A large number of central venous catheters (CVC) are placed each year in the emergency room, operation theatre and critical care unit. Although rarely associated with life threatening complications, femoral CVC is known to have the highest incidence of mechanical complications. It is important that clinicians are aware of wrong positioning of CVC even in the presence of good backflow of blood through all the lumens, especially in patients with haemo peritoneum. This article outlines a rare complication of misplaced femoral CVC into the peritoneal cavity in a patient with haemo peritoneum, its consequences and management. We further want to emphasize the importance of real time imaging during CVC insertion to improve safety and reduce complications rate.

Complications during central venous catheter (CVC) insertion are infrequent with an incidence of 0.1%–1%. We experienced a rare CVC complication with fragmentation of the angiocatheter at its hub during central venous cannulation while utilizing the modified Seldinger technique (ie, wire through the catheter technique). Vascular surgery was emergently required to remove the catheter fragment from the neck. Clinicians must remain vigilant during all aspects of CVC insertion, including awareness of the potential for fragmentation of the angiocatheter during its removal over the in situ guidewire. Prompt recognition and appropriate management included leaving the guidewire in place (to stabilize the distal fragmented segment) and promptly consulting vascular surgery for removal before potential vascular embolization of the angiocatheter fragment. We further recommend that all components of the insertion kit be inspected before and after patient use.