Delayed superior vena cava perforation: a rare and life-threatening case report

Central venous catheterization (CVC) is routinely performed in emergency and critical care settings and is generally considered safe, particularly when ultrasound guidance is used. However, rare and potentially fatal delayed complications may still occur. Delayed perforation of the superior vena cava (SVC) is exceedingly uncommon and may be under-recognized, especially following right-sided catheterization. A 63-year-old woman underwent ultrasound-guided right subclavian central venous catheterization prior to emergency laparotomy for small bowel obstruction. The procedure was uneventful. Blood return was confirmed in all lumens, and post-procedure chest radiography demonstrated appropriate catheter tip position within the lower SVC. Thirty hours postoperatively, she developed acute respiratory distress and hemodynamic instability. Imaging revealed a massive right-sided pleural effusion. Intercostal drainage yielded approximately 2.5 L of clear, low-protein fluid with biochemical features consistent with hydrothorax. Pleural fluid pH measured using a blood gas analyzer was 6.2. No alternative etiology for the rapidly accumulating effusion was identified. The catheter was immediately removed for presumed catheter-related vascular perforation. Despite aggressive supportive care, the patient developed refractory shock with multiorgan dysfunction and died on postoperative day 12. This case highlights delayed SVC perforation as a rare but catastrophic complication of central venous catheterization, even when performed under ultrasound guidance using right-sided access. Clinicians must maintain a high index of suspicion for catheter-related vascular injury in patients who develop unexplained pleural effusion or circulatory compromise after recent central venous access.