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Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 11  |  Issue : 3  |  Page : 773-775  

Coiling of central venous catheter: A rare and preventable complication


Department of Anaesthesia, Lady Hardinge Medical College, New Delhi, India

Date of Web Publication21-Jun-2017

Correspondence Address:
Nitin Hayaran
320-Dhruva Apartment, Plot Number 4, I P Extension, Patparganj, New Delhi - 110 092
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_47_17

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   Abstract 

Central venous catheter (CVC) placement is not only restricted to Intensive Care Units and operation theaters but its horizon has also expanded to the bedside placements. Meticulous care and aids such as ultrasound and fluoroscopy dramatically increase the successful placement of needles, guidewires, and catheters, but still a large number of catheter misplacements can occur. The formation of a loop in CVC is a rare complication occurring mostly during right-sided catheterization. We report a rare complication of coiling of left subclavian CVC.

Keywords: Central venous catheterization, subclavian, X-ray


How to cite this article:
Hayaran N, Goyal N, Joy S, Jain A. Coiling of central venous catheter: A rare and preventable complication. Anesth Essays Res 2017;11:773-5

How to cite this URL:
Hayaran N, Goyal N, Joy S, Jain A. Coiling of central venous catheter: A rare and preventable complication. Anesth Essays Res [serial online] 2017 [cited 2019 Nov 14];11:773-5. Available from: http://www.aeronline.org/text.asp?2017/11/3/773/208679


   Introduction Top


Central venous catheterization (CVC) is an essential component of modern-day critical care practice.[1] Subclavian vein (SV) central line placement is done commonly by landmark-guided technique followed by ultrasound-guided method. Despite careful placement using proper landmarks and technique, it might be associated with acute mechanical complications such as catheter malposition, hematoma formation at insertion site, inadvertent arterial puncture, pneumothorax, hemothorax, nerve injury, and thoracic duct injury. The formation of a loop in CVC is a rare complication occurring mostly during right-sided catheterization.[2] We report a rare complication of coiling of left subclavian CVC.


   Case Report Top


A 20-year-old female, a postoperative case of perforation peritonitis with ileostomy and fecal fistula, was advised bedside placement of CVC for administration of parenteral nutrition. After confirming the normal coagulation profile and platelet count, with all aseptic precautions under local anesthesia, left SV (as right internal jugular vein (IJV) and right SV were previously cannulated) was cannulated with triple lumen heparin saline flushed CVC (16–18-18G, 7 Fr, 20 cm, triple lumen; certofix, B Braun ®) using standard Seldinger method [1] through infraclavicular approach by landmark technique. The procedure of CVC insertion was uneventful. Central line was inserted till 15 cm mark. The guidewire was withdrawn without any resistance. It was found that middle port had no free aspiration of blood, but all ports could be flushed with heparinized saline. A chest X ray (CXR) was performed to confirm the position of catheter, which revealed that it was coiled in a C-shaped pattern in the left brachiocephalic vein region [Figure 1]. It was removed without resistance, and a new left IJV catheter was placed using landmark technique, all ports had free aspiration of blood. CXR was done, which showed the normal placement of CVC [Figure 2].
Figure 1: Coiled central venous catheter

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Figure 2: Correct position after removal of earlier central venous catheter

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   Discussion Top


Incidence of mechanical complication in SV cannulation is 6%–10%.[3] The formation of a loop is mostly reported during pulmonary artery catheterization or right-sided SV catheterization,[2] suggesting that left-sided CVC coiling is a rare complication.

Various theories have been postulated for these rare incidences of coiling or looping such as extra length of insertion of guidewire and catheter.[4] In our case as it was a left SV catheterization, 15 cm of insertion was adequate. Excessive force might lead to coiling,[5] but in our case, the guidewire and CVC were passed easily and there was no kinking of the guidewire. Direction of J-type guidewire tip during insertion [4] and its locking with catheter tip during removal both may cause looping of CVC.[6] In our case, J-tip was in caudal direction as it should be and no resistance was felt during guidewire removal. There was no manufacturing defect in CVC [6] as catheter was inspected and flushed before insertion. A bottleneck exists between the clavicle and first rib, which can impede the threading of the wire and might contribute to looping and knotting;[5] this was overcome by placement of sandbag between the scapulas along the axis of spine which opens up the space between the two. There was no mass in the thoracic region and no lung disease to distort the vascular anatomy.[4] We cannulated left SV as it was not perforated or cannulated even once so it decreases the chances of it being stenosed or thrombosed which may increase the chance of coiling.[1] There was no anatomical vascular abnormality as left subclavian CVC tip was not lying in any aberrant tributary and it fells back on itself in the same vein,[7] and left IJV catheter was not in left paramedian position on chest X-radiograph as would have been in persistent left superior vena cava (SVC).[1] The acute angle formed by left brachiocephalic vein with SVC may cause abutting of the guidewire and the catheter, leading to falling back of the catheter on itself.[7] This might be the cause of the coiling in our case.

