Left Jugular Approach Predisposes to Malposition of Hemodialysis Catheter Into the Azygos Vein

Malposition of central venous catheters (CVCs) into the azygos vein is an uncommon but significant complication. The left internal jugular vein (IJV) approach is a risk factor for this malposition. To our knowledge, only two published cases of azygos malposition of left jugular CVC had corresponding computed tomography (CT) images. This report uses novel CT reformats to illustrate why left IJV access may predispose to azygos catheterization. We present the case of a 68-year-old male with end-stage renal failure requiring hemodialysis (HD). Due to right IJV stenosis, a tunneled HD catheter was inserted via the left IJV. A post-procedure chest radiograph revealed the catheter tip malpositioned in the azygos vein, exhibiting a characteristic "fishhook" appearance, which CT subsequently confirmed. The catheter was successfully repositioned. CT reformats provided a clear anatomical explanation, demonstrating how the oblique trajectory of the left brachiocephalic vein relative to the superior vena cava and the posterior location of the azygos ostium predisposed the catheter to enter the azygos vein. This case underscores the importance of recognizing radiographic signs and understanding the anatomical challenges associated with a left-sided CVC approach. The left IJV approach for CVC placement carries an inherent risk of azygos malposition. Vigilant radiographic assessment is crucial, and the use of routine fluoroscopy should be strongly considered for this approach.