E1854. Overview of Rare Appearances of Malpositioned Central Venous Catheters
  1. Naeem Patel; Hartford Hospital
  2. George Weck; Hartford Hospital
  3. Timothy Herbst; Hartford Hospital
The purpose of this exhibit is to discuss the potential appearances and complications of a malpositioned central venous catheter (CVC) as shown through two cases. The first case details how advance knowledge of an anatomic venous variant can mask a misplaced CVC into the left common carotid artery. The second case demonstrates how a misplaced CVC into the left common carotid artery can lead to ischemic infarction in the brain due to arterial thrombosis.

Educational Goals / Teaching Points
The first educational goal is to illustrate the importance of careful radiographic assessment of CVCs that have an atypical course, which can be more definitively assessed with CT. The second educational goal is to review a serious potential complication of an arterially placed CVC resulting in a large cerebral territorial infarction.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
In the first case, arterial placement of the CVC was suspected on a frontal chest radiograph, with confirmation of arterial location made via subsequent CT. The key image finding shows the tip of the CVC in the ascending thoracic aorta. To the left of the aorta, there is another vascular structure that is a known left superior vena cava (SVC). In this example, the fact that the left-sided CVC does not cross midline on chest radiograph may at first be mistakenly attributed to its location within the left SVC, though on closer radiographic inspection the course of this catheter is more medial than would be expected if it were in the left SVC and is therefore suspicious for arterial placement. The second case shows malposition of a CVC which was initially suspected to be arterially placed on chest radiograph. Catheter placement within the left common carotid artery was then confirmed on CT, with the tip in the ascending thoracic aorta. Shortly afterwards, the patient developed neurologic symptoms, and emergent CT angiogram demonstrated occlusion of the left common carotid artery above the level of the catheter entrance; this is consistent with arterial thrombosis as a complication of arterial catheter placement. Accompanying head CT showed extensive infarct in the left middle and anterior cerebral artery territories.

CVCs may be prone to malpositioning due to both the anatomic variation of the patient as well as the techniques used to place them. The two cases outlined above show the importance of proper placement of lines and the vigilance required when assessing CVCs on chest radiography. Even in this setting, awareness of a known anatomic variant can lead one to mistakenly conclude that a CVC is placed properly, when in fact it is located intra-arterially. Use of careful technique and an ultrasound-guided approach can significantly diminish the risks of morbidity and mortality that can occur with misplaced CVCs.