Abstract
Background and Aims:
Central venous catheter (CVC) malpositions remain an underdiscussed complication despite their widespread recognition. This systematic review includes the published case reports to identify anatomical patterns of malposition, associated risk factors, detection strategies, and preventable causes of harm.
Methods:
A systematic search of PubMed, Embase, and Scopus was conducted for all the relevant articles from inception and published till December 2025. Two reviewers independently extracted data on demographics, catheter type, insertion site, mechanism of malposition, methods of detection, complications during procedure, and patient outcomes.
Results:
Sixty-six articles including 75 cases across 20 countries were included. The patient’s age ranged from 19 to 90 years. The left internal jugular vein was most frequently associated with severe malpositions, including the perforation of the left brachiocephalic vein, mediastinal haematoma, and aberrant cannulation of the left internal mammary, accessory hemizygous and peri-cardio-phrenic veins. Malpositions occurred despite ultrasound guidance in many of the cases. Anatomical variants such as persistent left superior vena cava, anomalous pulmonary venous connections, and right-sided aortic arch were implicated but were often unrecognised. Chest radiograph was the primary detection method but was found insufficient in many cases, requiring computed tomography or trans-oesophageal echocardiography. There were six deaths which were directly attributed to malposition and predominantly occurred from delayed recognition of the complication.
Conclusion:
To conclude, CVC malposition is a frequent, multifactorial complication with significant patient safety implications. Multimodal prevention strategies (e.g., ultrasound guidance, appropriate guidewire selection, vigilance during the procedure, and routine post-procedure imaging) can significantly reduce the incidence of CVC malposition and morbidity. Awareness of anatomical variants and technical pitfalls is essential for the procedure.
Keywords: Anatomical variants, central venous catheter, complications, CVC malposition, systematic review, ultrasound guidance
INTRODUCTION
Although central venous cannulation is an indispensable procedure in intensive care units (ICUs) and perioperative care, it carries a significant risk of complications, with reported rates varying from 5% to 19%.[1,2] The tip of a central venous catheter (CVC) should be in the lower third of the superior vena cava (SVC), close to the junction of the SVC and the right atrium, commonly referred to as the cavo-atrial junction (CAJ).[3] CVC malposition is defined as the unintended placement of the catheter tip in a location other than the CAJ. The incidence is reported to be as high as 3.3–9.1% of insertions.[2] The clinical presentation of a mispositioned CVC is highly variable, ranging from inaccurate central venous pressure measurements to life-threatening complications like arterial puncture.[4,5] Although individual case reports describing unusual anatomical malpositions and severe complications have been published, a comprehensive synthesis of their anatomical patterns, mechanisms, detection strategies, and clinical outcomes is lacking. Therefore, this systematic review was conducted to analyse published case reports and series using a structured framework: (P) patients who underwent central venous catheterisation, events (E) occurrence of catheter malposition, and outcomes (O) associated with anatomical patterns, detection methods, complications, and outcomes. The objectives were to identify the aetiology and risk factors, classify types of malposition, evaluate detection methods, describe associated complications, and synthesise prevention and management strategies.
METHODS
We developed this systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.[5] We registered the study protocol with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD420251070519). This systematic review analyses previously published case reports and case series, as well as letters to the editor (comprising related cases), with all data fully anonymised.
A comprehensive literature search was conducted by two independent reviewers (TG, BG), covering studies from database inception to 31 December 2025 including PubMed, Embase (via Ovid), and Scopus. The search strategy combined both MeSH terms and free text keywords related to CVC and malposition using Boolean operators as follows:
(“Central Venous Catheter” OR “central venous catheter” OR “central line” OR “CVC”) AND
(“Malposition” OR “misplacement” OR “incorrect position” OR “malplacement”) AND
(“Aetiology” OR “risk factors” OR “cause” OR “prediction” OR “detection” OR “diagnosis” OR “complications” OR “outcomes” OR “prevention” OR “avoidance” OR “management” OR “protocol”). Supplementary File 1 shows the exact search strings and the number of articles retrieved per database.
Inclusion and Exclusion Criteria: Included studies were case reports, case series, and letters to the editor, describing malpositioned CVCs in human patients that provided sufficient clinical details, including descriptions of imaging confirmation or figures showing malposition events, detection methods, complications, and outcomes.
Exclusion criteria: Those studies that involved the use of peripherally inserted central catheters (PICCs) or peripheral catheters, records not in the English language, records lacking detailed descriptions of malposition or insufficient clinical information, and duplicate publications of the same cases or data.
Supplementary File 1.
Search strategy
| Data bases | Date of search | Number of papers | ||||
|---|---|---|---|---|---|---|
| PubMed | (“Central Venous Catheter” [Mesh] OR “central venous catheter” OR “central line” OR “CVC”) AND (“Malposition” OR “misplacement” OR “incorrect position” OR “malplacement”) AND (“Etiology” OR “risk factors” OR “cause” OR “prediction” OR “detection” OR “diagnosis” OR “complications” OR “outcomes” OR “prevention” OR “avoidance” OR “management” OR “protocol”) | 31st December 2025 | 317 | |||
| Embase (via Ovid) | Do | 31st December 2025 | 832 | |||
| Scopus | Do | 31st December 2025 | 13 |
Initial screening of titles and abstracts was independently performed by the two reviewers (TG, BG) to identify potentially relevant articles. Full texts of selected citations were then retrieved and examined for eligibility. Disagreements were resolved through discussion and consensus, with consultation from a third reviewer (SS) when required.
A predefined data extraction form was used to collect relevant data from each included study systematically. We included these parameters in our Excel sheet: author(s), year of publication, and country; patient’s age and gender; indication of CVC insertion and clinical setting; catheter type and insertion site; use of ultrasonography (USG) or landmark technique; final catheter tip location and anatomical site of malposition; identified cause(s) of malposition (anatomical variant, technical, patient-related); diagnostic methods employed (e.g., chest radiograph, computed tomography (CT) scan, USG, or echocardiography); complications arising from malposition; management approaches; patient outcome; and preventive strategies recommended by the original authors. Data extraction was performed independently by two reviewers (TG, BG), with cross-checking for accuracy and completeness.
The included case reports were evaluated qualitatively using the Joanna Briggs Institute (JBI) critical appraisal checklist for case reports.[6] Each included case report was independently assessed by two reviewers using the JBI checklist. The appraisal focused on key domains: patient demographics, clinical history, diagnostic clarity, details of interventions, and outcomes reporting. Discrepancies were resolved through discussion.
Extracted data were tabulated and summarised descriptively. Quantitative meta-analysis was not conducted due to heterogeneity and the observational nature of the reports. A total of 1162 articles were identified from various databases. After removing 148 duplicates, 1014 articles were screened. Of these, 833 studies were excluded based on title and abstract screening. The full texts of 197 articles were assessed for eligibility; 131 were excluded for not meeting inclusion criteria. Ultimately, 66 articles describing 75 cases were included in the systematic review.[7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72] The PRISMA are summarised in Figure 1.
Figure 1.
Preferred Reporting Items for systematic reviews and meta-analyses (PRISMA) flow diagram of the study selection process. CVC: Central venous catheter; PICC:Peripherally inserted central catheter
RESULTS
Temporal trends and demographics: A total of 75 cases of CVC malposition were included in the review. The cases were published between 1994 to 2025, with a noticeable increase in reports after 2014 [Table 1].[7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72] India contributed the highest number of published cases (n = 20),[10,11,12,14,17,18,21,23,27,29,30,31,34,38,44,46,56,61,64,71,72] followed by the United States (n = 12),[9,16,32,36,40,41,52,53,62,63,65,66] with additional reports from Taiwan,[15,37,50] Korea,[22,24,25] Portugal,[13,43,49] and Japan[28,57,68]and other countries.
Table 1.
