as x-rays may not adequately visualize placement of a femoral vein catheter placement due to overlying structures. As described in our case, an x-ray of the abdomen did in fact show the tip of the catheter however did not rule out misplacement, possibly due to limited trajectory views. Therefore, in cases where there is doubt about the proper positioning of a CVC, CT scans should be considered for verification to avoid complications from misplaced lines. However, this can pose various limitations including cost, patient safety when critically ill and possibly hemodynamically unstable patients are transported to obtain imaging, radiation exposure, and ultimately, resources including radiology and nursing staff required to accommodate and accompany a critically ill patient.

Conclusion

Central venous catheters are widely used and serve multiple lifesaving purposes. Although CVC placement is a relatively common and low-risk procedure, complications are not uncommon and can be potentially fatal in severe cases. X-rays are usually obtained to confirm CVC placement however can be limited by overlying structures, poor radiographic quality, anatomical variations, and potential for misinterpretation. CT scans provide better images, and a more accurate assessment of catheter placement however have their own limitations including but not limited to cost, concern for patient safety, and use of resources. More data and studies are required to assess different imaging techniques, potentially incorporating use of ultrasonography, to confirm proper placement of CVCs in a timely, safe, and cost-effective fashion.

Patient consent

Written informed consent for publication of this case was obtained from the patient’s daughter as the patient was unable to provide consent at the time.