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Views: 25 Author: DERUK Publish Time: 2026-09-11 Origin: Site
Introduction
Central venous catheterization is a common procedure in emergency care, intensive care, and cardiac surgery. It is used for medication delivery, fluid administration, and hemodynamic monitoring. Ultrasound guidance is widely recommended because it improves success rates and helps reduce complications.
However, a case published in 2018 and indexed in PubMed shows that even ultrasound-guided venipuncture can still result in serious misplacement. In this case, a central venous catheter intended for the internal jugular vein entered the carotid artery.
The case comes from Aga Khan University Hospital in Pakistan and highlights important safety lessons for venipuncture and central venous access.
The patient was an adolescent with tetralogy of Fallot, a complex cyanotic congenital heart disease. He was admitted with hemoptysis, breathing difficulty, and severe low oxygen levels. Because of his critical condition, he required emergency total correction surgery.
Before surgery, the anesthesia team needed to establish central venous access. This required venipuncture of a large central vein, commonly the internal jugular vein.
The team attempted right internal jugular vein catheterization under direct ultrasound guidance. This is considered a standard approach for improving safety and accuracy.
During the puncture, the team briefly suspected that the artery might have been entered. However, ultrasound imaging showed the needle tip apparently within the vein. The team therefore proceeded with guidewire and catheter insertion.
A multi-lumen central venous catheter was successfully placed. At first, the procedure appeared to have been completed correctly.
After catheter placement, the pressure monitor showed a waveform consistent with arterial pressure. In addition, there was no blood return from the infusion port.
These findings should raise concern for arterial placement. However, the patient’s tetralogy of Fallot made interpretation more difficult. His underlying heart disease can alter pressure readings and make arterial versus venous blood color less reliable.
Because of these conflicting signals, the team did not immediately recognize that the catheter had passed through the posterior wall of the right internal jugular vein and entered the right common carotid artery.
After surgery, the abnormal pressure waveform persisted. The medical team then compared blood gas samples from the radial artery catheter and the suspected central venous catheter. The results confirmed that the central venous catheter was actually inside an artery.
Chest X-ray and ultrasound further showed that the catheter tip was in the aortic region and that the catheter tract passed through the right internal jugular vein into the right common carotid artery.
A new central venous catheter was placed through the right femoral vein. The misplaced catheter was removed, and the puncture site was managed with local compression. The patient later developed complications, required further treatment, and was eventually discharged after a prolonged hospital stay.
This case does not suggest that ultrasound guidance is ineffective. Instead, it shows that ultrasound is only one part of safe venipuncture practice.
Important lessons include:
Ultrasound does not guarantee that the catheter remains in the vein.
The needle tip may appear to be in the vein, but the guidewire or catheter can still pass through the posterior vein wall into an adjacent artery.
An arterial pressure waveform must be taken seriously.
It should not be dismissed too quickly, even in patients with complex heart disease.
No blood return does not prove correct placement.
Lack of blood return from the catheter does not rule out arterial misplacement.
Use multi-modal confirmation before using the line.
Blood color, pulsatile return, pressure waveform, blood gas analysis, ultrasound, and imaging should be used together when there is any doubt.
Complex congenital heart disease increases interpretation difficulty.
In tetralogy of Fallot and similar conditions, pressure and blood color may be misleading.
TEE can help, but only if properly interpreted.
Transesophageal echocardiography may help confirm catheter position during cardiac surgery, but it requires timely expert interpretation.
Managing a misplaced large-bore arterial catheter requires planning.
Simple removal with compression may carry risk. Surgical or interventional management may be needed in some cases.
This Pakistan case report is a strong reminder that venipuncture and central venous catheterization require more than ultrasound guidance alone. Even under ultrasound, a catheter can still enter an artery.
For safer practice, clinicians should combine ultrasound with pressure waveform assessment, blood gas confirmation, and other checks before using a central line. This is especially important in patients with complex congenital heart disease, where standard signs may be misleading.
The main message is simple: confirm before you use. Ultrasound helps, but it is not a substitute for multi-modal verification.
Disclaimer: This article is for medical information and case-review purposes only. It does not constitute clinical advice. Practitioners should follow institutional protocols and professional judgment.
