Cephalad Positioning of Internal Jugular Vein Central Venous Catheter – No Need to Worry!

Respected Editor, Central venous catheter (CVC) insertion is usually performed in operating rooms and intensive care units (ICU) for elective and emergency reasons. We write about a rare but easy to tackle complication of these CVC insertions. The CVC insertion was done for a 65-year-old lady with respiratory failure in our ICU. After local anesthesia, 18-gauge needle was inserted at sternocleidomastoid apex along medial border of lateral head about 45 degree to skin. After aspiration of venous blood from the internal jugular vein (IJV), J-shaped guidewire was introduced through Seldinger technique. Seven French triple lumen catheter was advanced through guidewire. Free flow was ensured from all ports and catheter sutured. Portable chest X-ray (CXR) anteroposterior view postprocedure did not show CVC [Figure 1]; however, backflow of blood in the catheter was good. A neck and CXR anteroposterior view was done revealed sharply bent CVC in cephalad direction in the right IJV [Figure 2]. We removed this catheter and inserted another CVC on the same side and reconfirmed correct positioning with CXR anteroposterior view [Figure 3].Figure 1: Postcentral venous catheter insertion chest X-ray anteroposterior view not showing tip of central venous catheterFigure 2: Neck and chest X-ray anteroposterior view showing bending of central venous catheter in cephalad directionFigure 3: Chest X-ray anteroposterior confirming correct position of central venous catheter in right internal jugular vein after repositioningCVC malposition is rarely seen with 5.3% rates in the IJV.[1] There are reports showing positioning of CVC through many routes especially right subclavian vein.[2] However, cephalad positioning is relatively rare owing to straight course of right IJV to right atrium. Theories explaining this rare occurrence are anatomical variation of venous system, acute angle of introducing needle, and bending of J-wire along vessel.[3] There was no anatomical variation in our case as a second attempt positioned the CVC correctly. Hence, the cephalad positioning must have occurred due to rare bending of J wire along venous wall. The intensivist should remember that though a rare complication, there is no need to worry even if this problem occurs. The catheter just needs repositioning correctly. A postprocedure X-ray should always be done to identify a malposition. CVC insertion done under ultrasound guidance may avoid this problem. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.