Study characteristics
| Studies (First author et al., year) | Country | No. of cases | Age (years) | Gender | CVC Type | USG guidance | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Maximo HT et al., 1994[7] | Venezuela | 2 | 23 | F | CVC | Without USG guidance | ||||||
| 79 | F | CVC | Without USG guidance | |||||||||
| Celiker V et al., 2004[8] | Turkey | 1 | 65 | F | CVC | Without USG guidance | ||||||
| Markovich MB 2006[9] | USA | 1 | 55 | F | Apheresis catheter | Not mentioned | ||||||
| Ghosh S et al., 2008[10] | India | 1 | 28 | M | CVC | Without USG guidance | ||||||
| Chauhan A et al., 2008[11] | India | 1 | 45 | F | CVC | Without USG guidance | ||||||
| Dubey PK et al., 2009[12] | India | 1 | 30 | F | DC | Not mentioned | ||||||
| Fernandes R et al., 2011[13] | Portugal | 1 | 54 | M | CVC | Not mentioned | ||||||
| Ghatak T et al., 2011[14] | India | 2 | 38 | F | CVC | Not mentioned | ||||||
| 45 | M | CVC | Not mentioned | |||||||||
| Liao HR et al., 2011[15] | Taiwan | 1 | 54 | M | CVC | Not mentioned | ||||||
| Stone PA et al., 2012[16] | USA | 1 | 49 | F | DC | USG-guided | ||||||
| Singh GP et al., 2012[17] | India | 1 | 62 | F | CVC | Without USG guidance | ||||||
| Mudaraddi RV et al., 2012[18] | India | 1 | 52 | F | CVC | Without USG guidance | ||||||
| Turi G et al., 2013[19] | Italy. | 1 | 38 | M | CVC | Not mentioned | ||||||
| Moeinipour AA et al., 2014[20] | Iran | 1 | 54 | M | CVC | Without USG guidance | ||||||
| Nazir O et al., 2014[21] | India | 1 | 65 | F | CVC | Not mentioned | ||||||
| Yang S-H et al., 2014[22] | Korea | 1 | 65 | M | CVC | Without USG guidance | ||||||
| Solanki SL et al., 2015[23] | India | 1 | 55 | M | CVC | USG-guided | ||||||
| Ahn SW et al., 2015[24] | Korea | 1 | 55 | M | CVC | Without USG guidance | ||||||
| Ryu et al., 2015[25] | Korea | 1 | 73 | F | CVC | Without USG guidance | ||||||
| Wang L et al., 2015[26] | China | 2 | 63 | F | DC | Without USG guidance | ||||||
| 38 | F | DC | Without USG guidance | |||||||||
| Yadla M et al., 2016[27] | India | 1 | 56 | F | DC | Without USG guidance | ||||||
| Kumada K et al., 2016[28] | Japan | 1 | 56 | F | CVC | Without USG guidance | ||||||
| Kumar M et al., 2016[29] | India | 1 | 55 | M | CVC | Not mentioned | ||||||
| Desai SN et al., 2015[30] | India | 1 | 50 | M | CVC | Without USG guidance | ||||||
| Kumar N et al., 2017[31] | India | 1 | 32 | M | CVC | USG-guided | ||||||
| Nasim F et al., 2017[32] | USA | 1 | 54 | M | CVC | Not mentioned | ||||||
| Shafiee H et al., 2017[33] | Iran | 1 | 19 | M | CVC | Without USG guidance | ||||||
| Takhar PR et al., 2017[34] | India | 1 | 23 | M | CVC | USG-guided | ||||||
| Bekele NA et al., 2017[35] | Botswana | 1 | Middle age | F | CVC | Not mentioned | ||||||
| Chaddha U et al., 2017[36] | USA | 1 | 76 | F | CVC | Not mentioned | ||||||
| Chen YJ et al., 2018[37] | Taiwan | 1 | 40 | M | CVC | Not mentioned | ||||||
| Shaw M et al., 2019[38] | India | 1 | 53 | M | CVC | Without USG guidance | ||||||
| Gallaher JA et al., 2019[39] | UK | 1 | 39 | M | CVC | Not mentioned | ||||||
| Wang Y et al., 2019[40] | USA | 1 | 67 | F | DC | USG-guided | ||||||
| Almanzar A et al., 2022[41] | USA | 1 | 83 | M | CVC | USG-guided | ||||||
| Faraj J et al., 2020[42] | Australia | 1 | 74 | M | CVC | USG-guided | ||||||
| Varela MNL et al., 2020[43] | Portugal | 1 | 52 | M | CVC | Without USG guidance | ||||||
| Bawa C et al., 2015[44] | India | 1 | 70 | M | CVC | Without USG guidance | ||||||
| Keyal NK et al., 2020[45] | Nepal | 3 | 48 | M | CVC | USG-guided | ||||||
| 63 | M | CVC | USG-guided | |||||||||
| 56 | M | CVC | USG-guided | |||||||||
| Biswas I et al., 2020[46] | India | 1 | 75 | M | CVC | USG-guided | ||||||
| Puspitasari M et al., 2020[47] | Indonesia | 1 | 40 | F | DC | USG-guided | ||||||
| Izumi Y et al., 2021[48] | New Zealand | 1 | 57 | F | DC | Not mentioned | ||||||
| Santos A et al., 2022[49] | Portugal | 1 | 80 | M | DC | Not mentioned | ||||||
| Chang SH et al., 2021[50] | Taiwan | 1 | 66 | F | CVC | Not mentioned | ||||||
| Qurashi HMS et al., 2021[51] | NM (virtual CP) | 1 | 64 | M | CVC | Not mentioned | ||||||
| Kohli A et al., 2022[52] | USA | 1 | 44 | F | DC | Not mentioned | ||||||
| Ahluwalia V et al., 2022[53] | USA | 1 | 79 | F | CVC | USG-guided | ||||||
| Rabia R et al., 2023[54] | Pakistan | 1 | 34 | M | CVC | USG-guided | ||||||
| Lucas SJ et al., 2023[55] | UK | 1 | 83 | F | CVC | Not mentioned | ||||||
| Brahmam D et al., 2023[56] | India | 1 | 60 | M | CVC | USG-guided | ||||||
| Kohyama T et al., 2023[57] | Japan | 1 | 85 | F | CVC | USG-guided | ||||||
| Umakanthan K et al., 2023[58] | NM (Hawaii CP) | 1 | 40 | F | CVC | Not Mentioned | ||||||
| Mcnierney D et al., 2023[59] | NM (Hawaii CP) | 1 | 55 | M | CVC | USG-guided | ||||||
| Gonzalez J et al., 2023[60] | NM (Hawaii CP) | 1 | 23 | F | CVC | USG-guided | ||||||
| Sanjeev G et al., 2023[61] | India | 1 | 60 | F | CVC | USG-guided | ||||||
| Hajeh H et al., 2023[62] | USA | 1 | 36 | F | CVC | USG-guided | ||||||
| Gudushauri N et al. 2024[63] | USA | 1 | 53 | M | CVC | Not mentioned | ||||||
| Arasu M et al., 2024[64] | India | 1 | Late 20 | F | CVC | USG-guided | ||||||
| Guirguis N et al., 2024[65] | USA | 1 | 41 | M | CVC | Not Mentioned | ||||||
| Gerstein NS et al., 2024[66] | USA. | 1 | 61 | M | CVC | USG-guided | ||||||
| Leguizamon R et al., 2024[67] | NM (Boston CP) | 1 | 56 | M | CVC | Not Mentioned | ||||||
| Ito SI et al., 2024[68] | Japan | 1 | 65 | M | CVC | Not mentioned | ||||||
| Feng Y et al., 2024[69] | China | 1 | 79 | F | CVC | Not mentioned | ||||||
| Tanyildizi B 2024[70] | Turkey | 5 | 78 | F | CVC | USG-guided | ||||||
| 90 | F | CVC | USG-guided | |||||||||
| 88 | M | CVC | USG-guided | |||||||||
| 71 | M | CVC | Without USG guidance | |||||||||
| 66 | M | CVC | Without USG guidance | |||||||||
| Bukka VC et al., 2025[71] | India | 1 | 37 | F | DC | USG-guided | ||||||
| Salam MA et al., 2025[72] | India | 1 | Middle age | F | CVC | Without USG guidance |
CVC: Central venous catheter; IVIG: Intravenous immunoglobulin; ICU: Intensive care unit: USG: Ultrasonography; TPN: Total parenteral nutrition; CRRT: Continuous renal replacement therapy; M: Male; F: female; DC: Dialysis catheter; NM: Not mentioned; CP: Conference proceeding; No: Number; USA: United States of America; UK: United Kingdom
The median patient age was 55 years (range: 19–90 years), excluding three cases in which age was not specified.[35,64,72] Female patients accounted for a substantial proportion of reported cases involving hydrothorax, haemopericardium, and vascular perforations [Table 1].[7,16,54,57]
Catheter characteristics, indications, and insertion technique: Triple-lumen central venous catheters were used in many cases (84%),[7,8,10,11,13,14,15,16,17,18,19,20,21,22,23,24,25,28,29,30,31,32,33,34,35,36,37,38,39,41,42,43,44,45,46,47,50,51,53,54,55,56,57,59,60,61,62,63,64,65,66,67,68,69,70,72] followed by dialysis catheters (eight cases),[12,16,26,27,48,49,52,71] while apheresis and double-lumen catheters[58] were less commonly reported [Table 1].[9,27,48,58,63] Most catheter insertions were performed in intensive care or perioperative settings. Ultrasound guidance was reported in 23 cases (30%), while the remaining procedures were performed using landmark techniques or did not specify the guidance method [Table 1].[11,17,23,31,34,42,44,45,46,56,57,61,64,66,72]
Insertion sites and anatomical patterns of malposition: The left internal jugular vein was the most frequently reported insertion site associated with rare and anatomically complex malpositions, including placement in the left internal mammary vein,[15,20] accessory hemiazygos vein,[48,62] left superior intercostal vein,[10,63] persistent left subclavian vein (LSCV),[39,47,49,53] and mediastinal perforation[37,59,64] [Table 2]. Malpositions following right internal jugular vein (RIJV) involved the subclavian, vertebral, and brachiocephalic veins and were generally less catastrophic.[12,22,31,44,60] Malposition into the right subclavian vein was also reported, including a case of “figure-of-eight” configuration.[23] Femoral vein catheterisations were less common but were associated with retroperitoneal or intra-abdominal misplacement, which may be occult and potentially fatal [Table 2].[8,33]
Table 2.
