Hidden danger: Unrecognized intrathoracic placement of a central venous catheter despite an initially normal-appearing chest radiograph: A case report

Abstract

Although a routine and generally safe procedure, central venous catheter insertion has inherent risks, which can be mitigated with the use of imaging studies. This case report describes the unrecognized intrathoracic placement of a central venous catheter in a 15-year-old female with a history of anorexia nervosa. A chest radiograph obtained immediately after the procedure appeared normal at the time, but retrospective review revealed a subtle right-sided pneumothorax. Subsequent computed tomography demonstrated that the catheter had perforated the right internal jugular vein and entered the thoracic cavity. The case highlights the limitations of relying solely on chest radiography for central venous catheter placement confirmation, the potential for missed subtle complications, and emphasizes the importance of clinical vigilance and additional imaging when catheter malposition is suspected.

Introduction

Central venous catheter (CVC) insertion is a common procedure in clinical practice, particularly in patients requiring long-term intravenous access for nutrition, medication, or hemodynamic monitoring. While the procedure is generally safe and effective, it carries inherent risks, including malposition, vessel perforation, and other complications. ¹ Ultrasound guidance and post-procedural chest radiography are routinely used to confirm the correct placement of CVCs and minimize these risks.^2,3 However, despite these precautions, the potential for misplacement remains. This risk is compounded by the fact that a malpositioned catheter may appear to be correctly positioned on a chest radiograph, leading to a false sense of security and potentially serious complications. ⁴ The following case report illustrates such a scenario, where a CVC was inadvertently placed intrathoracically despite an apparently normal chest radiograph, underscoring the need for vigilance and the potential limitations of relying solely on radiographic confirmation.

Case presentation

A 15-year-old female with a history of anorexia nervosa was admitted to the hospital for nutritional therapy. The condition had been present for approximately 3 years, during which time the patient had been hospitalized three times for nutritional interventions. Despite previous high-calorie intravenous nutrition administered using peripherally inserted central catheter (PICC) lines accessed via the left or right upper arms, her weight and nutritional status had shown minimal improvement. Upon admission, she was noted to have slow movements but no impairment in consciousness, and was able to communicate effectively. Her height was 152 cm and weight was 31 kg (body mass index: 13.4). Because she was unable to maintain adequate oral intake, central venous nutrition was indicated. Owing to occlusion of both upper-arm veins secondary to prior long-term PICC-related phlebitis, we elected to insert a CVC via the right internal jugular vein. Preprocedural upper-extremity venography confirmed bilateral occlusion extending from the upper-arm veins to the axillary veins, while the subclavian veins, brachiocephalic veins, and superior vena cava were patent without stenosis. The CVC was placed with real-time ultrasound guidance for venipuncture and fluoroscopic guidance for guidewire and catheter advancement. The procedure was performed in the interventional radiology suite under sterile conditions.

During CVC insertion using the Seldinger technique, after the right internal jugular vein was punctured with an 18-gauge needle, both the guidewire (0.035 inch) and catheter (7 Fr) advanced smoothly without resistance, and the patient’s vital signs remained stable. After placement, saline was infused through the catheter without resistance, but no blood return was noted. Although catheter malposition was considered, a chest radiograph taken post-procedure showed no abnormalities in the catheter’s course or position, and no pneumothorax was recognized at that time. In retrospect, careful review revealed a subtle right-sided pneumothorax that had not been appreciated immediately after the procedure. The procedure was therefore concluded (Fig. 1).

Figure 1.

Postoperative chest radiography. Postoperative chest radiograph obtained immediately after central venous catheter (CVC) placement, showing the catheter in an apparently normal position along the right internal jugular vein with the tip near the superior vena cava. No pneumothorax was recognized at the time; however, retrospective review revealed a subtle right-sided pneumothorax.

