Straight Puncture, Wrong Turn: Dialysis Catheter Tip in the Axillary Vein

A 6-year-old female with acute-on-CKD presented with fever, vomiting, abdominal pain, and respiratory distress. Laboratory evaluation showed severe uremia (urea 227 mg/dL, creatinine 11.35 mg/dL) and metabolic acidosis (bicarbonate 5.5 mEq/L). To initiate hemodialysis (HD), an 8.5-F double-lumen temporary HD catheter was inserted into the right internal jugular vein (IJV) under real-time ultrasound guidance, and both ports had good backflow. A post-procedure chest radiograph demonstrated lateral diversion with the tip in the right axillary vein [Figure 1]. It was removed, and a new catheter was placed via the left IJV under ultrasound guidance; a confirmatory radiograph showed appropriate position at the cavoatrial junction, after which dialysis proceeded uneventfully. The right IJV is preferred for HD access because of its straight course to the superior vena cava.¹ However, wire or catheter diversion into the ipsilateral subclavian vein can happen because of anatomical variation or guidewire behavior, even when ultrasound-guided venipuncture is used.² Reported malposition rates for right-sided cannulation are ∼4%, with higher rates for left-sided approaches due to anatomical differences.^1-3 Malposition is associated with risks of catheter dysfunction, thrombosis, and vessel injury, warranting prompt recognition and correction.¹ Current recommendations support ultrasound guidance for insertion, fluoroscopy-based confirmation of a caudal wire path and intrathoracic tip position when available, and post-placement imaging.¹ Figure 1 illustrates HD catheter malposition into the axillary vein despite real-time ultrasound-guided venipuncture. This is an underreported scenario, especially in pediatrics. Correct venipuncture does not guarantee proper tip placement, and our case highlights the importance of immediate imaging before use to confirm the tip’s position.

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Figure 1:

Anterior-posterior chest radiograph showing the right internal jugular hemodialysis catheter coursing laterally with the tip in the right axillary vein (white arrow).

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