Catheter Insertion site, tip location causes of malposition, and detection techniques used
| Studies (First author et al., year) | Insertion Site | Tip location | Detection Method | |||
|---|---|---|---|---|---|---|
| Maximo HT et al., 1994[7] | LIJV | Misplacement into left pericardiophrenic vein, one with perforation | Chest X-ray, contrast | |||
| LIJV | Misplacement into left pericardiophrenic vein | Chest X-ray, contrast | ||||
| Celiker V et al., 2004[8] | RFV | Venous perforation and misplacement into abdominal cavity | During laparotomy | |||
| Markovich MB 2006[9] | RSCV | Venous perforation and misplacement into thoracic cavity | Double-view chest X-ray | |||
| Ghosh S et al., 2008[10] | LIJV | Malposition into left superior intercostal vein | Chest X-ray | |||
| Chauhan A et al., 2008[11] | RSCV | Contralateral SCV | Chest X-ray | |||
| Dubey PK et al., 2009[12] | RIJV | Misplacement into ipsilateral SCV | Chest X-ray | |||
| Fernandes R et al., 2011[13] | RIJV | Catheter tip cephalically oriented, near jugular bulb | Chest and neck X-ray | |||
| Ghatak T et al., 2011[14] | LIJV | Small tributary of left brachiocephalic vein | Chest Xray | |||
| LIJV | Small tributary of left brachiocephalic vein | Chest X-ray | ||||
| Liao HR et al., 2011[15] | LIJV | Malposition into left internal mammary vein | Chest X-ray, CT | |||
| Stone PA et al., 2012[16] | RIJV | Malposition into right internal mammary vein | Chest X-ray, CT | |||
| Singh GP et al., 2012[17] | RIJV | Contralateral IJV | Chest X-ray | |||
| Mudaraddi RV et al., 2012[18] | RIJV | Ipsilateral IJV | Chest X-ray | |||
| Turi G et al., 2013[19] | RSCV | Secondary malposition into anterior mediastinum, vena caval perforation | CT, Chest X-ray | |||
| Moeinipour AA et al., 2014[20] | LIJV | Catheter in left internal mammary vein | During sternotomy | |||
| Nazir O et al., 2014[21] | RIJV | Malposition into intrapleural space | Chest X-ray | |||
| Yang S-H et al., 2014[22] | RIJV | Misplacement into vertebral vein | Chest X-ray, USG | |||
| Solanki S et al., 2015[23] | RIJV | Right external jugular vein | Chest X-ray | |||
| Ahn SW et al., 2015[24] | Right External Jugular Vein | Jugular venous arch after vessel laceration | During sternotomy | |||
| Ryu et al., 2015[25] | RIJV | RSCV | Chest X-ray | |||
| Wang et al., 2015[26] | LIJV | LIJV | Chest X-ray | |||
| LIJV | RIJV | Chest X-ray | ||||
| Yadla et al., 2016[27] | LIJV | Internal mammary vein | Lateral Chest X-ray | |||
| Kumada K et al., 2016[28] | RIJV | Right internal mammary artery malposition | Ct brachiocephalic angio | |||
| Kumar M et al., 2016[29] | RSCV | Malposition outside SVC | Chest X-ray, CECT | |||
| Desai SN et al., 2015[30] | LSCV | One of the tributaries of left brachiocephalic vein | Chest X-ray, CT | |||
| Kumar N et al., 2017[31] | RIJV | Malposition into RSCV | USG confirmation, flush test | |||
| Nasim F et al., 2017[32] | RSCV | Migration into LSCV | Chest X-ray, blood gas | |||
| Shafiee H et al., 2017[33] | RFV | Extravascular catheter migration to the retroperitoneal space | Laparotomy | |||
| Takhar PP et al., 2017[34] | RSCV | Malposition in LSCV | Chest X-ray | |||
| Bekele NA et al., 2017[35] | LSCV | Misdirected to ipsilateral IJV | Chest X-ray | |||
| Chaddha U et al., 2017[36] | LSCV | Late migration, extravascular, pleural space | Chest X-ray, CT | |||
| Chen YJ et al., 2018[37] | LIJV | Innominate vein perforation | CT, clinical | |||
| Shaw M et al., 2019[38] | LSV | Misplacement into subclavian artery | Chest X-ray, USG | |||
| Gallaher JA et al., 2019[39] | LIJV | Misplacement into LSCV | CT, Chest X-ray | |||
| Wang Y et al., 2019[40] | LIJV | Anomalous pulmonary venous connection | Chest X-ray, CT, blood gas | |||
| Almanzar A et al., 2022[41] | LIJV | Extravascular course, soft tissue, not vessel | Chest X-ray, CT | |||
| Faraj J et al., 2020[42] | RIJV | Malposition into brachiocephalic trunk, arterial injury | CT, angiography | |||
| Varela MNL et al., 2020[43] | RSV | Migration to neck vein | CT, palpation of the neck | |||
| Bawa C et al., 2015[44] | RIJV | Malposition into right vertebral vein | Chest X-ray, Doppler | |||
| Keyal NK et al., 2020[45] | RIJV | Malposition into right subclavian vein | USG, flush test | |||
| RSV | Catheter tip at right ipsilateral IJV | Chest X-ray | ||||
| LSV | Catheter tip at left ipsilateral IJV | Chest X-ray | ||||
| Biswas I et al., 2020[46] | RIJV | RIJV making a loop | Chest X-ray, TTE | |||
| Puspitasari M et al., 2020[47] | LIJV | Persistent left superior vena cava | Chest X-ray | |||
| Izumi Y et al., 2021[48] | LIJV | Malposition into accessory hemiazygos vein | Chest X-ray, CT | |||
| Santos A et al., 2022[49] | RIJV | Persistence left superior vena cava | CT | |||
| Chang SH et al., 2021[50] | RIJV | Penetration into spinal canal via vertebral vein | Chest X-ray, CT | |||
| Qurashi HMS et al., 2021[51] | LIJV | Migration to azygous vein | Chest X-ray, CT | |||
| Kohli A et al., 2022[52] | LIJV | Malposition into left internal mammary vein | Chest X-ray, CT | |||
| Ahluwalia V et al., 2022[53] | LIJV | Persistent left superior vena cava | Chest X-ray, blood gas, CT | |||
| Rabia R et al., 2023[54] | LIJV | Catheter malposition into lung parenchyma | Chest X-ray | |||
| Lucas SJ et al., 2023[55] | RIJV | Misplacement into aberrant artery | CT, angiography | |||
| Brahmam D et al., 2023[56] | RSCV | Figure-of-U malposition in right subclavian vein | Chest X-ray | |||
| Kohyama T et al., 2023[57] | RIJV | Right subclavian artery through the right internal jugular vein | CT, MRI, clinical signs | |||
| Umakanthan K et al., 2023[58] | RIJV | Malposition into right ventricle | ECG, clinical | |||
| Mcnierney D et al., 2023[59] | LIJV | Perforation of left brachiocephalic vein | Chest X-ray, CT | |||
| Gonzalez J et al., 2023[60] | RIJV | Cannulation of right internal mammary artery | CT angiography, blood gas | |||
| Sanjeev G et al., 2023[61] | RIJV | Left brachiocephalic vein malposition | CXR | |||
| Hajeh H et al., 2023[62] | LIJV | Accessory hemiazygos vein variant, looped course | Chest X-ray, CT | |||
| Gudushauri N et al., 2024[63] | LIJV | Malposition into left superior intercostal vein | Chest X-ray, CT | |||
| Arasu M et al., 2024[64] | LIJV | Perforation of left brachiocephalic vein, migration to mediastinum | Chest X-ray, CECT | |||
| Guirguis N et al., 2024[65] | LIJV | Misplacement into left intercostal vein | Chest X-ray, CT | |||
| Gerstein NS et al., 2024[66] | LIJV | Migration into pleura | Trans-oesophageal echocardiography | |||
| Leguizamon R et al., 2024[67] | RIJV | Extravascular migration in the mediastinum | Chest X-ray, CT angiography | |||
| Ito S et al., 2024[68] | RIJV | Malposition into vertebral vein via cervical foramen | Chest X-ray, CT angiography | |||
| Feng Y et al., 2024[69] | RSV | Malposition into azygos vein | CT, Chest X-ray | |||
| Tanyildizi B et al., 2024[70] | RSV | Malposition into left brachiocephalic vein | Chest X-ray | |||
| RSV | Malposition into right internal jugular vein | Chest X-ray | ||||
| RSV | Malposition into right internal jugular vein | Chest X-ray | ||||
| RIJV | Malposition into right brachiocephalic vein | Chest X-ray | ||||
| RSV | Malposition into right internal jugular vein | Chest X-ray | ||||
| Bukka VC et al., 2025[71] | LIJV | Tip of the catheter in the pericardium | CT, TT Echo | |||
| Salam MA et al., 2025[72] | RIJV | RSCV | Contrast enhanced ultrasound |
CVC: Central venous catheter; CT: Computed tomography; RIJV: Right internal jugular vein; LIJV: Left internal jugular vein; LFV: Left femoral vein; RFV: Right femoral vein; LSCV: Left subclavian vein; RSCV: Right subclavian vein; SVC, SCV: Subclavian vein; ECG: Electrocardiography; MRI: Magnetic resonance Imaging; CECT: Contrast-enhanced computed tomography; Chest X-ray: Chest radiograph; TT: Transthoracic; RSV: Right subclavian vein; LSV: Left subclavian vein
Several malpositions occurred despite USG-guided venous access; however, ultrasound facilitates vascular access but does not reliably confirm catheter tip position.[31,34,45,54,56,57,59,62,64,66] Malpositions were also associated with anatomical variants [Table 2], including persistent left superior vena cava (PLSVC),[39,47,49,53] anomalous pulmonary venous connection,[32] accessory hemiazygos vein,[48,62] contralateral vessel entry, ipsilateral venous diversion, and misdirection into thoracic tributaries such as the internal mammary, vertebral, azygos, or hemiazygos veins.
Extravascular catheter migration malpositions into the pleural space, mediastinum, or pericardium represented the most severe forms of clinical presentations.[17,36,41,54,66,67] Inadvertent arterial cannulation involving the carotid or subclavian arteries was also reported.[38,42,55,57,60] Delayed catheter migration occurring hours to days after initial placement was identified in several cases, particularly following patient movement, coughing, or high-flow infusions.[36,37,51] One such case resulted in fatal mediastinal haemorrhage due to delayed innominate vein perforation [Table 2].
Aetiology and risk factors: Reported factors associated with catheter malpositions were categorised as anatomical, technical, or patient-related factors. Anatomical contributors included congenital vascular variants, abnormal venous tributaries, venous stenosis,[12] and altered thoracic venous anatomy.[55] Technical factors included the use of the wrong guidewire tip (straight instead of J tip),[7] excessive advancement,[58] blind landmark techniques, guidewire characteristics, properties of the catheter material, excessive head rotation, and incomplete ultrasound confirmation of the guidewire trajectory.[34,56,73] There were patient-related factors as well, which included emergency insertions,[33,57] haemodynamic instability, prolonged arrhythmias, and physiological changes such as coughing or increased intrathoracic pressure.
