Accidental vertebral vein catheterization during internal jugular vein cannulation – A rare complication

Madam,

A 65-year-old male was admitted to our ICU with acute kidney injury and sepsis with a hemodialysis (HD) catheter in the right internal jugular vein (IJV). A decision was made to remove the existing HD catheter to eliminate further sources of sepsis. It was decided to cannulate the left IJV for further ICU management.

Using the landmark technique, with an anterior approach, a venous puncture was successfully established on the second attempt and the guidewire was threaded without any difficulty. Free return of venous blood was achieved through all three ports and it was assumed that the catheter tip was correctly located in the superior vena cava (SVC) and was confirmed with a chest X-ray [Figure 1].

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Figure 1

Chest X-ray showing the central venous catheter after insertion

The patient developed hoarseness of voice over the next 2 days for which ENT reference was sought and an MRI of the neck was advised. The MRI revealed left vocal cord palsy and an incidental finding of the central venous catheter (CVC) coursing through the left foramen transversarium in the vertebral vein at C7 vertebral level and traveling to the brachiocephalic vein [Figure 2]. The CVC was then promptly removed to prevent further complications. Any undue resistance was not felt during removal of the catheter and there was no hematoma formation or neurological complication. The patients' hoarseness of voice gradually improved over the next 3 weeks. He had no hoarseness or neurological deficit during his follow-up in out patient department 1 month later.

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Figure 2

MRI images showing the CVC coursing through the left foramen transversarium in the vertebral vein at C7 vertebral level and traveling to the brachiocephalic vein

Malposition of the catheter is a relatively common complication (5.01%), which results in the malfunction of catheters.[1] Malposition of a CVC means the catheter lies outside of the SVC, whose tip does not lie in the “ideal” position. It is currently recommended that the tip of CVC is positioned at the level of mid-lower SVC to cavo-atrial junction.[2] Misplaced catheters have been reported in almost every possible anatomical position – the arterial system, mediastinum, pleura, pericardium, trachea, esophagus, subarachnoid space, and other aberrant sites. Catheter malposition is usually associated with serious consequences, whereas some of them remain unrecognized resulting in incorrect diagnosis and delayed treatment. The misdirection of the CVC into a smaller tributary is still relatively rare and underreported.

Notable veins surrounding the IJV are the vertebral vein, the external jugular vein, the anterior jugular vein, and the thyroid vein. The only vein, passing posterior to the IJV, is the vertebral vein. In the sixth upper vertebrae, the transverse foramen gives passage to the vertebral artery and vein, whereas the seventh gives passage only to the vertebral vein.[3] Puncture of the vertebral artery adjacent to the vertebra vein is quite common, whereas puncture of the vertebral vein is quite rare, but it does happen.[4] As it lies posterior to the IJV, it is possible to pass the catheter into the vertebral vein if head is rotated excessively to more than 30° or if needle is inserted to more than 4-cm depth. It has been reported that the distance from the skin to the IJV rarely exceeds 3.5 cm if a 30° angulation is used.[5]

The misinsertion of the catheter into other veins, unlike arterial cannulation, cannot be easily distinguished as there is no difference in the color and pulsation of the blood flow. Catheter misplacement into a small vein increases the possibility of complications, including trapping of the catheter, thrombosis, endothelial damage, leakage of infused fluid, and inability to deliver hyperosmolar solutions.[4] Being a deep vein, giving external pressure on removal is difficult and may lead to bleeding or hematoma formation, arteriovenous fistula, or infarction of draining tissues. Winston et al. have described a case of brachial plexopathy following the infusion of chemotherapeutic agents through the catheter which migrated to the vertebral vein.[6] If the CVC is found to have been misplaced in a small vein, as in this case, the reinsertion of a new CVC in a different proper vein seems to be appropriate despite free regurgitated blood flow from the misplaced CVC.

Chest X-rays are considered the gold standard in confirming placement, but being a 2D image, it may not be possible to distinguish true SVC placement or placement in a vein anterior or posterior to SVC. Thus, ultrasonography (USG) is recommended to insert CVCs to prevent such complications. Not only is it useful to visualize the vein before puncture, but the longitudinal view helps to ascertain position of the guide wire in the central vein. Practice Guidelines for Central Venous Access by the American Society of Anesthesiologists (ASA) Task Force state that “The consultants and ASA members agree that static ultrasound imaging should be used in elective situations for prepuncture identification of anatomy and vessel localization when the IJV is selected for cannulation; they are equivocal regarding whether static ultrasound imaging should be used when the subclavian vein is selected.”[7] The usefulness of the USG to prevent such complications cannot be ignored. Increased awareness about identifying these complications in a timely manner can make this common procedure relatively safe.

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

There are no conflicts of interest.

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