Complication of femoral vein CV port catheter malposition

A 77-year-old man was admitted with multiple co-morbidities including cerebral infarction, postoperative ossification of the cervical posterior longitudinal ligament, sick sinus syndrome with a cardiac pacemaker inserted from the right subclavian vein, and panperitonitis due to a complicated gastrostomy catheter exchange. The patient developed a critical and rare complication of central venous (CV) catheterization from the femoral vein under ultrasonographically guided insertion and real-time fluoroscopy. Smooth backflow of blood from the catheter was confirmed, and the patient was stable. Twenty-nine days later, he developed a high fever and hypotension. Based on the laboratory data, a diagnosis of septic shock was made. On abdominal computed tomography (CT), malposition of the CV port catheter was identified. CT showed the catheter passed from the femoral vein into the lumbar vein and the tip ultimately penetrated into the retroperitoneal space. Despite resuscitation, the patient died. Although we used an ultrasonographically guided technique and fluoroscopy-guided catheterization, we could not avoid catheter misplacement. To avoid this critical complication, contrast fluoroscopy, to confirm that the catheter was in the appropriate vessel, should have been performed. Surgeons should be aware of such critical complications when inserting a CV catheter from the femoral vein.