CTICasesCentral Venous Catheter Malposition into the Pleural Space with Iatrogenic Effusion
Imaging findings
A central venous line placed emergently in a trauma patient appears on the initial radiograph to course normally before terminating near the cavoatrial junction. On subsequent CT performed to evaluate for pulmonary embolism, the catheter is seen to never actually enter the central veins, instead passing near the arch vessels directly into the right pleural space behind the superior vena cava, with an associated pleural effusion. A large new pleural effusion developed within about six hours of the initial radiograph after the line was used to infuse fluid.
Key takeaways
The catheter was believed to be correctly positioned based on the radiograph and the presence of blood return during placement, but was in fact entirely within the pleural space. Infusion through the malpositioned line produced a rapidly enlarging iatrogenic pleural effusion, illustrating that an unusual central line course and blood return alone are not sufficient to exclude extravascular malposition, even when placement is ultrasound-guided.
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