A 66 year old man with underlying chronic kidney disease, presumed secondary to hypertension, presented to the emergency room with one-week history of weakness, fatigue and poor oral intake. The patient was hypotensive (systolic blood pressure of 60 mmHg) and had severe azotemia (serum creatinine of 4.9 mg/dl form baseline of 1.7 mg/dl). Septic shock, methicillin-sensitive Staphylococcus aureus bacteremia and oliguric acute kidney injury were diagnosed. The patient was adequately resuscitated with intravenous fluids, vasopressors and broad-spectrum antibiotics, later narrowed to cefazolin. The source of infection was unclear after broad investigation of body fluids and imaging studies. Despite an initial transient clinical improvement, the patient remained in shock with high vasopressor requirements, became anuric and developed acute mental status changes. As a consequence, the decision to start the patient on CRRT was made. We inserted a 13.5 French diameter temporary dual-lumen Quinton-Mahurkar catheter (Covidien, Inc.) into the left IJV under US guidance. Although the right IJ is preferred, the intensive care unit team had already inserted a triple-lumen central venous catheter in this site for hemodynamic monitoring and fluid and medication administration. The initial puncture with an 18-gauge needle into the left IJV using real-time US guidance was successful with non-pulsatile back-flow and venous (dark red) blood appearance. Subsequently, after removal of the ultrasound transducer, the rest of the procedure was performed without any resistance to advancing the guidewire and catheter by the Seldinger technique []. Good flow of dark red blood was obtained from both catheter lumens. However, the routine post-cannulation chest X-ray (Figure ) showed that the tip of the catheter was not crossing the midline to the right side and the tip appeared to be lying over the aortic arch suggesting inadvertent carotid artery cannulation. We then obtained blood gas analysis from the catheter which showed: pH of 7.34, partial pressure of oxygen (PO2) of 140 mmHg and partial pressure of carbon dioxide (PCO2) of 22 mmHg, also suggestive of arterial cannulation. The vascular surgery team was emergently consulted. A pressure transducer was attached to the catheter and showed venous wave forms. To definitively determine the location of the catheter, a Computed Tomography Angiography (CTA) of the head and neck was obtained. The CTA showed the Quinton-Mahurkar catheter extending into the left IJV and subsequently descending to terminate in an anomalous left upper lobe pulmonary vein, just inferior to its anomalous insertion in the left brachiocephalic (innominate) vein (Figures A and B). Interestingly, manipulation of the catheter under fluoroscopy by interventional radiology showed that the left brachiocephalic (innominate) vein failed to cross the midline to empty into the right atrium, confirming the venous anomaly. The catheter was therefore removed and a new similar catheter was placed in the right IJV. CRRT was then initiated and continued uneventfully until the patient’s critical condition improved.
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.