Upon returning to the ward, a nurse attempted to administer medication through the catheter. However, during preparation, air was aspirated from the catheter instead of blood. Despite being able to infuse saline without resistance, the continued aspiration of air raised concerns. The patient’s vital signs remained stable. Contrast-enhanced computed tomography (CT) was performed, which revealed that the catheter had perforated the internal jugular vein and was positioned within the thoracic cavity (Fig. 2(a)–(c)). CT scan confirmed that the catheter had not caused arterial injury, and no hemothorax was observed. Given the absence of arterial injury or active contrast extravasation on CT, the catheter was carefully withdrawn and a chest drain was placed to manage the pneumothorax in the interventional radiology suite. Manual compression was applied at the right neck puncture site for 15 minutes, followed by pressure dressing. Because the intrathoracic perforation site was not compressible and there was no ongoing hemorrhage, conservative management with chest drainage and close monitoring was adopted. No delayed bleeding occurred. Two days later, the pneumothorax resolved, the chest drain was removed, and a new CVC was successfully placed via the right internal jugular vein, allowing for continued nutritional support.

Figure 2.

Postoperative computed tomography. Axial view of the computed tomography (CT) scan reveals a misplaced central venous catheter (CVC). (a) The CVC (arrowhead) had penetrated the internal jugular vein (arrow). (b and c) The CT shows the CVC located within the thoracic cavity (arrowhead). A small amount of pleural effusion and pneumothorax are present, but no evidence of hemothorax or arterial injury is observed.

Discussion

This case underscores the potential risks associated with central venous catheterization, even when performed under ultrasound guidance and confirmed by chest radiography. The unrecognized intrathoracic placement of the catheter despite an apparently normal radiograph highlights the limitations of relying solely on chest radiography for CVC placement confirmation. Radiographic confirmation does not guarantee correct catheter placement, and clinicians should remain vigilant for signs of malposition. ⁵

In retrospect, the immediate post-procedural chest radiograph demonstrated a subtle right-sided pneumothorax that was not appreciated at the time. This underscores the difficulty in detecting small pneumothoraces and other subtle complications on initial imaging, particularly when the primary focus is on confirming catheter position.

The absence of blood return at insertion is a recognized warning sign of malposition and should prompt immediate reassessment, ideally with ultrasound and fluoroscopy at the bedside/procedure suite. Where available, a saline microbubble (“flush” test under ultrasound and chest ultrasound for pleural sliding can rapidly confirm venous course/tip location and exclude pneumothorax.^6,7 In our case, additional intraprocedural confirmation would likely have expedited recognition.

Conversely, catheter dysfunction with inability to aspirate but preserved infusion may occur from fibrin tail/sheath; however, at initial placement this should not be presumed and mandates imaging confirmation. ⁸

While the internal jugular vein is often preferred for CVC insertion due to its lower risk of complications compared to the subclavian vein, complications such as pneumothorax, although rare, can still occur. The incidence of pneumothorax during CVC insertion via the internal jugular vein is reported to be 0.1%–0.2%. ⁶ This low incidence reflects the safer anatomical position of the internal jugular vein, which is further from the pleura compared to the subclavian vein. ⁷

Internal jugular venous wall perforation is typically related to posterior wall puncture from a steep needle trajectory, repeated attempts, and anatomic variants. In severely emaciated patients, reduced soft-tissue buffering may further shorten the distance to pleura and render the vein less forgiving to over-penetration. Preventive measures include continuous ultrasound visualization of the needle tip (preferably in-plane), a shallower approach angle, minimal advancement once venous entry is confirmed, and live fluoroscopy to confirm smooth guidewire course toward the SVC. When red flags (no blood return, air aspiration) arise, immediate adjunct imaging is warranted. ⁹

The present case highlights a potentially overlooked risk factor: the patient’s severely emaciated condition. Extreme thinness has not been widely reported as a risk factor for pneumothorax during CVC placement. In patients with severe malnutrition and low body weight, the reduced amount of tissue and distance between the internal jugular vein and the lung apex may increase the risk of pleural injury and consequent pneumothorax during catheter insertion. This anatomical consideration suggests that clinicians should exercise heightened caution in such patients, possibly considering alternative access sites or techniques to mitigate this risk.^10,11

This case also highlights the importance of a multidisciplinary approach in managing complications associated with central venous catheterization, ensuring patient safety and optimizing clinical outcomes.

In conclusion, this case demonstrates the critical importance of comprehensive clinical assessment and appropriate use of imaging modalities in the placement of central venous catheters. While chest radiography remains a valuable tool, it is not infallible, and additional measures, including CT imaging, should be considered when malposition is suspected. Prompt recognition and management of catheter-related complications are essential to ensure patient safety and optimal outcomes.