Detection and diagnostic modalities: Catheter malposition was clinically suspected in patients who presented with infusion resistance, inability to aspirate blood, pain during infusion, arrhythmias, respiratory distress, or neurological symptoms or unexpected haemodynamic changes.[10,13,16,58] Confirmation of arterial placement with the use of an arterial waveform transducer immediately identified arterial placement when present.[38,42,55,57,60]
Chest radiography was the most frequently used diagnostic modality; however, several reports demonstrated limitations of standard anteroposterior chest radiographs in identifying laterally coursing catheters, arterial malpositions, and extravascular migrations.[9,21,27] Numerous cases required CT and CT-based contrast studies. It was pivotal in 25 cases (40%), particularly for extravascular or delayed presentations.[19,29,36,37,38,41,42] USG-based saline flush tests,[31,45] blood gas analysis,[32,40,53] contrast studies, and transoesophageal echocardiography[46,66] were used selectively in diagnostically challenging cases. Catheter types: Most malpositions involved standard CVC, but dialysis catheters,[12,40,47,48,49,52] PICC lines,[9] apheresis catheters,[69] and large-bore sheaths have been associated with malpositions. Soft silicone catheters are noted to be more prone to malpositions than semirigid catheters due to their tendency to follow the path of least resistance or anomalous pathways. Malposition was asymptomatic in 34 cases (55%), although catheter dysfunction was common. The life-threatening symptomatic complications included vascular perforation with haemorrhage in thorax (hemithorax),[29,59] mediastinum (haemo-mediastinum)[37,64,67] or peritoneum (haemoperitoneum),[8,33] cardiac tamponade,[72] arrhythmias,[58] thrombosis,[42] and neurological injury;[50] several resulted in death. Moderate complications included pleural effusion, hydrothorax, and neurological risk, and mild or incidental complications included poor flow, CVP discrepancy, discomfort, or flushing. Treatment failure due to catheter non-function was the most frequent practical consequence [Table 3].
Table 3.
Summary of outcomes
| Studies (First author et al., year) | Complications (If Any) | Management/ Removal | Patient Outcome | |||
|---|---|---|---|---|---|---|
| Complicated- | ||||||
| Maximo HT et al., 1994[7] | Hydrothorax | CVC was removed | Recovered/Discharged | |||
| Celiker V et al., 2004[8] | Haemoperitoneum | CVC was removed during laparotomy | Died | |||
| Markovich MB, 2006[9] | Apical pneumothorax and haemothorax | CVC was removed after evaluation of the radiologist and the thoracic surgeons, | Recovered/Discharged | |||
| Ghosh S et al., 2008[10] | Thoracic pain syndromes on catheter flushing | CVC was removed and alternate venous access was obtained | Not Mentioned | |||
| Fernandes R et al., 2011[13] | Severe headache during TPN infusion | CVC was removed and alternate venous access was obtained | Recovered/Discharged | |||
| Stone PA et al., 2012[16] | Severe pain occurred with aspiration and flushing of the catheter next day | CVC was removed | Recovered/Discharged | |||
| Turi G et al., 2013[19] | Vena caval perforation and anterior mediastinal | CVC was removed | Not Mentioned | |||
| Ahn SW et al., 2015[24] | Venous perforation and entered into jugular venous arch | CVC was removed | Not Mentioned | |||
| Yadla M et al., 2016[27] | Haemothorax | CVC was removed | Survived | |||
| Kumada K et al., 2016[28] | Haemothorax | CVC was removed | Recovered/Discharged | |||
| Kumar M et al., 2016[29] | Haemothorax, pleural effusion, thrombosis | CVC was not removed | Recovered/Discharged | |||
| Nasim F et al., 2017[32] | Just after insertion patient died | CVC was not removed | Died | |||
| Shafiee H et al., 2017[33] | Haemoperitoneum | CVC was removed during laparotomy after 2 days | Not Mentioned | |||
| Chaddha U et al., 2017[36] | Pleural effusion, high fluid glucose, milky fluid | CVC was removed after 3 days | Not Mentioned | |||
| Chen YJ et al., 2018[37] | Mediastinal haematoma, death | CVC was removed on 4th day during sternotomy | Died | |||
| Shaw M et al., 2019[38] | Arterial injury, managed with stent | CVC was removed in OT with cardiovascular surgery and intervention radiology help | Not Mentioned | |||
| Faraj J et al., 2019[42] | Arterial injury, haemorrhage | CVC removed with endovascular help | Recovered/Discharged | |||
| Chang SH et al., 2021[50] | Neuronal damage risk | CVC was removed immediately | Died | |||
| Rabia R et al., 2023[54] | Hydrothorax | CVC was removed intra-operatively | Recovered/Discharged | |||
| Lucas SJ et al., 2023[55] | Arterial injury | CVC was removed; endovascular stenting was done in OT | Recovered/Discharged | |||
| Kohyama T et al., 2023[57] | Arterial injury, repair surgery | CVC removed in OT, artery also repaired | Recovered/Discharged | |||
| Umakanthan K et al., 2023[58] | Cardiac arrest, arrhythmia | CVC was retracted to 16 cm | Died | |||
| Mcnierney D et al., 2023[59] | Left haemothorax, mediastinal shift, death | CVC was retained as the patient was unstable for OT | Died | |||
| Gonzalez J et al., 2023[60] | Arterial injury, embolisation | Not mentioned | Died | |||
| Arasu M et al., 2024[64] | Mediastinal migration, pain in insertion site | CVC was removed while keeping the interventional radiology suite ready for backup. | Recovered/Discharged | |||
| Gerstein NS et al., 2024[66] | Pneumothorax | CVC was removed | Recovered/Discharged | |||
| Leguizamon R et al., 2024[67] | No blood return, swelling, mediastinal complications | CVC was removed | Recovered/Discharged | |||
| Bukka VC et al., 2025[71] | Haemopericardium | CVC was removed with the help of cardiothoracic surgeon through mini-sternotomy on day 2. | Recovered/Discharged | |||
|
No major complications- | ||||||
| Maximo HT et al., 1994[7] | No major complication | CVC was not removed | Died but not due to CVC complication | |||
| Chauhan A et al., 2008[11] | No major complication | CVC was removed | Recovered/Discharged | |||
| Dubey PK et al., 2009[12] | No major complication | CVC was not removed | Recovered/Discharged | |||
| Ghatak T et al., 2011[14] | No major complication | CVC was removed | Recovered/Discharged | |||
| No major complication | CVC was removed | Recovered/Discharged | ||||
| Liao HR et. al., 2011[15] | No major complication | CVC not removed | Recovered/Discharged | |||
| Singh GP et al., 2012[17] | No major complication | CVC was not removed | Recovered/Discharged | |||
| Mudaraddi RV et al., 2012[18] | Poor CVP tracing | CVC was removed | Recovered/Discharged | |||
| Moeinipour AA et al., 2014[20] | Blocked middle lumen, no major complication | CVC was removed after surgery | Recovered/Discharged | |||
| Nazir O et al., 2014[21] | No major complication | CVC was not removed | Recovered/Discharged | |||
| Yang SH et al., 2014[22] | No major complication | CVC was not removed | Recovered/Discharged | |||
| Solanki SL et al., 2015[23] | No major complication | CVC repositioned | Recovered/Discharged | |||
| Ryu et al., 2015[25] | None | No | Recovered/Discharged | |||
| Wang et al., 2015[26] | Poor flow | No | Recovered/Discharged | |||
| Desai SN et al., 2015[30] | No major complication | CVC was removed afterwards | Recovered/Discharged | |||
| Kumar N et al., 2017[31] | No major complication | CVC was pulled up to 7 cm and was reinserted over the guidewire maintaining proper asepsis. | Recovered/Discharged | |||
| Takhar PR et al., 2017[34] | No major complication | CVC was removed | Recovered/Discharged | |||
| Bekele NA et al., 2017[35] | Discomfort during injection, improper CVC function | CVC was pulled 3 cm out and reinserted | Not Mentioned | |||
| Gallaher JA et al., 2019[39] | No major complication | CVC was removed later | Recovered/Discharged | |||
| Wang Y et al., 2019[40] | No major complication | CVC was repositioned by interventional radiology | Recovered/Discharged | |||
| Almanzar A et al., 2022[41] | No major complication | CVC was removed | Recovered/Discharged | |||
| Varela MNL et al., 2020[43] | No major complication | CVC was removed | Recovered/Discharged | |||
| Bawa C et al., 2015[44] | No major complication | Not Mentioned | Recovered/Discharged | |||
| Keyal NK et al., 2020[45] | No major complication | CVC was removed after 6 hospital days | Recovered/Discharged | |||
| No major complication | CVC was removed after 6 hospital days | Recovered/Discharged | ||||
| No major complication | CVC was removed after 10 hospital days | Recovered/Discharged | ||||
| Biswas et al., 2020[46] | No major complication | Careful reposition under TTE guidance | Recovered/Discharged | |||
| Puspitasari M et al., 2020[47] | No major complication | CVC was not removed | Died but not due to CVC complication | |||
| Izumi Y et al., 2021[48] | No major complication | CVC was removed | Recovered/Discharged | |||
| Santos A et al., 2020[49] | No major complication | CVC was removed and new catheter placed | Recovered/Discharged | |||
| Qurashi HMS et al., 2021[51] | No major complication | CVC was removed | Recovered/Discharged | |||
| Kohli A et al., 2022[52] | No major complication | Not mentioned | Not Mentioned | |||
| Ahluwalia V et al., 2022[53] | No major complication | Not mentioned | Not Mentioned | |||
| Brahmam D et al., 2023[56] | No major complication | CVC was removed | Recovered/Discharged | |||
| Sanjeev et al., 2023[61] | None | No | Good | |||
| Hajeh H et al. 2023[62] | No major complication | Not mentioned | Recovered/Discharged | |||
| Gudushauri N et al., 2024[63] | No major complication, | CVC was removed | Recovered/Discharged | |||
| Guirguis N et al., 2024[65] | No major complication | Not mentioned | Recovered/Discharged | |||
| Ito S et al., 2024[68] | No major complication | CVC was removed using digital subtraction angiography | Recovered/Discharged | |||
| Feng Y et al., 2024[69] | No major complication | CVC was removed | Recovered/Discharged | |||
| Tanyildizi B 2024[70] | No major complication | Not mentioned | Not Mentioned | |||
| No major complication | Not mentioned | Not Mentioned | ||||
| No major complication | Not Mentioned | Not Mentioned | ||||
| No major complication | Not Mentioned | Not Mentioned | ||||
| No major complication | Not Mentioned | Not Mentioned | ||||
| Salam MA et al., 2025[72] | No major complication | CVC repositioned | Recovered/Discharged | |||
CVC: Central venous catheter; ACLS: Advanced cardiac life support; ECG: Electrocardiography; IJV: Internal jugular vein; OT: Operation theatre; TTE: Transthoracic echocardiography; CVP: Central venous pressure; TPN: Total parenteral nutrition
Nine patients (15%) died during or after the procedure within 24 h; of these, several deaths were directly attributable to malposition-related complications including mediastinal haematoma, or haemothorax, in immediate post-insertion time.[8,32,37,50,58,59,60] Two deaths were unrelated to catheter event, while the remaining were attributed to complications associated with malposition.[7,47]
Management strategies included immediate catheter removal to repositioning in many cases, but a significant subset required endovascular repair,[38,42,55] surgical intervention,[37,72] or cautious retention in a few unstable patients.[36,47] Preventive measures identified across reports included the use of ultrasound throughout the procedure,[17,31,45,46,56] mandatory post-procedure imaging,[9,30,42] J-tip guidewire preference,[7] electrocardiography-guided tip confirmation,[58,62] careful guidewire and catheter handling,[45,57] appropriate imaging confirmation, awareness of anatomical variants,[30,39,47,49,53,72] avoiding excessive guidewire or catheter advancement,[58] minimising head rotation,[22,45] and vigilant post-insertion monitoring.[1]
Risk of bias and quality of data: The attached case reports were evaluated using the JBI) critical appraisal checklist for case reports.[6] The majority of the studies described patient demographics, clinical histories, diagnostic detail, and intervention supported by imaging confirmation. Recurring clinical lessons emphasising the importance of routine imaging, and adverse events such as haemothorax, vascular injury, and arrhythmia are well documented [Supplementary File 2].
