A 56-year-old woman with a medical history of multiple sclerosis, quadriplegia, sacral decubitus ulcer, chronic osteomyelitis, chronic deep vein thrombosis (DVT), chronic steroids use, and chronic Foley catheter use presented to the emergency department with severe sepsis due to multiple potential sources including urinary tract infection, soft tissue infection, or osteomyelitis. Vital signs were significant for blood pressure of 85/59 mmHg, heart rate of 63 beats per minute, respiratory rate of 33 breaths per minute, and oxygen saturation of 83% on room air. At the beginning, patient declined intubation so she was placed on 100% oxygen via nonrebreather mask. Arterial blood gas (ABG) on 100% oxygen was 7.29/49/55. Initial chest X-ray (CXR) showed small bilateral pleural effusions with suspected left lower lobe infiltrate. Despite intravenous (IV) fluid resuscitation, broad spectrum IV antibiotics, and stress dose steroids, patient became more hypotensive and IV norepinephrine was started through a right femoral CVL that was placed in the emergency department. Patient was started on heparin drip for suspected pulmonary embolism that was stopped later due to large bleeding from femoral line site and consideration of pneumonia as the cause of hypoxemia. Patient agreed later to be intubated and decision was made to remove femoral line and place a 7.0 Fr triple-lumen CVL through the left internal jugular vein (IJ) over a guidewire and under full ultrasound (U/S) guidance, which was placed easily with no complications. A CXR was obtained to confirm placement which showed that the catheter tip did not cross the midline; instead, it was extending towards the left of the aortic arch probably into an anomalous vein as read by the radiologists (). Ultrasound examination of the neck showed proper catheter placement in the left IJ. A pressure transducer was connected which showed a venous wave form with a pressure of 10 mmHg. ABG obtained from the catheter on continuous mechanical ventilation (FiO2 = 50%, positive end expiratory pressure = 5 CM H2O) showed PaO2 of 102 mmHg compared to 79 mmHg from radial arterial site. A transthoracic echocardiography, which was done to evaluate cardiac function, did not show evidence of atrial septal defect or any other cardiac malformation. Fluoroscopy study was used to place a left peripherally inserted central catheter (PICC) and to confirm the location of the left IJ CVL which demonstrated contrast injection in an anomalous pulmonary vein (). We concluded that the patient has partial anomalous pulmonary venous return (PAPVR) and the left IJ CVL was removed. The PICC line was used instead for central access.
A 65-yr-old woman with an underlying chronic kidney disease was presented to the emergency room (ER) with uremia because of sepsis accompanied by oliguria and severe metabolic acidosis on August 29, 2008. To begin emergency HD, we attempted to insert a 7.5 French (Fr) catheter into the right IJV under ultrasound guidance. The initial puncture with an 18-gauge needle into the right IJV using real-time US guidance by the short-axis method was successful with no pulsatile arterial back flow. Thereafter, the rest of the procedure with removal of the ultrasound transducer was performed without any resistance to advancing the guide wire and HD catheter by the Seldinger technique. No immediate complications such as rapidly expanding hematoma, pain, dyspnea, shock, or signs of neurologic deficits were noticed during insertion of the THC. However, a routine post-cannulation chest X-ray suggested that the catheter tip had been misplaced into the right subclavian artery (SCA) (), and subsequent computed tomographic (CT) angiography with contrast enhancement revealed that the catheter had indeed passed through the right IJV and been misplaced into the right SCA (). We assumed that the puncture needle had initially been inserted into the right IJV, but had been unintentionally advanced into the right SCA after the absence of arterial back flow had been established and before inserting the guide wire.\nThe HD catheter into the right SCA was left in place without an immediate catheter removal and direct external compression, because of the uncontrollable arterial bleeding that might result from application of the pull/pressure technique. Following consultation with a vascular surgeon, the surgical exploration in the operating room revealed that the HD catheter had transected the right IJV and the right SCA. The catheter was removed and the SCA injury was surgically repaired without complications. An angiogram under real-time fluoroscopy revealed no further bleeding or fistula between right IJV and right SCA (). Also, subsequent evaluation of neurological status following open surgical repair and angiography for any intra-arterial catheter-related thrombi or emboli, revealed no neurologic deficit. The patient underwent an uneventful hospital course with antibiotic therapy and intermittent hemodialysis through the THC into the right femoral vein, as required. HD was stopped on the 12th hospital day.