|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 3 | Page : 415-416
Intratumoral migration of central venous catheter in a patient with malignant bronchial carcinoid
Ranvinder Kaur, Tanvir Samra, Lalita Chaudhary, Aruna Jain
Department of Anesthesia and Intensive Care, Lady Hardinge Medical College, New Delhi, India
|Date of Web Publication||29-Jul-2015|
C-I/77, Moti Bagh-1, New Delhi - 110 021
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kaur R, Samra T, Chaudhary L, Jain A. Intratumoral migration of central venous catheter in a patient with malignant bronchial carcinoid. J Anaesthesiol Clin Pharmacol 2015;31:415-6
|How to cite this URL:|
Kaur R, Samra T, Chaudhary L, Jain A. Intratumoral migration of central venous catheter in a patient with malignant bronchial carcinoid. J Anaesthesiol Clin Pharmacol [serial online] 2015 [cited 2021 Mar 2];31:415-6. Available from: https://www.joacp.org/text.asp?2015/31/3/415/161706
A 66-year-old male patient with bronchial carcinoid of left upper lobe of lung was scheduled for lobectomy. Standard monitors were attached and patients trachea intubated with a 35 Fr left sided double lumen tube. Left internal jugular vein (IJV) was cannulated with a 7 Fr 20 cm triple lumen catheter using anatomical landmark based technique in a single attempt using central approach and catheter was fixed at 13 cm. Central venous pressure (CVP) trace was normal and venous back flow was present in all the ports.
The CVP trace began to dampen after thoracotomy and retraction of ribs. Free flow of intravascular fluids and aspiration of blood was also hampered. Repositioning the catheter over a guidewire was not feasible as patient was in right lateral position. Intratumoral location of the tip of the central venous catheter (CVC) was noted during dissection of the left upper lobe of the lung [Figure 1].
Catheter tip migrations are unavoidable. Change in patient position led to migration of the tip of the CVC into the left brachiocephalic vein in our case; the anterior wall of which was eroded by the malignancy leading to intratumoral placement. Malignant infiltrations in vessels is thus a relative contraindication for catheterisations. Imaging of the central vessels should be performed preoperatively in patients with suspicion of invasion.
Magnitude of displacement of CVC's inserted through IJV with neck flexion and extension is 1.5-3.0 cm in downward and upward direction respectively.  Catheter migrations of 3-4 cm have been reported with supine to upright positioning.  Hyper abduction of the arm (>180°) also predisposes to the same.  Spontaneous migration of a CVC tip into another venous tributary is favoured by jet effect of drug injections, mechanical ventilation, increased intrathoracic and intra-abdominal pressures. 
Central venous catheter tips should be placed in distal superior vena cava (SVC), above the pericardial reflection with <40° of impingement angle between the catheter and vessel wall. Visualisation of tip at right tracheobronchial angle in a chest X-ray in a supine patient ensures a minimum distance of 3 cm above the pericardial reflection  (median length of SVC is 6.8 cm and maximum distance of right tracheobronchial angle from origin of SVC is 3.8 cm). Catheter placements at right tracheobronchial angle thus permit upto 3 cm of displacements with change in neck, arm and patient positioning.
Periodic radiological visualisations of chest (anterior-posterior and lateral view) can detect malpositions in large venous tributaries; IJV or subclavian vein. But malpositions in smaller tributaries like internal mammary vein (located in the anterior mediastinum), pericardiophrenic vein (middle mediastinum) and superior intercostal vein (posterior mediastinum) can be detected by computed tomography scans and venography only.
Estimations of insertion depth using either the anatomical technique (distance between the needle insertion point and the clavicular notch and the vertical length between the clavicular notch and the carina on the chest radiograph) or the Peres' formula (height 10 cm) should be made in all catheterisations. Insertion depth of 12-13 cm in males and 11-12 cm in females for right IJV and 13-14 cm in males and 12-13 cm in females for left IJV cannulations are optimal. 
| References|| |
Curelaru I, Linder LE, Gustavsson B. Displacement of catheters inserted through internal jugular veins with neck flexion and extension. A preliminary study. Intensive Care Med 1980;6:179-83.
Kowalski CM, Kaufman JA, Rivitz SM, Geller SC, Waltman AC. Migration of central venous catheters: Implications for initial catheter tip positioning. J Vasc Interv Radiol 1997;8:443-7.
Jahagirdar SM, Laxmimani, Athiraman U, Ravishankar M. Migration of subclavian venous catheter tip: Patient positioning in ICU makes a difference. Indian J Crit Care Med 2013;17:193-4.
Aslamy Z, Dewald CL, Heffner JE. MRI of central venous anatomy: Implications for central venous catheter insertion. Chest 1998;114:820-6.
Kujur R, Rao MS, Mrinal M. How correct is the correct length for central venous catheter insertion. Indian J Crit Care Med 2009;13:159-62.