Supplementary File 2.
Summary of published case reports on central venous catheter (CVC) malposition
| Studies (First author et al., year) | Demo graphics | Clinical History Adequate | Diagnostic Methods Appropriately Detailed | Intervention Clearly Reported | Outcome Clearly Described | Adverse Consequences | Overall Quality Rating | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Maxico HT et al., 1994[7] | Yes | Yes | Yes (radiograph, contrast) | Yes | Yes | Yes | High | |||||||
| Celiker V et al., 2004[8] | Yes | Yes | Yes (clinical) | Yes | Yes | Yes | High | |||||||
| Markovich MB, 2006[9] | Yes | Yes | Yes (CXR, CT) | Yes | Yes | Yes | High | |||||||
| Ghosh S et al., 2008[10] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Chauhan A et al., 2008[11] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Dubey PK et al., 2009[12] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Fernandes R et al., 2011[13] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Ghatak T et al., 2011[14] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Liao HR et al., 2011[15] | Yes | Yes | Yes (CXR, CT, CVP) | Yes | Yes | Yes | High | |||||||
| Stone PA et al., 2012[16] | Yes | Yes | Yes (CXR, CT) | Yes | Yes | Yes | High | |||||||
| Singh GP et al., 2012[17] | Yes | yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Mudaraddi RV et al.,[18] | Yes | yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Turi G et al., 2013[19] | Yes | Yes | Partially (CXR/CT) | Yes | Yes | Yes | Moderate-High | |||||||
| Moeinipour AA et al., 2014[20] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Nazir O et al., 2014[21] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Yang S-H et al., 2014[22] | Yes | Yes | Yes (CXR, USG) | Yes | Yes | Yes | High | |||||||
| Solanki S et al., 2015[23] | Yes | Yes | Yes (USG, CXR) | Yes | Yes | Yes | High | |||||||
| Ahn SW et al., 2015[24] | Yes | Yes | Yes | Yes | Yes | Yes | High | |||||||
| Ryu et al., 2015[25] | Yes | Yes | Yes (CXR, C-arm fluoroscopy) | Yes | Yes | Yes | High | |||||||
| Wang L et al., 2015[26] | Yes | Yes | Yes (fluoroscopy) | Yes | Yes | Yes | High | |||||||
| Yadla M et al., 2016[27] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Kumada K et al., 2016[28] | Yes | Yes | Yes (CXR, CT) | Yes | Yes | Yes | High | |||||||
| Kumar M et al., 2016[29] | Yes | Yes | Yes (CXR, CECT) | Yes | Yes | Yes | High | |||||||
| Desai SN et al., 2015[30] | Yes | Yes | Yes (CXR lateral, CT) | Yes | Yes | Yes | High | |||||||
| Kumar N et al., 2017[31] | Yes | Yes | Yes (USG, CXR) | Yes | Yes | Yes | High | |||||||
| Nasim F et al., 2017[32] | Yes | Yes | Yes | Yes | Yes | Yes | High | |||||||
| Hamed S et al., 2017[33] | Yes | Yes | Yes (contrast imaging) | Yes | Yes | Yes | High | |||||||
| Thakar RP et al., 2017[34] | Yes | Yes | Yes (colour Doppler, X-ray) | Yes | Yes | Yes | High | |||||||
| Bekele NA et al., 2017[35] | Yes | Yes | Yes (CXR) | Yes | Yes | Yes | High | |||||||
| Chaddha U et al., 2017[36] | Yes | Yes | Yes (CXR, CT) | Yes | Yes | Yes | High | |||||||
| Chen Y-J et al., 2018[37] | Yes | Yes | Yes (CT) | Yes | Yes | Yes | High | |||||||
| Shaw M et al., 2019[38] | Yes | Yes | Yes (Angiography) | Yes | Yes | Yes | High | |||||||
| Gallaher JA et al., 2019[39] | Yes | Yes | Yes (CXR, CT) | Yes | Yes | Yes | High | |||||||
| Wang Y et al., 2019[40] | Yes | Yes | Yes (USG, waveform, blood gas, CXR, CT) | Yes | Yes | Yes | High | |||||||
| Almanzar A et al., 2019[41] | Yes | Yes | Yes (CXR, CT neck, USG) | Yes | Yes | Yes | High | |||||||
| Faraj J et al., 2020[42] | Yes | Yes | Yes (CXR, CT angiogram) | Yes | Yes | Yes | High | |||||||
| Varela MNL et al., 2020[43] | Yes | Yes | Yes (CT and clinical exam) | Yes | Yes | Yes | High | |||||||
| Bawa C et al., 2020[44] | Yes | Yes | Yes (CXR, colour Doppler) | Yes | Yes | Yes | High | |||||||
| Keyal NK et al., 2020[45] | Yes | Yes | Yes (CXR, clinical follow-up) | Yes | Yes | Yes | High | |||||||
| Biswas I et al., 2020[46] | Yes | Yes | Yes (CXR; TTE) | Yes | Yes | Yes | High | |||||||
| Puspitasari M et al., 2020[47] | Yes | Yes | Yes (CXR, TTE) | Yes | Yes | Yes | High | |||||||
| Izumi Y et al., 2021[48] | Yes | Yes | Yes (CT) | Yes | Yes | Yes | High | |||||||
| Afonso-Santos A et al., 2020[49] | Yes | Yes | Yes (USG, CXR, CT) | Yes | Yes | Yes | High | |||||||
| Chang S-H et al., 2022[50] | Yes | Yes | Yes (CT, MRI) | Yes | Yes | Yes | High | |||||||
| Siddiqui HM et al., 2021[51] | Yes | Yes | Yes (CXR, CT chest) | Yes | Yes | Yes | High | |||||||
| Kohli A et al., 2022[52] | Yes | Yes | Yes (CXR, CT) | Yes | Yes | Yes | High | |||||||
| Ahluwalia V et al., 2022[53] | Yes | Yes | Yes (USG, CXR, prior CT) | Yes | Yes | Yes | High | |||||||
| Rabia R et al, 2023[54] | Yes | Yes | Yes | Yes | Yes | Yes | High | |||||||
| Lucas SJ et al., 2023[55] | Yes | Yes | Yes (CXR, CT, angiogram) | Yes | Yes | Yes | High | |||||||
| Brahmam D et al., 2023[56] | Yes | Yes | Yes (USG, CXR, clinical) | Yes | Yes | Yes | High | |||||||
| Kohyama T et al., 2023[57] | Yes | Yes | Yes (Ultrasound, CT, MRI) | Yes | Yes | Yes | High | |||||||
| Umakanthan K et al., 2023[58] | Yes | Yes | Yes (ECG, telemetry) | Yes | Yes | Yes | High | |||||||
| McNierney D et al., 2023[59] | Yes | Yes | Yes (USG, CXR,) | Yes | Yes | Yes | High | |||||||
| Gonzalez J et al., 2023[60] | Yes | Yes | Yes (US, CXR, CT angiogram) | Yes | Yes | Yes | High | |||||||
| Sanjeev G et al., 2023[61] | Yes | Yes | Yes (US, CXR) | Yes | Yes | Yes | High | |||||||
| Hajeh H et al., 2023[62] | Yes | Yes | Yes (USG, CXR, CT) | Yes | Yes | Yes | High | |||||||
| Gudushauri N et al., 2024[63] | Yes | Yes | Yes (CXR, CT) | Yes | Yes | Yes | High | |||||||
| Arasu M et al., 2024[64] | Yes | Yes | Yes (USG, CXR, CT) | Yes | Yes | Yes | High | |||||||
| Guirguis N et al., 2024[65] | Yes | Yes | Yes (USG, CXR) | Yes | Yes | Yes | High | |||||||
| Gerstein NS et al., 2024[66] | Yes | Yes | Yes (TEE) | Yes | Yes | Yes | High | |||||||
| Leguizamon R et al., 2024[67] | Yes | Yes | Yes (CT Angiography) | Yes | Yes | Yes | High | |||||||
| Ito SI et al., 2024[68] | Yes | Yes | Yes (angiography) | Yes | Yes | Yes | High | |||||||
| Feng Y et al., 2024[69] | Yes | Yes | Yes (CT radiographic) | Yes | Yes | Yes | High | |||||||
| Tanyildizi B 2024[70] | Yes | Yes | Yes | Yes | Yes | Yes | High | |||||||
| Bukka VC et al., 2025[72] | Yes | Yes | Yes (USG, CXR, CT, TTE) | Yes | Yes | Yes | Hi | |||||||
| Salam MA et al., 2025[74] | Yes | Yes | Yes (CXR, USG) | Yes | Yes | Yes | High |
CVC: Central venous catheter; IJV: Internal jugular vein; SCV: Subclavian vein; CXR: Chest X-ray; CT: Computed tomography; USG: Ultrasonography; CVP: Central venous pressure; TTE: Transthoracic echocardiography; TEE: Transoesophageal echocardiography; IR: Interventional radiology; ECG: Electrocardiography; MRI: Magnetic resonance imaging; US: Ultrasound
DISCUSSION
This systematic review synthesised 75 reported cases of CVC malpositions published across 66 studies and highlights the wide anatomical variability, diagnostic challenges, and potential serious complications.[7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72] The increasing number of reports published after 2014 may reflect greater awareness, wider use of advanced imaging modalities, and increased utilisation of ultrasound-guided vascular access techniques. Female patients appeared disproportionately among cases of CVC malpositions with serious complications including vascular perforation, haemothorax, and haemopericardium[7,16,27,28,54,57,71]; however, no definitive conclusions regarding risk can be drawn from case-based evidence, and the dataset is insufficient for definitive statistical inference. This observation may be associated with established anatomical features, for example, smaller vessel calibre, acute angulation at venous junctions, and the presence of less subcutaneous tissue around vascular structures. Across the available literature, malpositions were more commonly associated with left-sided catheter insertions,[7,10,14,15,20,26,27,37,39,41,47,48,51,52,53,54,59,62,63,64,65] mostly via the left internal jugular vein (LIJV). This could be explained by anatomical factors, a longer and more angulated course of the left brachiocephalic vein, which increases the likelihood of guidewire deviation into smaller tributaries or anomalous venous channels, including the PLSVC. Moreover, brachiocephalic, subclavian, and jugular veins have multiple branches that may capture an advancing guidewire or catheter. Previous history of cannulation, thrombosis, or external compression can also alter venous anatomy. There have been several late migrations, that is, displacement of an initially correctly positioned catheter to an aberrant location after a period of normal use. Proposed mechanisms of delayed malposition of CVC include patient movement (arm elevation, neck rotation, coughing, intrathoracic pressure from positive-pressure ventilation, Valsalva manoeuvre) and a jet effect from high-pressure drug infusions.[32,36,43,51,66] Small catheters and silicon material were noted to predispose to such late migrations in certain reports.[36,43]
