Malpositioned central venous catheter: Step wise approach to avoid, identify and manage

Vivek Bangarau

Department of Anaesthesiology and Critical Care, Kauvery Hospital, Salem



Cannulating a Central venous catheter (CVC) is almost always done promptly and unhesitatingly in critically ill patients to provide effective critical care. Although ultrasonography (USG) guidance has been appreciated to improve insertion site accuracy, inadvertent complications still exist. Malposition of CVC tip is a most common complication, with incidence of 3 to 15% [1]. Malposition is defined as CVC tip placement in a vein other than superior vena cava (SVC) or right atrium. The fear of CVC in an abnormal position leads to dilemma in management, unnecessary investigations and removal of CVC [2]. For its rostral location and straight course, right internal jugular vein (IJV) is most preferred vein to secure CVC, and generally considered easily accessible compared to subclavian vein (SCV). However, malposition also occurs with IJV cannulation, and at times, clinical situation like head injury may demand SCV cannulation, where chance of malposition is much higher 9.1% [3]. This case report describes a misplaced CVC from right SCV to right IJV, along with applied anatomy of central veins, step wise approach to avoid, identify and manage CVC malposition.

Case Presentation

A 62-year-aged female patient was admitted to ICU with a diagnosis of left superior cerebellar artery aneurysm. Considering her need for coiling, prolonged hospitalisation and fluid management, we planned to insert a central venous line. With USG guidance a CVC was placed into the right subclavian vein by infraclavicular approach using Sledinger technique. Overall procedure was uneventful and good back flow of blood was confirmed from all the three lumens. Post procedural chest x-ray was done, which showed acute angulation of CVC at the junction of SCV and IJV and catheter tip misplaced in right IJV. Considering CVC functionality and patient’s stable condition, we continued with the same central line for the further treatment.


Fig. 1. Acute angulation of CVC at the junction of SCV and IJV and catheter tip misplaced in right IJV.


Right SCV is preferred route of central line cannulation in neurosurgical patients, where malposition is a fairly common complication [4]. Though malposition of CVC can be expected in any great vein, right side subclavian vein has been associated with high incidence of malposition [3]. There are case reports describing malposition of CVC as simple as rotation and upward direction of CVC intraluminally in great veins to inadvertent placement of CVC in persistent left SCV (PLSCV), intrathoracic vein and even in left atrium [5-6].

Anatomical variation like duplication, fenestration or lateral branching of IJV, PLSCV can have major impact while attempting to cannulate cvc in these patients [7-9]. Hence it is extremely important to perform a Scot scan and trace the entire course of the great veins as much as possible before attempting for cannulation. This can help us in identifying anomalous vein, narrowing due to thrombus or valve, acute angulation of venous course and its surrounding structure, there by preventing perforation and proper placement of catheter.

Jasper M. Smit et al evaluated diagnostic accuracy of USG to detect central venous catheter malposition and pneumothorax. They demonstrated that USG can detect CVC malposition with moderate sensitivity (70%) and high specificity(99%) [10].

They designed 3 staged USG examination.

  1. Bilateral ultrasound examination of the internal jugular vein and subclavian vein
  2. Flushing catheter with 5ml of agitated saline, and examination of the right atrium and ventricle. They considered CVC malpositioned if microbubbles appeared after 2 s or was not seen at all.
  3. Bedside Lung Ultrasound in Emergency, to identify LUNG POINT and pneumothorax.

Literatures also suggest that direction of insertion needle bevel and J-tip of guide wire can influence guide wire and subsequently catheter path. Authors suggest caudal direction of bevel and J-tip can reduce chance of malposition and hematoma formation [11,12].

Further we recommend performing a scan of great veins after inserting guide wire to identify their position, whereby malposition of guide wire, perforation of vein can be identified and dilation can be avoided. Michel B Stone et al described a case in which guide wire resistance was encountered and real-time ultrasound showed guidewire indenting the posterior wall of ijv. Under usg visualization j wire was rotated 180 degrees, following which guidewire was negotiated freely [13]. If guide wire is found in IJV while approaching through SCV, removing and repositioning guide wire with ipsilateral head turning and supraclavicular pressure can narrow IJV lumen and reduce the risk of inadvertent IJV cannulation from 9.1 to 3.6% [14]. Further, if resistance is felt anytime during the procedure, attempt should be made to locate the problematic site with USG to troubleshoot the problem or it’s safe to redo instead of negotiating guide wire or catheter blindly. When malposition is suspected due to lack of free back flow, abnormal waveform further work up should be made to identify catheter tip. If it is identified in abnormal location or extraluminally, cross consultation should be sort with radiologist and vascular surgeon rather than removing it blindly which may end up with devastating complication.


In order to avoid complication during CVC cannulation, the performer should have a clear knowledge of the great veins and a decent experience of using USG. The step wise approach to avoid, identify and manage the complications are

  1. Performing a scout scan, rule out anomalous vein and select appropriate vein based on patient.
  2. Procedure to be performed with bevel and j tip in caudal direction.
  3. Avoiding forceful negotiations.
  4. USG confirmation of guide wire in intended location.
  5. Real time USG guided correction of guide wire in case of malposition.
  6. Not all malpositioned catheter has to be replaced. If functionally intact and fulfils patient’s need, it can be left in place.
  7. Performing a lung scan where pneumothorax is suspected.
  8. Cross consultation with radiologist and vascular surgeon in case of complication.


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