Superior vena cava perforation after central venous catheterization: the diagnostic role of progressive CVP elevation in occult injury-a case report

Central venous catheter (CVC) placement is crucial for perioperative hemodynamic management in anesthesia, and superior vena cava (SVC) injury is a rare but life-threatening complication. A 63-year-old woman underwent surgery for hepatic hemangioma. During preoperative CVC placement via the left internal jugular vein (LIJV), mechanical injury resulted in SVC perforation and subsequent hemorrhage. Immediately after catheter placement, aspiration and flushing of both lumens were performed. Blood return was unobstructed with no abnormal resistance, and baseline central venous pressure (CVP) was recorded at approximately 5 cm H₂O. As CVP progressively and persistently increased with hemodynamic changes, thoracic ultrasound revealed right-sided pleural effusion. Thoracoscopy confirmed extrapericardial SVC injury, which may have resulted from either direct trauma by the guidewire at the angulated vascular junctions, or initial guidewire-induced submucosal injury that was subsequently disrupted by catheter advancement. This case highlights a potential risk of SVC injury associated with the LIJV approach, particularly in patients with complex anatomy or prior catheterizations. Ultrasound monitoring should be optimized during catheter placement. Abnormally elevated CVP after catheter placement warrants high vigilance and prompt thoracic/pericardial evaluation.