Misplacement of a Left Internal Jugular Central Venous Catheter in the Pericardiophrenic Vein

This chest X-ray (CXR) image [Figure 1] was obtained after placing a left internal jugular (IJ) central venous catheter (CVC). The CVC was inserted easily under ultrasound guidance using a modified Seldinger technique, with pressure transduction confirming venous placement. However, the CXR revealed that the catheter did not cross the midline and instead took an abnormal lateral course. It also did not follow the course of the aorta. A blood gas sample was then drawn from the catheter confirming venous placement. A CT scan was then performed and revealed that the CVC terminated in the pericardiophrenic vein [Figure 2]. This abnormal placement was likely due to an occluded left brachiocephalic vein in our patient, which prevented the CVC from crossing the midline [Figure 3].Figure 1: Bedside CXR showing a left IJ CVC not crossing the midline and instead taking an abnormal lateral course (white arrows) with the tip projecting over the left heart. A CT confirmed the CVC to be placed in the left pericardiophrenic veinFigure 2: CT with contrast. The left image is an axial CT plane with a white arrow pointing to the CVC that appears as a filling defect within a dilated pericardiophrenic vein. The right image is a coronal CT plane with a white arrow also pointing to the dilated pericardiophrenic veinFigure 3: CT with contrast. The left image is an axial CT plane with a white arrow pointing to the chronically occluded left brachiocephalic vein that does not opacify with contrast. The right image is a coronal CT plane with a white arrow also pointing to the chronically occluded left brachiocephalic veinThe correct location for a CVC tip should be at the superior vena cava (SVC)—right atrial junction or the upper right atrium, distal to the last venous valve located at the junction of IJ and subclavian vein.[1,2] The right IJ is generally preferred over the left due to its straight path to the SVC and the higher risk of malposition associated with left-sided cannulation. This increased risk is likely due to the longer course and more oblique path of the left brachiocephalic vein, as well as the presence of small tributaries in the area.[3] Potential venous locations for a misplaced left IJ CVC tip that does not cross the midline include the left pericardiophrenic vein, left subclavian vein, left internal mammary vein, left superior intercostal vein, the accessory hemiazygos vein, or persistent left SVC in patients with abnormal anatomy.[2,3] For a left IJ CVC that crosses the midline or a right IJ CVC, potential atypical venous locations also include the right internal mammary vein, right pericardiophrenic vein, and azygos vein[2,3] [Figure 4]. Arterial and extravascular placement, such as in the pericardial and pleural spaces, are also potential sites for CVC misplacement.[1,3]Figure 4: Potential sites for IJ misplacement. 1: left pericardiophrenic vein, 2: left internal mammary vein, 3: left superior intercostal vein, 4: accessory hemiazygos vein through potential connection with the superior intercostal vein,[ 2 ] 5: persistent left SVC in some patients with abnormal anatomy. Left SVC typically regresses during fetal development. It drains the left jugular and subclavian veins to the coronary sinus,[ 2 ] 6: right internal mammary vein, 7: right pericardiophrenic vein and 8: azygos veinThe pericardiophrenic veins carry venous drainage from the pericardium, pleura, and diaphragm and are not a suitable location for a CVC because of their small size and the increased risk of thrombosis.[2] Consequently, we removed the CVC once adequate venous access was established. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.