|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 57-58
Subclavian catheter tip in the contralateral vein: An unwanted 'necklace'
Dilip Gude, Chaitanya Sawant, Aslam Abbas
Department of Internal Medicine, Princess Durru Shehvar Children's and General Hospital, Hyderabad, India
|Date of Web Publication||28-Mar-2013|
Department of Internal Medicine, Princess Durru Shehvar Children's and General Hospital, Hyderabad
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gude D, Sawant C, Abbas A. Subclavian catheter tip in the contralateral vein: An unwanted 'necklace'. J Sci Soc 2013;40:57-8
Subclavian vein catheter malpositions are not uncommon. However, the catheter tip being in the contralateral subclavian is rare. We discuss one such experience and review the literature.
A 52-year-old woman was electively catheterized via the right subclavian vein to better manage her low blood pressure and to gauge her central venous pressure. The Seldinger guidewire method was used and no complications were noted. A check X-ray revealed the tip of the catheter to be in the contralateral subclavian vein [Figure 1]. The catheter was then removed and right internal jugular was cannulated with success.
Subclavian catheterization has the advantages of being more comfortable for the patient, having better landmarks in obese patients (compared to internal jugular), easier maintenance of dressings, and being accessible when airway control is being established. The safety and reliability of subclavian catheterization can be increased when the shoulder position is lowered. This increases overlap of clavicle and the subclavian vein as well as bringing them closer. 
On the other hand, the longer path from skin to vessel makes subclavian vein catheterization more prone for injury/damage to tissues. There can be an increased risk of pneumothorax and higher chances of catheter malpositions. Procedure-related bleeding that is less amenable to direct pressure is another disadvantage that cripples subclavian catheterization. Also, the success rate may be lesser with inexperienced operators and in cardiopulmonary resuscitation, it may interfere during chest compressions.
There is no international consensus on the preference of site of central venous catheter placement. It is largely dependant on the operator experience and ease and the local practice. While there are no significant differences in the incidence of hemo- or pneumothorax and vessel occlusion, there are considerably more arterial punctures with the internal jugular compared with the subclavian access. The latter is crippled by the higher number of catheter malpositions, our case being an example. 
A retrospective review of 500 subclavian vein catheterizations showed that about 30% of catheter placements were malpositioned.  The malposition of right subclavian into the right internal jugular (upwards) is more common (60-70%)  than into the opposite subclavian. The guidewire in our case must have passed trough the right subclavian, the right brachiocephalic trunk, the left brachiocephalic vein, and finally into the left subclavian [Figure 2]. Changed orientation of the J-tip of guidewire during the procedure, longer (>18 cm insertion), and individual anatomical variation (the right and left brachiocephalic trunks being at a more horizontal level) may have resulted in such a malposition. A similarly malpositioned subclavian catheter in to the opposite side has been reported in literature. , Ultrasonography may familiarize us with the venous anatomy and patency and can also reduce time to venous cannulation and the risk of complications. Another poor indicator may be the observation of atrial ectopics upon guidewire insertion.
|Figure 2: A schematic showing the possible guide-wire/catheter positionings via right subclavian cannulation|
Click here to view
We reiterate that the subclavian catheterization technique is a blind procedure and despite following measures as those enumerated, there is still a chance for catheter tip malposition. We also feel that such malpositions should not deter the choice of the subclavian site for catheterization owing to its obvious advantages as discussed.
| Acknowledgments|| |
We thank our colleagues and staff of the department of Internal medicine for their perpetual support.
| References|| |
|1.||Kitagawa N, Oda M, Totoki T, Miyazaki N, Nagasawa I, Nakazono T, et al. Proper shoulder position for subclavian venipuncture: A prospective randomized clinical trial and anatomical perspectives using multislice computed tomography. Anesthesiology 2004;101:1306-12. |
|2.||Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: Internal jugular versus subclavian access - A systematic review. Crit Care Med 2002;30:454-60. |
|3.||Conces DJ Jr, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293-5. |
|4.||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. |
|5.||Sharma D, Goyal R. Malpositioned right subclavian vein catheter into contralateral subclavian vein: A case report. The Indian Anaesthetist's Forum 2009. p. 1-3. |
|6.||Chauhan A. Malpositioning of central venous catheter: Two case reports. Indian J Anaesth 2008;52:337-9. |
[Figure 1], [Figure 2]