Emergent use of a central venous catheter placed in the internal mammary vein

Introduction: Central venous catheter (CVC) insertion plays an important role in critical care medicine, often utilized for vasopressor administration, volume resuscitation, reliable venous access, and central venous pressure monitoring. However, there are potential complications associated with placement, including arterial cannulation, catheter fragmentation, venous injury, pneumothorax, and malposition into a tributary vessel. Case Report: A 35-year-old woman with a history of severe psoriasis with recurrent superinfection, and right internal jugular (RIJ) venous thrombosis was transferred to the intensive care unit with septic shock. A CVC was inserted via left internal jugular (LIJ) to facilitate antimicrobial administration and continued vasopressor support, as it was patent by bedside ultrasound. The patient was asymptomatic during and after CVC placement. However, post-procedure chest X-ray demonstrated a CVC projecting directly inferiorly, ending over the left hemidiaphragm. After review of recent cross-sectional imaging, physical examination, blood gas assessment, and ultrasound evaluation, the catheter was thought to be within the internal mammary vein (IMV). Given the patient’s instability and being asymptomatic after line placement with the CVC functioning normally, the decision was made to temporarily use the line. The next day, its placement was confirmed by using computed tomography (CT). Conclusion: Miscannulation of a tributary vessel during CVC placement can cause significant morbidity and even mortality. However, it has been postulated that a line placed within the IMV could be used safely in the emergent setting. Our case demonstrates the safe utilization of a CVC within the IMV and provides a reasonable framework for approaching a misplaced LIJ CVC.