Coiled or knotted intravascular catheters may lead to catheter breakage and embolization, no free aspiration of blood from port, and central venous pressure (CVP) readings may be falsely elevated.[2],[8] They are more likely to traumatize the vein, resulting in perforation or thrombosis.[8] Therefore, coiled catheter should ideally be removed, and new line from a different route should be inserted. Negative aspiration of blood from middle port may be due to acute coiling of CVC occluding the distal end of middle port or its lumen.[2]

Different landmarks, Peres formula (height [cm]/10), CXR, CVP waveform, right atrial electrocardiography (ECG), ultrasonography, and fluoroscopy have been used to ensure the correct placement of CVC.[9] USG only helps in safe and visible venous puncture but not in detecting malposition of the tip of the CVP catheter.[10] C-arm fluoroscopy cannot be used as a bedside procedure. ECG monitoring is routinely done throughout the procedure. It should be modified into right atrial ECG using wire provided with the CVC set [Figure 3] and an adapter, as it does not increase the financial burden and is more accurate in securing correct position within the SVC even when used as a bedside tool.[11] CXR radiograph remains the gold standard to confirm the tip of catheter.[12]
Figure 3: Electrocardiography lead with central venous catheter

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   Conclusion Top


Negative aspiration of blood from any of the port must raise an alarm for the malposition of the CVC tip. Right atrial ECG which is readily available in central line set should be used. Chest radiography should to be done immediately after insertion of every CVC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gibson F, Bodenham A. Misplaced central venous catheters: Applied anatomy and practical management. Br J Anaesth 2013;110:333-46.  Back to cited text no. 1
    
2.
Pereira S, Preto C, Pinho C, Vasconcelos P. When one port does not return blood: Two case reports of rare causes for misplaced central venous catheters. Rev Bras Anestesiol 2014;66:1-3.  Back to cited text no. 2
    
3.
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 3
    
4.
Samanta S, Samanta S. Recurrent central venous malposition caused by severe lower airway distortion. Am J Emerg Med 2014;32:101-2.  Back to cited text no. 4
    
5.
Lee JJ, Kim JS, Jeong WS, Kim DY, Hwang SM, Lim SY. A complication of subclavian venous catheterization: Extravascular kinking, knotting, and entrapment of the guidewire – A case report. Korean J Anesthesiol 2010;58:296-8.  Back to cited text no. 5
    
6.
Agrawal P, Gupta B, D'souza N. Coiled central venous catheter in superior vena cava. Indian J Anaesth 2010;54:351-2.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Singh PK, Ali Z, Rath GP, Prabhakar H. Catheter malposition following supraclavicular approach for subclavian vein catheterisation – Case reports. Middle East J Anaesthesiol 2008;19:1405-10.  Back to cited text no. 7
    
8.
Mitchell SE, Clark RA. Complications of central venous catheterization. AJR Am J Roentgenol 1979;133:467-76.  Back to cited text no. 8
    
9.
Kumar A. Folding back of central venous catheter in the internal jugular vein: Methods to diagnose it at the time of insertion? J Anesth Clin Res 2012;3:226-7.  Back to cited text no. 9
    
10.
Goyal V, Sahu S. Coiling of central venous catheter in the left subclavian vein, a rare complication. Indian J Crit Care Med 2014;18:105-6.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Sharma D, Singh VP, Malhotra MK, Gupta K. Optimum depth of central venous catheter – Comparision by pere's, landmark and endocavitory (atrial) ECG technique: A prospective study. Anesth Essays Res 2013;7:216-20.  Back to cited text no. 11
  [Full text]  
12.
Ambesh SP, Pandey JC, Dubey PK. Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein. Anesthesiology 2001;95:1377-9.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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