Challenges in central venous catheter placement due to thoracic venous anomaly in an infant – A case report

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Dear Editor, Using ultrasound and portable X-rays has greatly improved the successful placement of central venous catheters (CVCs).[1] Despite the available technologies, thoracic venous anomalies increase the complication rate after CVC placement. We present the case of an infant with left-sided superior vena cava (SVC) and emphasise the techniques used to confirm the correct placement of CVC in such anomalies. A 5-month-old female child, an ex-premie with a gestational age of 32 weeks, presented with spontaneous caecal perforation in the neonatal period and had undergone ileostomy on day 3 of life. The infant weighed 3 kg on present admission and was scheduled for ileostomy closure. Given the need for long-term antibiotics, ultrasound-guided placement of central venous access was attempted in the right internal jugular vein (IJV). The guidewire was passed through, and some resistance was felt, after which the guidewire was withdrawn without advancing it further. Since the guidewire passage offered resistance during repeated attempts, cannulation of the right subclavian vein was attempted through an infraclavicular approach. After the guidewire was passed, an X-ray showed the guidewire passing along the left cardiac border [Figure 1a]. Since the position of the guidewire was not satisfactory and we suspected arterial placement, the procedure was abandoned. After 2 days, the child was again posted for central venous access, and with ultrasound guidance, the right IJV was approached. The guidewire passed through, but resistance was felt at the clavicle level. The subclavian vein was then targeted with a supraclavicular approach under ultrasound guidance. The guidewire passed through easily; ectopics were noted in the electrocardiogram. The guidewire was again noted to pass to the left side, which was confirmed with an X-ray. So, a provisional diagnosis of persistent left SVC was made. The arterial placement of the guidewire before dilating the vein was ruled out by the colour of blood from the introducer needle, backflow of blood through the needle and later after removal of guidewire by analysing the waveform tracing via needle, which showed central venous pressure (CVP) tracing. A transthoracic echocardiogram was performed simultaneously with the injection of saline through the needle, and the passage of agitated saline through the right atrium to the right ventricle was confirmed in the apical view. A blood gas analysis confirmed the venous placement of the needle. The venous catheter was placed after dilating the vein [Figure 1b]. After extubation, the child was shifted to the postoperative ward. A transthoracic echocardiogram was done, which confirmed the presence of persistent left-sided SVC in the roofed coronary sinus.Figure 1: (a) Chest X-ray shows the guidewire passing along the left cardiac border. (b) Final position of the central venous catheterA left SVC, the most common congenital venous anomaly in the chest, drains into the coronary sinus.[2] The guidewire placement is easily mistaken for arterial when encountering an unexpected venous anomaly. When suspecting a misplacement of the guidewire, it is crucial to confirm the venous placement of the needle before dilating the vein or abandoning the procedure. Obtaining a CVP waveform by connecting a pressure transducer to the introducer needle, blood gas analysis to confirm the venous placement and agitated saline injection rapidly in the catheter while simultaneously viewing it pass from the right atrium to the right ventricle using transthoracic echocardiography[3] helped us to confirm venous placement. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents consented to images of the infant and other clinical information to be reported in the journal. The parents understand that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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