Subclavian catheter tip in the contralateral vein: An unwanted ′necklace′

Sir, Subclavian vein catheter malpositions are not uncommon. However, the catheter tip being in the contralateral subclavian is rare. We discuss one such experience and review the literature. A 52-year-old woman was electively catheterized via the right subclavian vein to better manage her low blood pressure and to gauge her central venous pressure. The Seldinger guidewire method was used and no complications were noted. A check X-ray revealed the tip of the catheter to be in the contralateral subclavian vein [Figure 1]. The catheter was then removed and right internal jugular was cannulated with success.Figure 1: Right subclavian catheter tip in left subclavian veinSubclavian catheterization has the advantages of being more comfortable for the patient, having better landmarks in obese patients (compared to internal jugular), easier maintenance of dressings, and being accessible when airway control is being established. The safety and reliability of subclavian catheterization can be increased when the shoulder position is lowered. This increases overlap of clavicle and the subclavian vein as well as bringing them closer.[1] On the other hand, the longer path from skin to vessel makes subclavian vein catheterization more prone for injury/damage to tissues. There can be an increased risk of pneumothorax and higher chances of catheter malpositions. Procedure-related bleeding that is less amenable to direct pressure is another disadvantage that cripples subclavian catheterization. Also, the success rate may be lesser with inexperienced operators and in cardiopulmonary resuscitation, it may interfere during chest compressions. There is no international consensus on the preference of site of central venous catheter placement. It is largely dependant on the operator experience and ease and the local practice. While there are no significant differences in the incidence of hemo- or pneumothorax and vessel occlusion, there are considerably more arterial punctures with the internal jugular compared with the subclavian access. The latter is crippled by the higher number of catheter malpositions, our case being an example.[2] A retrospective review of 500 subclavian vein catheterizations showed that about 30% of catheter placements were malpositioned.[3] The malposition of right subclavian into the right internal jugular (upwards) is more common (60-70%)[4] than into the opposite subclavian. The guidewire in our case must have passed trough the right subclavian, the right brachiocephalic trunk, the left brachiocephalic vein, and finally into the left subclavian [Figure 2]. Changed orientation of the J-tip of guidewire during the procedure, longer (>18 cm insertion), and individual anatomical variation (the right and left brachiocephalic trunks being at a more horizontal level) may have resulted in such a malposition. A similarly malpositioned subclavian catheter in to the opposite side has been reported in literature.[56] Ultrasonography may familiarize us with the venous anatomy and patency and can also reduce time to venous cannulation and the risk of complications. Another poor indicator may be the observation of atrial ectopics upon guidewire insertion.Figure 2: A schematic showing the possible guide-wire/catheter positionings via right subclavian cannulationWe reiterate that the subclavian catheterization technique is a blind procedure and despite following measures as those enumerated, there is still a chance for catheter tip malposition. We also feel that such malpositions should not deter the choice of the subclavian site for catheterization owing to its obvious advantages as discussed. ACKNOWLEDGMENTS We thank our colleagues and staff of the department of Internal medicine for their perpetual support.