Rare central venous catheter malposition - an ultrasound-guided approach would be helpful: a case report.
BACKGROUND
A central venous catheter enables the measurement of hemodynamic variations, such as accurate central venous pressure; catheter malposition may induce potentially fatal complications. This case report describes a rare central venous catheter tip malposition in the right internal mammary artery.


METHODS
A 56-year-old Japanese woman who presented with severe pneumonia secondary to scleroderma was treated under ventilator support because of acute respiratory failure. A right central venous catheter was inserted using a landmark technique to monitor central venous pressure and administer medications. However, central venous waveforms detected by the catheter using a pressure lot transducer were later found to be absent. Further imaging studies, including plain radiography, computed tomography, and angiography, confirmed central venous catheter malposition in the internal mammary artery. Her right internal mammary artery was embolized using two interlocking detachable coils, and the central venous catheter was removed from her internal mammary artery without further complications.


CONCLUSIONS
Internal mammary artery malposition is a rare but potentially lethal complication of central venous catheter catheterization; however, caution should be taken regarding the assessment of risk factors and management of a severe complication. An ultrasound-guided approach would be helpful.
Patient Safety Division, Gifu University Hospital, Yanaido1-1, Gifu, ZC: 501-1194, Japan. kkumada@gifu-u.ac.jp.
Keisuke
K
Kumada
Patient Safety Division, Gifu University Hospital, Yanaido1-1, Gifu, ZC: 501-1194, Japan.
Nobuo
N
Murakami
Department of Emergency & Disaster Medicine, Gifu University School of Medicine, Gifu, Japan.
Hideshi
H
Okada
Department of Emergency & Disaster Medicine, Gifu University School of Medicine, Gifu, Japan.
Izumi
I
Toyoda
Department of Emergency & Disaster Medicine, Gifu University School of Medicine, Gifu, Japan.
Shinji
S
Ogura
Department of Radiology, Teikyo University Hospital, Tokyo, Japan.
Hiroshi
H
Kondo
Shonan Kamakura General Hospital, Kanagawa, Japan.
Atsuhiro
A
Fukuda
D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods*; D003422:Critical Care; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D008323:Mammary Arteries / Q000000981:diagnostic imaging*; D019300:Medical Errors; D008875:Middle Aged; D011014:Pneumonia / Q000628:therapy*; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D012594:Scleroderma, Localized / Q000628:therapy*; D014057:Tomography, X-Ray Computed
Adverse event; Central venous catheter; Internal mammary artery; Malposition