Download Accidental Cannulation of the Ascending Lumbar Vein via Femoral

Accidental cannulation of ascending lumbar vein
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急重症影像
Accidental Cannulation of the Ascending Lumbar Vein via
Femoral Access
Yu-Chung Kung1, Chao-Hsien Lee1,2, Chien-Liang Wu1,2
A 35-year-old young male patient has a past
medical history of AIDS with poor compliance.
He discontinued HAART by himself for 1 year.
He has progressive dyspnea with mild fever (body
temperature of 37.9℃) for 3 days prior to emergency
room. The chest tomography showed extensive
bilateral lung consolidation, infiltrates and ground
glass opacities. He took invasive ventilation due to
acute respiratory distress syndrome. Pneumocystis
Jiroveci pneumonia is of concern, therefore he took
Co-trimoxazole 240 mg q6h plus Solu-Medrol 40
mg every 6 hours. The right femoral vein catheter
should be removed because an exit site infection
occurred. We placed left femoral venous catheter to
administer medications and fluids. The abdominal
film was performed because of difficulty inserting
catheter to premeasured length, lack of blood return,
difficulty with removal of the guidewire from the
catheter, and easy flushing the device without
resistance during inserting central venous catheter
(CVC). The abdominal film revealed the catheter
passed from the femoral vein into the ascending
lumbar vein (ALV) (Fig. 1), therefore the catheter
was immediately withdrawn before intravenous fluid
was administration.
Fig. 1 T h i s c o m p l i c a t i o n o c c u r s a l m o s t
exclusively on the left has been attributed
to the unique anatomy of the left ileofemoral vein (white arrow) compared to
the right (black arrow)
Identification of malpositioned catheters is
critical to proper catheter function and prevention
of complications. Due to the potential morbidity
Received: June 24, 2014 Accepted for publication: July 22, 2014
From the 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
MacKay Memorial Hospital, Taipei, Taiwan
2
MacKay Medicine, Nursing and Management College, Taipei, Taiwan
Address reprint requests and correspondence: Dr. Chao-Hsien Lee
Division of Pulmonary and Critical Care Medicine, MacKay Memorial Hospital
92 Section 2, Chungshan North Road, Taipei 10449, Taiwan (R.O.C.)
Tel: (02)25433535 ext 2058 Fax: (02)25433535 ext 2059
E-mail: [email protected]
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J Emerg Crit Care Med. Vol. 25, No. 1, 2014
and mortality involving CVC-associated neurologic events, this problem bears further scrutiny. The
ALV arise from the right and left common iliac
veins at the level of L5–S1 and join the common
iliac veins to the lumbar veins as well as to the subcostal veins (Fig. 2)(1). The catheter may travel from
the ALV into the intervertebral plexus, promoting
rupture of the vessel wall allowing the catheter to
lodge in the epidural space2. Catheter residing in the
ALV may induce venous stasis, leading to possible
neurologic sequelae, including perforation and further damage to the epidural or subarachnoid space,
resulting in spinal cord injury, local mass effects,
chemical meningitis, adhesion, seizure(2), shock(3),
quadriplegia, paraplegia, and urinary retention (3).
Physicians could identify catheter malposition,
Fig. 2
including cognizance of insertion-related clues, radiographic assessment, and symptoms presenting
during the catheter insertion (Table 1)(4). The prognosis is good when malposition is recognized and
treated promptly. Even correctly positioned, CVCs
can migrate with the dynamic forces. Catheter migration should be suspected in patients presenting
with neurologic or sepsis like symptoms.
Identification of malpositioned CVCs dwelling
near or within the ALV is critical to patient safety.
The malposition of CVCs may be diagnosed under
CT scan of the abdomen with intravenous contrast(5), real-time fluoroscopy(3), or ultrasound guidance(6). Selection of an appropriate catheter insertion of lower extremity insertion site is important.
