Delayed innominate vein perforation and massive hemothorax following left-sided PICC placement

Rationale: Peripherally inserted central catheters are common venous access devices; however, they can cause rare and life-threatening mechanical complications. Delayed vascular perforations often present with nonspecific findings, making early diagnosis challenging. Herein, we report a case of delayed innominate vein perforation, highlighting the importance of careful interpretation of serial chest radiographs. Patient concerns: An 82-year-old woman with acute ischemic stroke underwent bedside left-arm placement of a peripherally inserted central catheter. The initial postprocedural chest radiograph showed a catheter tip at the fifth thoracic vertebra with subtle proximal tortuosity; the tip appeared obliquely oriented relative to the expected central venous axis. The next day, the catheter tip had moved caudally, and the tortuosity resolved, which was misinterpreted as an improved position. Five days after the procedure, chest radiography revealed a massive right-sided pleural effusion. Diagnoses: Computed tomography confirmed that the delayed perforation of the innominate vein allowed the catheter to migrate into the mediastinum, resulting in a massive hemothorax. Interventions: The patient underwent urgent chest tube insertion followed by successful surgical repair of the perforated vein. Outcomes: The patient recovered without further complications and was discharged in a stable condition. Lessons: This case highlights a critical diagnostic paradox: the resolution of catheter tortuosity on follow-up chest radiography is normally a positive sign, indicating that the catheter tip had exited the vessel and released mechanical tension. Clinicians must interpret radiographic changes in catheter position with great caution and verify findings with functional assessments.