Central venous catheter migration to the arterial system occurred due
to the surgical procedure during total cavopulmonary shunt. The cathet
er seems to have crept into the portion of the vena cava that had been
designated for clamping, because of the position for the surgery and
the anatomic characteristics of the patient. The catheter migrated in
the right popliteal artery and was removed immediately; however, it co
uld enter the pulmonary arterial system and the other systemic arteria
l branches.