Inadvertent catheterization of the ALV occurs pri-
The anatomy of the ascending lumbar vein
Accidental cannulation of ascending lumbar vein
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Table 1 Signs and symptoms of catheters residing in or near the ascending lumbar vein
Difficulty inserting catheter to premeasured length
Lack of blood return
Sepsis-like symptoms
Parenteral nutrition fluid retrieved from CSF after lumbar puncture or markedly abnormal levels of glucose,
protein, or lipids obtained from CSF sample
Seizures or neurologic deficits
Flaccid quadraplegia
Urinary retention
Radiographic Clues:
• Left-sided CVC insertion that fails to cross the midline to enter the IVC and appears to overlay the midline
• A bend, kink, or hump in the catheter at the L4–5 level on anterior- posterior view or a zigzag course in the
paraspinal area, particularly on left-sided insertions and when the catheter was threaded to or beyond the
level of L3
• A 360-degree curl in the catheter in the inguinal region with the tip slightly to the left of the lumbar spine or
before advancement up the ALV
• A marked posterior deviation of the catheter at L4–5 through S1 on lateral view (A catheter deviating
posteriorly may be in the ALV, whereas a catheter presenting anterior to the spinal column on lateral x-ray is
typically in the IVC.)
• Vertebral and paravertebral venous plexuses filled by contrast injection into the ALV
marily on the left, most likely because the angle of
ALV entry to the right common iliac vein is greater
on that side. A right-sided entrance will decrease
the risk of catheter malposition.
References
1. Carol WT. Inadvertent catheterization of
the ascending lumbar vein. Neonatal Netw
2009;28:179-83.
2. Vidwans A, Neumann DP, Hussain N, et al.
Diagnosis and management of spinal epidural
space extravasation complicating percutaneous
central venous line placement in a premature
infant: case report and review of literature.
Conn Med 2000;64:79-82.
3. Satoko T, Toshiya A, Yoichi H, et al. Complication of femoral vein CV port catheter malposition. Kitasato Med J 2013;43:74-8.
4. Janet P. Neurologic complications resulting
from malpositioned or malfunctioning central
venous catheters. Newborn and Infant Nursing
Review 2006;6:212-24.
5. Ivan G, Rene MW, ChriStian S, et al. Accidental cannulation of the left ascending lumbar
vein through femoral access: still often unrecognized. ASAIO Journal 2012;58:435-7.
6. Enrique C, James HH, Andrew WG, et al. Misplacement of a femoral venous catheter into
the ascending lumbar vein repositioning using
ultrasonographic guideline. Intensive Care Med
2001;27:240-2.
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J Emerg Crit Care Med. Vol. 25, No. 1, 2014
股靜脈導管錯位至升腰靜脈
龔昱中1　李昭賢1,2　吳健樑1,2
股靜脈途徑被認為是一個快速和安全的靜脈通路。我們的報告描述一個股靜脈導管錯位至升腰靜脈
之病人，而此種錯位可發生嚴重的併發症如血管穿孔，損害硬膜外或蛛網膜下腔，脊髓損傷，化學性腦
膜炎，粘黏，癲癇，休克，四肢麻痺，截癱，和尿瀦留。臨床醫生應該注意到股靜脈導管可能錯位至升
腰靜脈，特別是在左側置入股靜脈導管時，可能是因為升腰靜進入到左側髂總靜脈的夾角較小。股靜脈
導管錯位至升腰靜脈除可根據導管置入時之情況及放射影像診斷，亦可使用靜脈造影、即時螢光透視、
超音波或腹部電腦斷層掃描確認。
關鍵詞： 升腰靜脈，中央靜脈導管置放
收件：103年6月24日　接受刊載：103年7月22日
台北馬偕紀念醫院內科部胸腔暨重症科　2馬偕醫護管理專科學校
通訊及抽印本索取：李昭賢醫師　104台北市中山北路二段92號
馬偕紀念醫院內科部胸腔暨重症科
電話：(02)25433535轉2058　傳真：(02)25433535轉2059
E-mail: [email protected]
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