Perforation of the superior vena cava due to unrecognised stenosis. Case report of a lethal complication of central venous catheterization

We report on a case of fatal perforation of the superior vena cava. The per foration occurred after catheterization of the left internal jugular vein w ith a hemodialysis catheter, due to an unrecognised stenosis of the superio r vena cava. Vascular trauma induced by a previous, also left-sided,subclav ian vein-hemodialysis catheter (in place for 14 days), seemed to be the mos t likely pathomechanism of the stenotic lesion. It should be emphasised tha t this is a frequent complication especially of left-sided dialysis cathete rs. In the case described a stenosis was complicated by a misdirected secon d hemodialysis catheter. Although being repositioned under fluoroscopic con trol via a guide wire, an extravasal placement occurred but was unrecognise d. In order to rule out catheter misplacement, the position of every centra l venous catheter has to be controlled. Standard methods are either chest X -ray or right atrial electrocardiography. Additionally,confirmation of corr ect intravenous placement requires a combination of free venous backflow of all lumen and/or blood gas analysis or venous pressure monitoring. Only a combination of tests gives ample certainty as each test for itself has its pitfalls. After placement of hemodialysis catheters, in particular left-sid ed catheters, we demand chest X-ray in order to verify that the catheter ru ns parallel with the long axis of the superior vena cava. ln doubtful cases the threshold for contrast-enhanced angiographic control of the catheter s hould be low. If a perforation by the catheter is suspected it should be ru led out by computed tomographic scanning or transesophageal echocardiograph y.