Delayed hydrothorax following percutaneous central venous cannulation

Isolated cases of delayed complications associated with prolonged use of percutaneous central venous lines have been reported. We report four patients who developed hydrothorax more than 24 h after central venous cannulation due to perforation of an intrathoracic vein wall by the catheter tip. The patients were all adults of average body habitus. Left-sided catheters were placed in the operating room after anesthetic induction by experienced personnel using the Seldinger technique and secured in position with a dressing and tape. Chest x-rays taken in the recovery room showed all catheter tips terminated in the central vein and no evidence of hydrothorax. Hydrothorax was manifested in the post-operative period and occurred 1-7 days postcannulation. We are left with the conclusion that the delayed hydrothorax resulted from gradual penetration of the vein wall by the catheter tip. We feel a combination of factors probably contributed to the vein wall erosion. First, the insecure fixation of the catheter combined with head, neck, and cardiopulmonary motion has been shown to result in the back-and-forth movement of the catheter tip. Second, the stiff catheters in the left jugular system take a curved course to the superior vena cava bringing the catheter tip into close proximity to the wall of the superior vena cava. We therefore conclude that late developing hydrothorax can be minimized by using a soft, pliable catheter, sutured firmly in place. Right-sided line placement is preferable to left-sided placement because of the anatomic relationships.