Rare Case of Hemodialysis Catheter Malposition Accidental Placement in the Right Internal Mammary Vein

Introduction

Hemodialysis catheter placement is a common yet crucial procedure for patients requiring urgent renal replacement therapy. Despite advancements in ultrasound-guided insertion techniques, catheter malpositioning remains a potential complication. This case report presents a rare instance of accidental catheter tip placement in the right internal mammary vein, emphasizing the importance of vigilance in central venous catheterization.

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Case Summary

A 57-year-old male with Chronic Kidney Disease (CKD) stage 5 secondary to diabetic kidney disease had been undergoing hemodialysis for four years. Due to a malfunctioning left tunneled internal jugular catheter, a new temporary right internal jugular catheter was inserted.

Despite successful ultrasound-guided placement, resistance was encountered beyond 15 cm, accompanied by mild chest discomfort. Initial chest X-ray suggested proper placement in the superior vena cava (SVC); however, due to clinical suspicion, a contrast-enhanced chest CT was performed, revealing the catheter tip malpositioned in the right internal mammary vein.

Clinical Findings & Management

• Complications: The patient’s catheter malfunction resulted in suboptimal blood flow (150 mL/min).
• Intervention: The catheter was adjusted by withdrawing 2-3 cm, improving flow to 250 mL/min.
• Definitive Correction: A tunneled catheter insertion under fluoroscopy confirmed proper placement in the SVC.

Discussion & Clinical Implications

• Rare Occurrence: Catheter misplacement into the internal mammary vein is rare (1-2%), and right-sided occurrences are even more uncommon.
• Diagnostic Challenges: Chest X-ray alone may not reliably detect misplacements. CT angiography or fluoroscopy is recommended when malposition is suspected.
• Guidelines & Recommendations: While ultrasound guidance improves insertion accuracy, clinicians must maintain a high index of suspicion for misplacement, especially when resistance is encountered.

External Medical Reference

The National Kidney Foundation (NKF) emphasizes early planning for arteriovenous fistulas to reduce catheter dependence, minimizing associated complications.

Further Reading

Read the full study: 10.29328/journal.jcn.1001098

Conclusion

This case highlights the importance of post-procedural imaging when catheter malposition is suspected. Early detection and correction prevent complications, ensuring optimal dialysis efficiency.

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