- Joined
- Sep 16, 2008
- Messages
- 487
- Reaction score
- 211
I wanted to share an interesting central line case, as I think troubleshooting challenging central venous access is a skillset that continues to evolve for me as an attending.
The patient had bilateral AV fistulas (one failed). History of multiple tunneled HD lines -- most recently RIJ which was removed shortly before the case. The patient had a history of difficult access and patient/surgeon requested a CVC to facilitate lab draws and access postop. We chose to access LIJ given her recently removed tunneled line.
Access was uncomplicated, but the wire would not advance past 18cm. Placed a 10cm 18g sheath over the wire from our kit and manometry confirmed venous placement, but still after reintroducing the wire I was unable to advance past 18cm. I opted to place the line over the wire I had which was uneventful, but the blood return from the most distal port of the CVL was sluggish (prox and medial ports with brisk blood return). I suspected a possible line malposition, so I brought in fluoro to help confirm line placement and possibly reposition.
Initial image shows line seemingly well positioned but with an odd angulation to the tip of the line and just lateral to the R mainstem bronchus - possible appearance for azygous placement. Introduced a 0.032" wire under fluoro to try and reposition and... the wire goes straight to the RA. Hard to tell if the line was in the azygous and popped out when I introduced the wire or if it was never there to begin with.
Patient to PACU, formal CXR and... now the line looks like it's possibly back in the azygous vein? The "down the barrel" view on CXR is a/w azygous placement, but I have no idea as to the specificity.
What would you do / have done? Do you remove the line? Would you have never placed it with the wire hung up at 18cm in the first place?
As a bonus, here's a diagram from a 2011 AJR paper showing appearance of azygous vein CVLs on PA CXR - also even the radiologists had trouble identifying the less obvious ones. Our rads read her line as at the SVC/brachiocephalic junction with no concern for malposition.
The patient had bilateral AV fistulas (one failed). History of multiple tunneled HD lines -- most recently RIJ which was removed shortly before the case. The patient had a history of difficult access and patient/surgeon requested a CVC to facilitate lab draws and access postop. We chose to access LIJ given her recently removed tunneled line.
Access was uncomplicated, but the wire would not advance past 18cm. Placed a 10cm 18g sheath over the wire from our kit and manometry confirmed venous placement, but still after reintroducing the wire I was unable to advance past 18cm. I opted to place the line over the wire I had which was uneventful, but the blood return from the most distal port of the CVL was sluggish (prox and medial ports with brisk blood return). I suspected a possible line malposition, so I brought in fluoro to help confirm line placement and possibly reposition.
Initial image shows line seemingly well positioned but with an odd angulation to the tip of the line and just lateral to the R mainstem bronchus - possible appearance for azygous placement. Introduced a 0.032" wire under fluoro to try and reposition and... the wire goes straight to the RA. Hard to tell if the line was in the azygous and popped out when I introduced the wire or if it was never there to begin with.
Patient to PACU, formal CXR and... now the line looks like it's possibly back in the azygous vein? The "down the barrel" view on CXR is a/w azygous placement, but I have no idea as to the specificity.
What would you do / have done? Do you remove the line? Would you have never placed it with the wire hung up at 18cm in the first place?
As a bonus, here's a diagram from a 2011 AJR paper showing appearance of azygous vein CVLs on PA CXR - also even the radiologists had trouble identifying the less obvious ones. Our rads read her line as at the SVC/brachiocephalic junction with no concern for malposition.