“Extracaval Shepherd's Crook” Sign

Abstract

Inaccurate positioning is a well-known and documented complication of central venous catheterization. Inadvertent placement of a central venous catheter into the right internal thoracic vein has been reported in the literature; however, the characteristic radiographic appearance for this complication has yet to be described. We report 3 cases that demonstrate central venous catheters improperly terminating in the right internal jugular vein. Characteristic radiographic findings of this altered catheter course are described. Recognition of these characteristic findings should prompt consideration for line repositioning or replacement.

Inadvertent insertion of a venous catheter into the internal thoracic vein: a word of caution

“…Acute complications include hematoma, pneumothorax, inadvertent arterial puncture or cannulation, failure to cannulate the target vessel, hemothorax, false path, arrhythmia, and cardiac tamponade. Catheter malpositioning can also be included in these early complications, although it can either be detected right away in the operating room or after a delay of hours or days, depending on the clinical picture 4. Most common late complications include infection (bacteremia or skin), thrombosis and venous stenosis 2…”

“…Inadvertent insertion of a venous catheter into the right internal thoracic vein can be quite easily overlooked during insertion, due to the apparent normal positioning in anteroposterior fluoroscopic view 7. The right internal thoracic vein is a tributary of the right innominate vein 4. It travels adjacent to the right internal thoracic artery on the posterior face of the anterior chest wall.…”