Chest radiograph remains the most widely used method for post-procedural CVC verification, whereas additional imaging modalities, such as CT, CT angiography, or transoesophageal echocardiography, may be required in a few selected cases of anterior mediastinal catheter migration. Importantly, several case reports demonstrated correct venous puncture but an incorrect guidewire advancement, emphasising that successful aspiration of venous blood does not ensure optimal catheter trajectory. Repeated imaging should be considered particularly for catheters inserted via the left side or inpatients requiring prolonged respiratory support presenting with new symptoms of pain, infusion resistance, or unexpected haemodynamic changes.[6,14,16,17,18,19] This reinforces the principle that wire and catheter tracking must continue beyond the point of vascular entry.
A recurring role of anatomical variants in directing catheter tips into unexpected locations, particularly PLSVC, has been identified in at least four cases.[47,49,53,69] Although the incidence of PLSVC is approximately 0.3–0.5% in the general population, it can be up to 10% in those with congenital heart diseases, particularly those that drain into the coronary sinus.[73] A catheter advanced through the left internal jugular vein in a patient with PLSVC may follow this anomalous vessel into a posterior or inferior course. Other anatomical variants implicated include anomalous pulmonary venous connection, right-sided aortic arch with aberrant arterial anatomy,[55] an accessory hemiazygos vein diverting catheters into a looping course,[48,62] dilated intercostal veins secondary to chronic venous congestion providing a low-resistance pathway,[65] and a thrombosed innominate vein forcing catheter deviation into the pericardium.[71] These findings have an important preventive implication: Routine review of prior cross-sectional imaging (CT chest or echocardiography) before CVC insertion, particularly in patients with known cardiovascular disease, prior thoracic surgery, or chest radiographs showing unusual venous anatomy may identify variants and reduce malposition risk.
The type of catheters used also influences the malposition risk in a few cases as a silicon-based catheter was used in one of the cases, which is more prone to malposition than stiffer, semi-rigid polyurethane catheters, as soft material tends to follow the path of least resistance and deviate at venous junctions rather than advancing blood flow.[41,44] Conversely, excessively rigid or large-bore catheters with aggressive advancement can be associated with perforation of the vessel. Operator technique errors were identified in a subset of cases. The use of a straight-tipped rather than J-tipped guidewire has been implicated in the earliest reported cases.
Manual compression of the ipsilateral internal jugular vein during subclavian insertion to prevent cephalad migration paradoxically caused a U-shaped malposition in one case. These operator-related factors are important because they are amenable to training and simulation-based education. Emergency conditions appeared to be a consistent risk factor for both malposition and serious complications; cases inserted under haemodynamic stability or shock tended to have more complex malpositions and worse outcomes, likely reflecting rushed technique, altered venous dynamics, suboptimal patient position, and reduced post-procedure vigilance.[33,57,59]
Real-time ultrasonographic visualisation in the longitudinal axis can assist in following the guidewire and catheter progression.[74] While USG ensures correct vein entry, it does not always track the guidewire deep in the mediastinum, which is a key limitation. Adjunctive confirmation modalities, such as intracavitary electrocardiography, Doppler waveform analysis, and fluoroscopic tracking,[25] were also reported to improve accurate tip placement.
The findings from these case-based reviews are further strengthened by evidence from higher-quality comparative and interventional studies. One of the most clinically relevant findings comes from a landmark randomised controlled trial by Shin et al.,[75] which included around 449 surgical patients. USG-guided left infraclavicular subclavian vein central venous catheterisation was compared to right-sided approaches. The incidence of malpositions was significantly lower on the left side: 4.5% vs. 13.8%; odds ratio 0.29 (95% confidence interval 0.14 to 0.61, P = 0.001), representing a 66% relative risk reduction. In the right-sided subclavian group, the most common malposition was an aberrant entry into the internal jugular vein, 10.7% vs. 4% (P = 0.007). Although contralateral brachiocephalic malposition was also higher on the right side (3.1% vs. 0.4%), the difference did not reach statistical significance (P = 0.068). Complementing this evidence, Vouri Kokkori et al.[76] reported a significantly reduced malpositioning rate of CVCs using a structured two-step ultrasound protocol during internal jugular vein catheterisation. This protocol included (1) direct visualisation of guidewire tracking caudally within the internal jugular vein in the longitudinal axis and (2) active exclusion of guidewire entry into the subclavian vein. Although ultrasound guidance improves the accuracy of vascular access, it does not eliminate the risk of catheter malposition. Its effectiveness is highly dependent on technique.
We propose best-practice recommendations that include pre-procedural ultrasound assessment to identify anatomical variations, real-time needle insertion with continuous visualisation of the needle tip, and ultrasound confirmation of guidewire position within the vein. Careful ultrasonographic assessment to ensure that the guidewire does not enter adjacent vessels, such as the subclavian vein during internal jugular cannulation, is essential. Post-procedural ultrasonographic evaluation, including assessment of lung sliding to exclude pneumothorax, can further enhance procedural safety. Delayed recognition of malposition was frequently associated with a few avoidable complications, including vascular perforation, mediastinal or pleural infusion, arrhythmias, pericardial tamponade, and ineffective delivery of vasoactive medications. A common issue in many reported cases was giving medications before checking the position of the catheter tip, even though early imaging or bedside checks could have avoided problems.
This systematic review, based exclusively on a limited number of case reports and case series, carries inherent methodological limitations. Reporting quality is heterogeneous, with many cases omitting key data on insertion techniques, ultrasound guidance, catheter material, or prevention strategies.[7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72] Denominator data were unavailable; that is, the total number of CVC insertions performed in each study setting is unknown, making incidence estimates difficult to calculate. Outcomes have also been reported inconsistently, with many studies failing to mention patient survival. However, case-based evidence has limitations, including publication bias towards unusual or severe events and incomplete reporting in some descriptions. Prospective studies and standardised reporting of catheter placement techniques would further clarify risk factors and best practice recommendations. The findings of this review should be interpreted in the context of the inherent publication bias in case-based evidence, where rare or severe complications are preferentially reported. Geographic variation in reported cases may also reflect differences in reporting practices rather than true epidemiological trends.
