Discussion
Central venous catheters (CVCs) are frequently associated with
complications, notably
when placed on the patient’s left side. 1-3 Abdelkefi
et al. 3 reported that the catheter tip is often
positioned so that it is in direct contact with the lateral wall of the
SVC where the innominate vein is at a right angle to the SVC. Several
mechanisms of vascular injury due to insertion of CVCs have been
reported, including (1) direct trauma during insertion of the guide-wire
or catheter, (2) the movement of the catheter tip after insertion due to
changes in arm, neck and/or head position, (3) continuous contact of the
catheter tip with vascular wall associated with the heartbeat, and (4)
the vascular endothelial damage due to infusion of a hyperosmolar
solution through the distal port.4-6
In this case, we speculate that the catheter perforated the vessel wall
due to continuous contact of the tip with the vessel and movement
associated with a change in neck and head position. The perforation was
unlikely to have occurred during insertion; positioning of the catheter
was confirmed at that time by evaluation of blood regurgitation and
saline flushes through all three lumens. Moreover, only crystalloid
fluids were introduced via distal port; as such, the perforation was not
likely to be related to infusion of hyperosmolar solutions.
A chest radiograph performed after initiation of CRRT revealed an
enlarged mediastinum; this finding suggested the possibility of vascular
injury, although we misdiagnosed it as mediastinitis associated with the
first unsuccessful attempt at catheter insertion. At that time, CRRT
continued with no difficulties: this observation led to the initial
misdiagnosis in this case. Ultimately, we determined that both the
drainage and return ports were remained within the vessel. To our
knowledge, this is the first documented case of the vascular injury
associated with multi-lumen catheters in which hemodialysis could be
continue. Clearly, had we checked to determine appropriate blood
regurgitation from the infusion port, this condition would have been
diagnosed earlier.