Kavin Malhotra MD, Presenter: Nothing to Disclose

Tamara Miner Haygood MD, PhD, Abstract Co-Author: Nothing to Disclose

Chaan Ng MD, Abstract Co-Author: Nothing to Disclose

Beth Chasen MD, Abstract Co-Author: Nothing to Disclose

Kevin William McEnery MD, Abstract Co-Author: Medical Advisory Board, Research In Motion Limited

Marvin H. Chasen MD, Abstract Co-Author: Nothing to Disclose

Secondary catheter malpositioning, most commonly into the jugular system, has been reported as a rare complication of long term central venous catheter use.  We have found only 3 case reports of secondary malposition into the azygous arch.  In this investigation, we present a series of 12 such cases.

Immediate post-procedure and follow up radiographs were reviewed, with catheter position defined by radiographic signs delineated in the literature.  All documented cases of azygous malposition were verified by both frontal and lateral chest radiographs as well as CT if available.  Clinical charts were  reviewed for potential catheter-related complications.  8 cases were initially positioned in the superior vena cava (SVC), while 4 cases were initially positioned  in the azygous arch, with prompt repositioning into the SVC and subsequent movement back into the azygous arch.

All 12 cases were associated with left-sided catheters, with 6 subclavian, 5 peripherally inserted, and 1 internal jugular approach.  The time between catheter positioning in the SVC and secondary malpositioning into the azygous arch ranged from 13 to 159 days, with a mean of 60.3 days. Of the 12 cases, 5 had at least 1 additional episode of azygous malpositioning with the same catheter after initial correction and 2 demonstrated secondary azygous malpositioning with a subsequent catheter after exchange.  No catheter-related adverse effects were reported in any of the 12 cases.  Interestingly, retrospective analysis of radiographs revealed a failure to recognize azygous malpositiong on at least 1 radiograph in 3 of 12 cases.   

We conclude that secondary azygous malpositioning is an unusual complication of long term central venous catheter use mainly associated with left-sided approaches.  Additionally, initial episodes of secondary azygous malpositioning may be associated with repeat episodes with the same catheter as well as subsequent catheters after exchange.  Furthermore, failure to recognize azygous malpositioning of central venous catheters is not uncommon, and careful attention must be paid to both the frontal and lateral radiographs in determining positioning. 

Secondary azygous malpositioning of central venous catheters is associated with left-sided access and may go unrecognized on radiographs.  We review signs of azygous malposition.

Malhotra, K, Haygood, T, Ng, C, Chasen, B, McEnery, K, Chasen, M, Secondary Displacement of Long Term Central Venous Catheters into the Azygous Arch.  Radiological Society of North America 2009 Scientific Assembly and Annual Meeting, November 29 - December 4, 2009 ,Chicago IL. http://archive.rsna.org/2009/8003361.html