Perforation of the Left Brachiocephalic Vein Secondary to Central Venous Catheterization

Vascular access has prime importance in patients on hemodialysis. Vascular accesses may become unusable due to various complications in patients with multiple vascular problems. An eighty two-year old female patient who had been on chronic hemodialysis program three times a week for four years was admitted to the nephrology clinic due to dyspnea. A permanent cuffed tunneled catheter was inserted to the left internal jugular vein with guidance of ultrasonography to the patient who could not have dialysis for a week due to the vascular access problem. Blood could not be drawn from both venous and arterial ends of the catheter right after the insertion (primary malfunction). Posteroanterior chest radiography and computed tomography angiography revealed that the catheter was decsending in the anterior mediastinum ending at the level of the aortic valve instead of going through the left brachiocephalic vein. There was no hematoma or bleeding. Perforation and rupture may complicate catheter insertion especially in old patients with multiple vascular problems due to thrombotic complications and decresed elasticity of the vessels. Perforation of the brachiocephalic vein is a complication with high mortality rate that has been reported in the literature as single case reports. Central venous catheters should be the last choice due to high morbidity and mortality. Arterio-venous fistulas are the best choice as the vascular access with the lowest rates of morbidity and mortality in patients with end stage renal failure.