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Adv Biomed Res 2012,  1:16

Unusual right internal jugular vein catheter malposition into the right axillary vein: A rare case report

Department of Anesthesia, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission27-Nov-2011
Date of Acceptance20-Feb-2012
Date of Web Publication11-May-2012

Correspondence Address:
Mohammadreza Safavi
Department of Anesthesia, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan
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Source of Support: Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran, Conflict of Interest: None

DOI: 10.4103/2277-9175.96072

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One of disastrous complications of central venous cannulation (CVC) is malposition of central venous catheter. In this case report, we present an adult patient with history of multiple trauma and intracranial hemorrhage in whom the right axillary vein was accidentally cannulated during CVC insertion.

Keywords: Central venous cannulation, malposition of central venous catheter, right internal jugular vein, right axillary vein

How to cite this article:
Honarmand A, Safavi M. Unusual right internal jugular vein catheter malposition into the right axillary vein: A rare case report. Adv Biomed Res 2012;1:16

How to cite this URL:
Honarmand A, Safavi M. Unusual right internal jugular vein catheter malposition into the right axillary vein: A rare case report. Adv Biomed Res [serial online] 2012 [cited 2023 Mar 23];1:16. Available from:

  Introduction Top

There are several anatomic access points for cannulation of central veins. Cannulation from the upper body is generally more common. It is due to less contamination of upper body sites. Since the upper body is used more generally, the incidence of mal-positioning of central venous cannulation (CVC) is also more prevalent. One of rare form of these CVC mal-positionings is right axillary vein that presents in this case report.

  Case Report Top

A 60-year-old man presented with intracranial hemorrhage secondary to multiple trauma that was treated under mechanical ventilation due to respiratory failure. He was candidate for cannulation of internal jugular vein (IJV) due to unavailability of peripheral veins.

Cannulation of right IJV was performed via a central approach after preparing and draping. The procedure was performed without any significant problem. After IJV cannulation, chest X-ray was done [Figure 1].
Figure 1: Conventional chest radiograph with abnormal position of the tip of central venous catheter. (a) before pulling back the catheter, (b) after pulling back the catheter. Point a = the tip of catheter that seems is in axillary vein. Point b = the part of catheter which seems is outside axillary vein

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In retrospection, the nearly symmetrical chest X-ray [Figure 1]a and b illustrated an unusual position of the central line: Deviation of the catheter to the lateral and the apparent position of the tip into right axillary vein.

For confirmation of axillary vein cannulation, guide-wire was inserted antegradely and the final position of catheter traced clinically. It was documented that the catheter was inserted into the right axillary vein. Interestingly, there was no problem for infusion of fluids via catheter. However, we removed the catheter without further complications and IJV cannulation was performed successfully via left.

  Discussion Top

Insertion of the central venous catheter has some complications that are mostly arterial puncture, pneumothorax and hematoma which are presented mostly during insertion of a catheter. Mark and colleagues [1] reported an incidence of axillary vein malposition of 14% and showed that clinical factors alone will not consistently recognize malpositioned catheters. Fortunately, we had no adverse complication.

As reported data showed, there was an extremely wide range of catheter malposition from less than 1% to more than 60%. Malatinsky and colleagues [2] reported 5.3% incidence for malpositioning and coiling with 30% incidence for external jugular vein. Paw [3] reported that the incidence of malpositioning following catheterization via the left IJV was more than the right IJV. Muhm et al.[4] reported respective incidence of 4.12% for the left internal jugular access and 1.1% for the right internal jugular. Pikwer and colleagues [5] reported the total incidence of radiographic catheter tip malposition which defined as extrathoracic or ventricular positioning was 3.3% with confidence interval 25% to 4.3%. They reported that cannulation by the right subclavian vein had the highest risk of malposition with the incidence of 9.1% compared with 1.4% by the right IJV. In a systematic review performed by Ruesch et al., [6] it was reported that catheter malposition rates was 5.3% and 9.3% for IJV and subclavian vein catheterization, respectively.