CONCLUSION
We conclude from this systematic review that CVC malposition remains a frequent potentially serious complication, which can be influenced by anatomical variations, technical factors, and patient-specific conditions. This review demonstrates that CVC malposition occurs across all age groups, access routes, and catheter types. Malposition may occur despite ultrasound-guided venous access and can be influenced by anatomical variations, technical factors, catheter characteristics, and patient-related outcomes. Routine post-procedural catheter tip confirmation, careful guidewire handling, awareness of anatomical variants, and early recognition of abnormal clinical signs are essential to minimise catheter-related complications.
Author contributions
TG: Conceptualisation. BG, SS: Data collection. All the authors have participated in the writing, review, drafting and final approval of the manuscript.
Study data availability
De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors’ Institution policy.
Disclosure of use of artificial intelligence (AI)-assistive or generative tools
AI-assisted or generative tools were not used.
Supplementary material
This article has supplementary material which can be accessed at the following link - https://links.lww.com/IJOA/A91.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Ghatak T, Gupta B, Samanta S, Dube BN, Halemani K. A systematic analysis of published Indian case reports of whole guidewire loss during central venous catheterisation: Causes, detection and management strategies. Ann Card Anaesth. 2025;28:417–26. doi: 10.4103/aca.aca_16_25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Zheng Y, Zhou HJ, Tao N, Tian Y, Qin SW, Qin BY, et al. Prevention of catheter tip malposition with an ultrasound-guided finger-pressure method to block the internal jugular vein during PICC placement: A meta-analysis. Wideochir Inne Tech Maloinwazyjne. 2022;17:289–8. doi: 10.5114/wiitm.2022.115198. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Practice Guidelines for Central Venous Access 2020: An updated report by the American Society of Anesthesiologists Task force on central venous access. Anesthesiology. 2020;132:8–43. doi: 10.1097/ALN.0000000000002864. [DOI] [PubMed] [Google Scholar]
- 4.Gibson F, Bodenham A. Misplaced central venous catheters: Applied anatomy and practical management. Br J Anaesth. 2013;110:333–46. doi: 10.1093/bja/aes497. [DOI] [PubMed] [Google Scholar]
- 5.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Systematic reviews of etiology and risk. Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. 2020:219–71. JBI. [Google Scholar]
- 7.Maximo HT, Kaduo A. Hydrothorax after inadvertent placement of a central venous catheter in the left pericardiophrenic vein. J Intensive Care Med. 1994;9:257–60. [Google Scholar]
- 8.Celiker V, Akinci SB, Basgul E, Aypar U. Misplacement of femoral catheter into the abdominal cavity. Acta Anaesthesiol Scand. 2004;48:258. doi: 10.1111/j.0001-5172.2004.00295d.x. [DOI] [PubMed] [Google Scholar]
- 9.Markovich MD. Central venous catheter tip placement: Determination of posterior malposition-a case study. JAVA. 2006;11:85–9. [Google Scholar]
- 10.Ghosh S, Dewan H, Bhattacharyya S. A rare malposition of the thoracic venous catheter introduced via the left internal jugular vein. Indian J Crit Care Med. 2008;12:201–3. doi: 10.4103/0972-5229.45083. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Chauhan A. Malpositioning of central venous catheter: Two case reports. Indian J Anaesth. 2008;52:337–9. [Google Scholar]
- 12.Dubey PK. Misplacement of an internal jugular hemodialysis catheter due to stenosis caused by previous short-term catheterisation. Indian J Crit Care Med. 2009;13:44–5. doi: 10.4103/0972-5229.53118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Fernandes R, Costa C, Rabico R, Aguiar I. Headache related with central venous catheter tip malposition: 17AP3-2. Eur J Anaesthesiol. 2011;28:218–9. [Google Scholar]
- 14.Ghatak T, Azim A, Baronia AK, Muzaffar SN. Malposition of central venous catheter in a small tributary of left brachiocephalic vein. J Emerg Trauma Shock. 2011;4:523–5. doi: 10.4103/0974-2700.86653. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Liao HR, Li TS, Chen KB, Li CY, Jeng LB, Yang HR, et al. Rare malposition of a central venous catheter into the left internal mammary vein in a liver transplantation patient. J Anesth. 2011;25:462–4. doi: 10.1007/s00540-011-1115-6. [DOI] [PubMed] [Google Scholar]
- 16.Stone PA, Hass SM, Knackstedt KS, Jagannath P. Malposition of a central venous catheter into the right internal mammary vein: Review of complications of catheter misplacement. Vasc Endovascular Surg. 2012;46:187–9. doi: 10.1177/1538574411433288. [DOI] [PubMed] [Google Scholar]
- 17.Singh GP, Prabhakar H, Reddy BK. Malposition of internal jugular vein catheter into contralateral internal jugular vein: An uncommon position. Indian J Anaesth. 2012;56:205–7. doi: 10.4103/0019-5049.96317. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Mudarraddi RR. Unusual malpositioning of the central venous catheter. J Clin Diagn Res. 2012;6:1124–5. [Google Scholar]
- 19.Turi G, Tordiglione P, Araimo F. Case report: Anterior mediastinal central line malposition. Anesth Analg. 2013;117:123–5. doi: 10.1213/ANE.0b013e31824e2d37. [DOI] [PubMed] [Google Scholar]
- 20.Moeinipour AA, Amouzeshi A, Joudi M, Fathi M, Jahanbakhsh S, Hafez S, et al. A rare central venous catheter malposition: A case report. Anesth Pain Med. 2014;4:e16049. doi: 10.5812/aapm.16049. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Nazir O, Wani M A, Jain AK, Misra R. Central venous catheter malposition into intrapleural space. J Sci Soc. 2014;41:197–9. [Google Scholar]
- 22.Yang SH, Jung SM, Park SJ. Misinsertion of central venous catheter into the suspected vertebral vein: A case report. Korean J Anesthesiol. 2014;67:342–5. doi: 10.4097/kjae.2014.67.5.342. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Solanki SL, Thota RS, Patil VP. Malpositioning of right internal jugular central venous catheter into right external jugular vein forming “figure of eight”. Ann Card Anaesth. 2015;18:414–5. doi: 10.4103/0971-9784.159813. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Ahn SW, Lee JH, Park C, Hong YW, Chun DH. Malposition of central venous catheter in the jugular venous arch via external jugular vein -A case report. Korean J Anesthesiol. 2015;68:175–8. doi: 10.4097/kjae.2015.68.2.175. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Ryu J, Yoon JH, Lee EJ, Lee CA, Woo SC, Jeong CY. Correction of malposition of central venous catheter with 9-Fr introducer sheath assisted by mobile type diagnostic X-ray apparatus: A case report. Korean J Anesthesiol. 2015;68:402–6. doi: 10.4097/kjae.2015.68.4.402. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Wang L, Liu Z, Wang C, Liu D, Yua Y. Original article rare malposition following left jugular vein catheterisation: Case reports and a literature review. Int J Clin Exp Med. 2015;8:18543–7. [PMC free article] [PubMed] [Google Scholar]
- 27.Yadla M, Jalli M. An unusual complication of malposition of left internal jugular catheter in a patient with chronic kidney disease. Saudi J Kidney Dis Transpl. 2016;27:1052–4. doi: 10.4103/1319-2442.190887. [DOI] [PubMed] [Google Scholar]
- 28.Kumada K, Murakami N, Okada H, Toyoda I, Ogura S, Kondo H, et al. Central venous catheter malposition an ultrasound-guided approach would be helpful: A case report. J Med Case Rep. 2016;10:248. doi: 10.1186/s13256-016-1026-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Kumar M, Singh A, Sidhu KS, Kaur A. Malposition of subclavian venous catheter leading to chest complications. J Clin Diagn Res. 2016;10:PD16–8. doi: 10.7860/JCDR/2016/19399.7860. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Desai SN, Dasar SK, Mithali V. Malposition of the central venous catheter: A diagnostic dilemma. Indian J Crit Care Med. 2017;21:235–7. doi: 10.4103/ijccm.IJCCM_338_14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Kumar N, Kaushal A, Dev Soni K, Tomar GS. A rare case of malposition of central venous catheter detected by ultrasonography-guided saline flush test. BMJ Case Rep. 2017;6:bcr2017220657. doi: 10.1136/bcr-2017-220657. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Nasim F, Sims CR, Wilson ME. Case of right to left malpositioned subclavian central access. Am J Respir Crit Care Med. 2017;195:A1961. [Google Scholar]
- 33.Shafiee H, Safari S, Aminnejad R. Intraperitoneally located tip of femoral vein catheter; clinical suspicion for avoidance of unnecessary laparotomy. Anesth Pain Med. 2017;7:e64557. doi: 10.5812/aapm.64557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Takhar PR, Motilal B, Savita A. Malpositioning of central venous catheter from right to left subclavian vein: A rare complication. Indian J Crit Care Med. 2017;21:799–801. doi: 10.4103/0972-5229.218155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Bekele NA, Abebe WA, Shifa JZ. Misplaced subclavian central venous catheter. Pan Afr Med J. 2017;26:27–59. doi: 10.11604/pamj.2017.27.59.9532. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Chaddha U, Kaghihara J, Bagavathy K, Prosper A, Oren A. When your central line decides to go for a stroll. Chest. 2017;152:A878. [Google Scholar]
