B50-22 Mediastinal Malposition: A Rare Complication of Central Venous Catheter Placement

Abstract Introduction Central venous catheter placement is a very common procedure, but it is not without risk of complications. The incidence of catheter misplacement is approximately 3%-4% for both subclavian and internal jugular vein access procedures. Case Presentation A 41-year-old male with a history of intravenous drug use presented from an outside hospital with concern of internal jugular (IJ) venous catheter malpositioning. Patient initially presented to outside hospital for left arm erythema and concern for sepsis. Central line access was obtained due to inability to obtain peripheral access. Chest X-ray at outside hospital showed kinking of the central line and chest CT angiography showed extravasation of contrast into the mediastinum. Patient was then transferred to a Level 1 tertiary care center where CT chest demonstrated “Right IJ central venous catheter with probable perforation of the right brachiocephalic vein and extravasation of contrast into the mediastinum and pleural space. The tip of the catheter appears to be in the mediastinum.” Cardiothoracic surgery and vascular surgery were consulted and recommended prompt removal of the central line per interventional radiology (IR). IR gained access to the right internal jugular vein via two access points—the right common femoral vein and an existing right brachial vein peripheral catheter. Digital subtraction angiography and balloon angioplasty catheter were utilized to identify and balloon tamponade the site of vein injury. The mispositioned central line was then removed over guidewire. With the angioplasty balloon inflated, digital subtraction angiography from the right upper extremity vascular sheath confirmed no contrast extravasation within the mediastinum. The angioplasty balloon was deflated and repeat venography was performed documenting no contrast extravasation into the mediastinum. Throughout the procedure, the patient remained hemodynamically stable and had no postprocedural complications. Discussion Central line misplacement in the mediastinum is a life-threatening complication that can result in hydro/hemomediastinum, mediastinitis and other infections. There is a high level of concern in removing the misplaced catheter at bedside considering there may be a tamponade effect preventing active hemorrhage. Timely removal of a mispositioned central line is imperative to mitigate hemodynamic instability and clinical decompensation. Here we identify a safe and minimally invasive approach to remove a central venous catheter malpositioned in the mediastinum with IR guidance. This abstract is funded by: none