Infected mediastinitis secondary to perforation of superior vena cava by a central venous catheter

Abstract

We describe the first case of infected mediastinitis associated with central venous catheter insertion. The rare occurrence of this complication may be explained by the fact that it results from central venous catheter-related bloodstream infection and catheter perforation of superior vena cava. The symptoms of this complication (chest pain, dyspnoea) are not specific. Diagnosis should be confirmed by chest x-ray and computerized tomography which show hydromediastinum and pleural effusion. Removal and subsequent culture of the catheter tip will confirm infection. Appropriate antibiotic therapy, guided by sensitivities of the cultured organisms, should be commenced. Any pleural effusion should be drained by thoracocentesis, and the pleural fluid cultured. In case of fever, bacteraemia or shock, a thoracotomy to drain mediastinal and pleural effusions may be considered.

Acute Mediastinitis Due to Extravasation of Parenteral Nutritional Formula via a Central Venous Catheter

“…5 An infectious source can lead to bacterial mediastinitis, complicating vascular perforation by a CVC. 1 In our case, the sudden onset of respiratory insufficiency 6 days after placement of a CVC, the lack of fever, and the negative results of cultures suggest, as in other reported cases, that leakage of parenteral nutritional formula from the CVC migrated into the mediastinum, causing chemical mediastinitis. 4 The lack of blood in the pleural effusion and the mediastinum, as in our case, has been reported previously.…”

“…Previous studies 1,5 have indicated that the risk of perforation is greater with left-sided CVCs than with right-sided CVCs. The predisposition of catheters inserted through the left subclavian or left internal jugular vein to perforate the vessel probably is due to the horizontal orientation of the left brachiocephalic vein.…”

“…1,2 The most common complications of CVC placement include infection, phlebitis, catheter failure, thrombosis, bleeding, excessive pain at the insertion site, and malposition of the catheter. 2,3 Nevertheless, the development of vascular erosion after or during CVC placement, a development that may cause mediastinitis, is extremely uncommon; the reported incidence ranges from 0.17% to 0.4%.…”

“…This delayed vascular injury (perforation of a blood vessel by a CVC several days after placement) has 2 suggested mechanisms. 1,3,4 The first mechanism is mechanical trauma from the catheter tip against the wall of the vessel days after placement. The more perpendicular the catheter tip is to the wall of the vein, the greater is the risk of perforation.…”

Perforation of the superior vena cava after subclavian catheterization: a rare complication after autologous PBSCT

“…7 The more perpendicular the catheter tip to the wall of the vein, the greater the risk of perforation. 6,8,9 Catheters inserted through the left subclavian or internal jugular vein are more likely to cause perforation, because the innominate vein forms a right angle to the SVC and the catheter tip may be positioned against the lateral wall of the SVC with a wide angle. 4,6,8,10 In conclusion, any unexplained respiratory deterioration should arouse suspicion of catheter erosion and clinicians should recognize the development of a pleural effusion as a potential delayed complication, days after apparently successful central venous catheter placement.…”