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.