- 37.Chen YJ, Chung SC, Liu YC. Delayed malposition of central venous catheter induced mediastinum hematoma with innominate vein perforation. Asian J Anesthesiol. 2018;56:66–9. doi: 10.6859/aja.201806_56(2).0005. [DOI] [PubMed] [Google Scholar]
- 38.Shaw M, Chandrashekhara SH, Sharma A, Kumar S. Inadvertent arterial placement of central venous catheter: Salvage using endovascular treatment. BMJ Case Rep. 2019;12:e231751. doi: 10.1136/bcr-2019-231751. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Gallaher JA, Somasundaram K. Left-sided superior vena cava complicates central line insertion. BMJ Case Rep. 2019;12:e228474. doi: 10.1136/bcr-2018-228474. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Wang Y, Egan A, Hoskote S. 995: Where is that line? An unusual case of a malpositioned central venous catheter. Crit Care Med. 2019;47:476. [Google Scholar]
- 41.Almanzar A, Danckers M. An unusual misplacement of a central venous catheter into the superior mediastinum. Crit Care Med. 2019;47:477. [Google Scholar]
- 42.Faraj J, Choudhary A, Ritter JC. Covered stenting as bail-out technique for central venous catheter malposition within the brachiocephalic trunk. Vasc Endovascular Surg. 2020;54:65–8. doi: 10.1177/1538574419873175. [DOI] [PubMed] [Google Scholar]
- 43.Varela MNL, Flores L, Patraquim R, Nuneza D, Granja C. A rare misdirected subclavian venous catheter to the neck. Case Rep Acute Med. 2020;3:53–5. [Google Scholar]
- 44.Bawa C, Dabla L, Raina JJ, Chadha H. Malpositioning of central venous catheter from Right internal jugular vein (RIJV) into ipsilateral vertebral vein: A rare phenomenon. Indian J Public Health Res Dev. 2020;11:519–22. [Google Scholar]
- 45.Keyal NK, Thapa S, Adhikari P, Yadav SK. Malposition of central venous catheter inserted under ultrasound guidance in intensive care unit: A case series. J Nepal Med Assoc. 2020;58:515–8. doi: 10.31729/jnma.4655. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Biswas I, Bhat IH, Negi SL. Correction of a malpositioned central venous catheter using pointofcare transthoracic echocardiography. Ann Card Anaesth. 2020;23:2478. doi: 10.4103/aca.ACA_141_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Puspitasari M, Sinorita H, Bagaswoto HP, Kuswadi I, Prasanto H, Wardhani Y, et al. Persistent left superior vena cava identified after hemodialysis catheter insertion: A case report. Int Med Case Rep J. 2020;13:465–9. doi: 10.2147/IMCRJ.S266858. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Izumi Y, Cammack I, Yokoyama T. Management of a malpositioned central venous catheter in the accessory hemiazygos vein. BMJ Case Rep. 2021;14:e245654. doi: 10.1136/bcr-2021-245654. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Santos A, Gaspar A, Lima A, Brás C, Campos P, Madeira C, et al. Persistence of left superior vena cava: A rare cause of hemodialysis tunneled catheter malposition. J Bras Nefrol. 2022;44:597–601. doi: 10.1590/2175-8239-JBN-2020-0263. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Chang SH, Huang HY, Hung HY, Sung WY, Chang CH. Central venous catheter penetrating the spinal canal via the spinal foramen: A case report and literature review. Ann Vasc Surg. 2022;80:393. doi: 10.1016/j.avsg.2021.09.027. e1-4. [DOI] [PubMed] [Google Scholar]
- 51.Qurashi HMS, Yari K, Saleem T, Sangillo M, Brar N. Tread carefully on this side of the road: Left-sided central venous catheter migration to the azygous vein. Chest. 2021;160:a2024. [Google Scholar]
- 52.Kohli A, Hayrabedian M, Abdulfattah O. Central venous catheter misplacement into left internal mammary vein (abstract): A case report. Am J Respir Crit Care Med. 2022;205:A2942. [Google Scholar]
- 53.Ahluwalia V, Albitar HAH, Iyer VN, Caples SM. Persistent left superior vena cava in an adult diagnosed incidentally after left internal jugular central venous catheter placement (abstract) Am J Respir Crit Care Med. 2022;205:A2939. [Google Scholar]
- 54.Rabia R, Liaqat A, Mariam M, Kanwal A, Khan ZA, Mumtaz H. A case of accidental displacement of a central venous catheter in lung parenchyma leading to hydrothorax: A case report. Int J Surg Case Rep. 2023;102:107813. doi: 10.1016/j.ijscr.2022.107813. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Lucas SJ, Bready E, Banks CA, Gaillard WF, Beck AW, Spangler E. Accidental central venous catheter cannulation into aberrant arterial anatomy requiring endovascular intervention. J Vasc Surg Cases Innov Tech. 2023;9:101164. doi: 10.1016/j.jvscit.2023.101164. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Brahmam D, Palamattam DJ, Sherif MJ. Catheter misplacement following subclavian vein catheterization under ultrasound guidance: An infrequent and unusual malposition. J Vasc Ultrasound. 2023;47:204–7. [Google Scholar]
- 57.Kohyama T, Fujimaki K, Sasamori H, Tokumine J, Moriyama K, Yorozu T. Inadvertent catheter misplacement into the subclavian artery during ultrasound-guided internal jugular venous catheterisation: A case report. JA Clin Rep. 2023;9:58. doi: 10.1186/s40981-023-00649-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Umakanthan K, Batta P, Juneja P, Vagnik H, Gerber DR, Batta A. Life saver, heart breaker- central venous catheter induced cardiac arrest in setting of acidosis. Chest. 2023;164:a2910–1. [Google Scholar]
- 59.Mcnierney D, Rayyan E, Shamsid-Deen N. Loculated pleural effusion masks brachiocephalic vein perforation via ultrasound-guided central line placement into left internal jugular vein. Chest. 2023;164:A2526–7. [Google Scholar]
- 60.Gonzalez J, Olson B, Kitcher A. When somethin’s not right, it’s wrong”: Inadvertent cannulation of the right internal mammary artery during right internal jugular central venous catheter placement. Chest. 2023;164:A5332–3. [Google Scholar]
- 61.Sanjeev G, Subha D, Divya D. Malposition of right internal jugular vein cannulation into left brachiocephalic vein. Ain-Shams J Anesthesiol. 2023;15:88. [Google Scholar]
- 62.Hajeh H, Garcia A, Mishra S, Radicic K. Malposition of the central venous catheter secondary to accessory hemiazygos vein variant. J Vasc Access. 2024;25:995–7. doi: 10.1177/11297298231154291. [DOI] [PubMed] [Google Scholar]
- 63.Gudushauri N, Lemonjava I, Martinez Manzano J, Chewaproug D. A rare case of central venous catheter malposition in the left superior intercostal vein (abstract) Am J Respir Crit Care Med. 2024;209:A3619. [Google Scholar]
- 64.Arasu M, Kayarat B, Kumar A, Malhi AS. Catheter-associated vessel perforation presenting as an occluded lumen: Lessons learned and preventive strategy. BMJ Case Rep. 2024;17:e263256. doi: 10.1136/bcr-2024-263256. [DOI] [PubMed] [Google Scholar]
- 65.Guirguis N, Eilers E, Robins J, Duvvuri P. 1043: An anomalous course of central venous catheter. Crit Care Med. 2024;52:S493. [Google Scholar]
- 66.Gerstein NS, Garcia AJ, Carbol QJ. Central venous catheter migration into pleura diagnosed by transoesophageal echocardiography. Semin Cardiothorac Vasc Anesth. 2024;28:230–4. doi: 10.1177/10892532241294186. [DOI] [PubMed] [Google Scholar]
- 67.Leguizamon R, Lara AQM. Lost in the mediastinum: Extravascular placement of a central venous catheter. Chest. 2024;166:A2845. [Google Scholar]
- 68.Ito S, Maki Y, Hatsuda N. Malpositioning of a central venous catheter in the vertebral vein through the cervical transverse foramen: A case report. Cureus. 2024;16:e76637. doi: 10.7759/cureus.76637. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 69.Feng Y, Liu Y, Xu S, Zhong H, Jiang S. On the way to the azygos vein: A road of return rather than ruined. J Cardiothorac Surg. 2024;19:259. doi: 10.1186/s13019-024-02708-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 70.Tanyıldızı B. Rare central venous catheter malpositions: A case series. Cureus. 2024;16:e63872. doi: 10.7759/cureus.63872. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71.Bukka VC, Dixit PK, Poddar N, Sunkara S, Vardhan RV, Swarnalatha G. A rare case of central venous catheter malposition – Handled by sternotomy. Indian J Kidney Dis. 2025;4:28–30. [Google Scholar]
- 72.Salam MA, Shinde V, Birru JD. Rare malposition of central venous catheter – Repositioned under ultrasound guidance. J Emerg Trauma Shock. 2025;18:201–2. doi: 10.4103/jets.jets_99_25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 73.Kasarla R, Ditchek J, Elias M, Tadepalli PS, Shoja MM. Persistent left superior vena cava: Clinical and procedural challenges. Cureus. 2025;17:e81931. doi: 10.7759/cureus.81931. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 74.Ghatak T, Singh RK, Baronia AK. Use of optimized ultrasound axis along with marked introducer needle to prevent mechanical complications of internal jugular vein catheterization. Ann Card Anaesth. 2013;16:296–8. doi: 10.4103/0971-9784.119185. [DOI] [PubMed] [Google Scholar]
- 75.Shin KW, Park S, Jo WY, Choi S, Kim YJ, Park HP, et al. Comparison of catheter malposition between left and right ultrasound-guided infraclavicular subclavian venous catheterizations: A randomised controlled trial. Crit Care Med. 2024;52:1557–66. doi: 10.1097/CCM.0000000000006368. [DOI] [PubMed] [Google Scholar]
- 76.Vouri Kokkori MN, Teklu AN, Hilber ND, Prosenz K, Mauermann E. A prospective observational quality improvement study of a two-step ultrasound protocol for guidewire confirmation during the internal jugular central venous catheter placement. Cureus. 2025;17:e92911. doi: 10.7759/cureus.92911. [DOI] [PMC free article] [PubMed] [Google Scholar]