For confirmation of malpositioning of the catheter, we inserted guide-wire into catheter as a radio-opaque material to make the catheter more visible in chest X-ray. It was preferable that we confirmed malposioning of CVC by contrast agents but it was unavailable at that time and we were obligated changing the position of the catheter as soon as possible. However, we did this procedure very carefully and had no complication.

In [Figure 1]a it is shown that the tip of the catheter (point a) is in the axillary vein. The part of catheter that is external to the axillary vein seems going over the acromion (point b). Also, in [Figure 1]b, the external part of the catheter seems to be going over the acromion. The comparison of two figures shows the part of catheter which is outside of the axillary vein and going over the acromion is approximately without displacement despite of pulling back the tip of catheter. This confirms the extra-venous position of catheter that going over near the acromion. We didn't pullback the catheter with guide-wire in it.

The deep system of the upper extremity veins is composed of paired veins (ulnar, radial, and interosseous) which are located underneath the elbow. [7] Subsequently, these construct the paired brachial veins that connect the basilic vein to form the axillary vein. The axillary vein keeps on as the subclavian. After that, the subclavian vein links to the IJV to form the brachiocephalic veins.

At the left side, the brachiocephalic crosses the midline and subsequently joins to the right brachiocephalic vein and form the superior vena cava. [8] The venous anatomy of the upper extremity has greater variability compared with the lower extremity. There are more inter-individual difference in the number of venous branches and their respective lengths in the upper extremity. [9]

For prevention of the adverse effect of CVC insertion via IJV, some authors recommended the use of ultrasound-guidance. [10] Nevertheless, in a prospective randomized trial, Mansfield and colleagues [11] showed no difference in prevention of iatrogenic cannulation using ultrasound guidance.

In our center, insertion of a central venous catheter is usually performed without the use of ultrasound guidance. The above findings emphasize taking routine chest radiograph to confirm appropriate catheter tip position in the superior vena cava.

  Acknowledgments Top

The authors wish to sincerely thank the support all of the staff Isfahan Nursing ICU and all the colleagues in Kashani Hospital Medical Center affiliate to Isfahan University of Medical Sciences in Isfahan, Iran. Furthermore, our special thanks go to the patient, who wholeheartedly and actively assisted us to carry out this case report. No conflict of interest existed.

  References Top

1.Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE. Cannulation of the internal jugular vein: Is postprocedural chest radiography always necessary? Crit Care Med 1999;27:1819-23.  Back to cited text no. 1
2.Malatinský J, Kadlic T, Májek M, Sámel M. Misplacement and loop formation of central venous catheters. Acta Anaesthesiol Scand 1976;20:237-47.  Back to cited text no. 2
3.Paw HG. Bilateral pleural effusions: Unexpected complication after left internal jugular venous catheterization. Br J Anaesth 2002;89:647-50.  Back to cited text no. 3
4.Muhm M, Sunder-Plassmann G, Apsner R, Pernerstorfer T, Rajek A, Lassnigg A, et al. Malposition of central venous catheters. Wien Klin Wochenschr 1997;109:400-5.  Back to cited text no. 4
5.Pikwer A, Bååth L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: A prospective cohort study in 1619 patients. Anaesth Intensive Care 2008;36:30-7.  Back to cited text no. 5
6.Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: Internal jugular versus subclavian access-a systematic review. Crit Care Med 2002;30:454-60.  Back to cited text no. 6
7.Burbridge SJ, Finlay DE, Letourneau JG, Longley DG. Effects of central venous catheter placement on upper extremity duplex US findings. J Vasc Interv Radiol 1993;4:399-404.  Back to cited text no. 7
8.Falk, RL, Smith DF. Thrombosis of upper extremity thoracic inlet veins: Diagnosis with duplex Doppler sonography. AJR Am J Roentgenol 1987;149:677-82.  Back to cited text no. 8
9.Baarslag HJ, van Beek EJ, Koopman MM, Reekers JA. Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities. Ann Intern Med 2002;136:865-72.  Back to cited text no. 9
10.Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: A meta-analysis of literature. Crit Care Med 1996;24:2053-8.  Back to cited text no. 10
11.Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735-8.  Back to cited text no. 11


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