Right subclavian catheter perforation of the aorta due to an incorrect external landmark-guided insertion technique

Emergency placement of a right subclavian triple lumen silastic catheter in an obese, unstable postoperative patient caused a perforation of the aorta, resulting in sudden cardiac tamponade. Because this complication was immediately recognized and surgical decompression with suturing of the perforation in the aorta was performed, the patient survived. A standardized approach for all central venous line insertions should be emphasized for all clinicians. Use of ultrasound guidance whenever feasible is encouraged.