Rare Malposition of Central Venous Catheter – Repositioned Under Ultrasound Guidance

Dear Editor, Central venous catheters (CVCs) are indispensable tools in emergency and critical care for fluid administration, vasopressor support, renal replacement therapy, and other advanced interventions. The right internal jugular vein (IJV) is often the preferred access route due to its anatomical proximity and lower risk of complications.[1,2] Nevertheless, malpositioning can occur despite best practices. This letter discusses a rare malposition of CVC with an acute angulation into the right subclavian vein from a right IJV approach, which was successfully repositioned using ultrasound guidance and a sterile guidewire – thus avoiding catheter reinsertion or a second venipuncture. A middle-aged female presented to the emergency department in septic shock, with a right IJV CVC in situ, but two lumens failed to demonstrate backflow. The chest X-ray revealed an unusual course: the catheter originated in the right IJV and acutely angulated into the right subclavian vein [Figure 1a]. Recognizing the malposition, a sterile guidewire was inserted under ultrasonographic visualization, and the catheter was repositioned. A contrast-enhanced ultrasound (CEUS) confirmed correct placement, further validated by a follow-up chest radiograph.Figure 1: (a) Central venous catheter originated in the right internal jugular vein and acutely angulated into the right subclavian vein. (b) The guidewire’s tip tracked in real time at the cavoatrial junction, confirming correct positioning. (c) Visualization of microbubbles in the right atriumFor optimal visualization, a high-frequency linear (5–12 MHz) probe was used. The guidewire’s progression was tracked in real time at the cavoatrial junction [Figure 1b] and confirmed using CEUS, which involves injecting a saline–air mixture through the catheter to observe the bubble transit within the heart. Correct catheter placement results in immediate visualization of microbubbles in the right atrium [Figure 1c]; delayed or turbulent appearance indicates malposition, prompting repositioning.[3] This case also emphasizes the importance of operator vigilance. Though malposition into the IJV from subclavian access is reported, the reverse – where a right IJV catheter enters the right subclavian vein – is extremely rare and, to our knowledge, undocumented. Factors such as anatomical variations, guidewire manipulation errors, vessel tortuosity, and angulated branches may contribute to such misdirection.[4,5] Clinicians must maintain a high index of suspicion for malposition in cases with dysfunctional lumens or unexpected resistance. Resistance during advancement should prompt immediate reevaluation through ultrasound or fluoroscopic assistance.[4] The letter demonstrates that ultrasound can be employed not just for initial CVC insertion but also for real-time repositioning. In conclusion, this rare instance of a right IJV catheter misdirected into the right subclavian vein highlights both an unusual complication and a minimally invasive correction technique. This letter supports the integration of ultrasound not only for CVC insertion but also as verification protocols to enhance patient safety and procedural success. Thanking You, Research quality and ethics statement The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.