Unusual Placement of a Central Venous Catheter: Left Pericardiophrenic Vein

A 62-year-old man presented to the emergency department with hypotension and diarrhea secondary to Clostridium difficile infection. Due to poor peripheral access, a left internal jugular vein triple lumen central venous catheter (CVC) was inserted for fluid resuscitation. The CVC was placed under real-time ultrasound guidance, which revealed normal anatomy, with no resistance during placement. Good blood return was noted in all three ports. Follow-up chest radiograph showed an abnormal course of the CVC (Figure 1). Despite the abnormal course, blood gas analysis and pressure transduction via the CVC were consistent with venous placement. Chest computed tomography without contrast revealed placement of the CVC in the left pericardiophrenic vein (Figure 2). Left paramediastinal central line position can be extravascular with direct placement in the mediastinum or pleural space, arterial with extension into the descending thoracic aorta, or venous. Differential diagnosis of venous left paramediastinal CVC position includes leftUniversity of Louisville, Department of Pulmonary, Critical Care, and Sleep Disorders Medicine, Louisville, Kentucky