” A 75-year-old gentleman underwent combined aortic valve replacement and coronary artery bypass grafting surgery for severe aortic stenosis with triple-vessel coronary artery disease. Before anesthetic induction, a triple-lumen central venous catheter (CVC) and an 8.5-Fr single-lumen venous sheath were inserted uneventfully in the right internal jugular vein (IJV) under ultrasound (US) guidance following the confirmation of the presence of both the guidewires within the IJV lumen. On postoperative chest X-ray (CXR), however, the terminal 6-cm portion of the CVC was found to be looping back from the junction of the brachiocephalic veins toward the ipsilateral IJV [Figure 1]a. Although there was no problem with the infusion of fluid and inotropes through the lumens and there was only a minimal resistance in backflow, as the patient needed accurate central venous pressure and central venous oxygen saturation monitoring (which requires tip of the CVC to be in the distal portion of superior vena cava [SVC]) for assessment and management of hemodynamics and cardiac output (as the patient had poor left ventricular ejection fraction), decision to reposition the CVC was undertaken.
After strict aseptic preparation of the insertion site and sterile draping, the CVC was unfixed from the skin fixation site and was carefully withdrawn by 6 cm. A sterile guidewire was passed through its distal lumen carefully while holding the catheter stable. A point-of-care transthoracic echocardiography (TTE) was performed simultaneously through the subcostal region. The guidewire was advanced till its passage through the SVC into the right atrium (RA) could be observed in the subcostal bicaval view [Figure 1]b. Thereafter, the CVC was advanced over the guidewire and refixed at the same 15-cm mark, where it was fixed previously. A CXR done afterward confirmed proper position of the CVC tip within SVC [Figure 1]c. Although passing a guidewire through the distal port of an in situ CVC is controversial, the same was undertaken as the risk of significant bacterial colonization of the CVC was minimal within such a few hours’ time. We also tried to avoid inserting a fresh CVC, as the procedure can itself cause complications.”

Biswas, I., Bhat, I.H. and Negi, S.L. (2020) Correction of a malpositioned central venous catheter using point-of-care transthoracic echocardiography. Annals of Cardiac Anaesthesia. 23(2), p.247-248. doi: 10.4103/aca.ACA_141_18.