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.
This case is being reported after obtaining written consent from the patient.\nA 38-year-old woman was admitted with per rectal bleeding and abdominal pain. She had a history of Crohn's disease. She had undergone four previous bowel resections during the last 15 years. Total parenteral nutrition was planned through a CV catheter, and a referral was made to the on-call anesthesia resident for gaining CV access. Preprocedural examination showed normal vital signs. The patient's coagulation profile was normal. Patient had been receiving azathioprine, zopiclone, tramadol, and amitriptyline. She had history of the previous catheterization of both the right and left internal jugular veins during the last 5 years.\nWith noninvasive monitoring of blood pressure and pulse oximetry established, right IJV catheterization was attempted in the High Dependency Unit (HDU) using a triple lumen catheter (16 cm 7.5 Fr Multicath 3 L Expert/VYGON GmbH and Co., Germany). Due to technical reasons, ultrasound (US) could not be used, and the right IJV was accessed by the standard landmark approach at the apex of two heads of sternomastoids using the Seldinger's technique. The right IJV was first accessed with a 22G finder needle. The vein was then cannulated with the 70 mm larger needle and nonpulsatile dark blood was aspirated freely. The J-tip guide-wire was then passed successfully through the needle, and the dilator was advanced without any resistance over the guide-wire and was then removed. The catheter was threaded over the guide-wire up to the 7 cm mark, when some resistance was encountered. Further attempts to thread the catheter were abandoned as aspiration revealed bright red and pulsating blood giving rise to suspicions of an arterial placement. Immediately, the catheter along with the guide-wire was removed, and firm pressure applied over the site. 4 h later, IJV cannulation was performed on the same side by identifying the IJV with a finder needle and then successfully inserting the catheter without any resistance. Dark venous blood was aspirated freely from all the three ports of the catheter. A chest X-ray was taken, and satisfactory position of the catheter tip was confirmed. 2 h later, the patient woke up from sleep complaining of pain from the right shoulder to the elbow and also a dead feeling in the right arm. Physical examination revealed a cold and tender right arm, with a delayed capillary refill and absent radial, brachial and axillary pulses on the right side. Doppler signals were also negative for axillary, brachial and radial pulsations on this side. The radial and brachial pulsations on the other side were normal. A partial or complete arterial occlusion due to spasm or thrombosis was suspected, and the patient was transferred to the regional vascular center for further management. At the regional center, the IJV catheter was removed and anticoagulation by low molecular weight heparin was commenced. Ascending aortography with selective catheterization of the brachiocephalic trunk was performed subsequently, which confirmed an intraluminal thrombus in the proximal right SCA []. The patient was started on a heparin infusion. Thrombolysis was not thought to be appropriate in view of the risk of bleeding at the CV access site, active rectal bleeding and Crohn's disease. Subsequently, right SCA thrombectomy with graft was performed under general anesthesia. A Fogarty catheter was passed easily, and a large volume of clot extracted. Postoperatively positive Doppler signals for arterial flow were obtained. She was transferred to the ward after 3 days of monitoring in the intensive care unit and was discharged home a week after surgery.