Anatomical patterns and clinical outcomes of central venous catheter malpositions: A systematic review of published case reports and case series.

Abstract

Background and aims: Central venous catheter (CVC) malpositions remain an underdiscussed complication despite their widespread recognition. This systematic review includes the published case reports to identify anatomical patterns of malposition, associated risk factors, detection strategies, and preventable causes of harm.

Methods: A systematic search of PubMed, Embase, and Scopus was conducted for all the relevant articles from inception and published till December 2025. Two reviewers independently extracted data on demographics, catheter type, insertion site, mechanism of malposition, methods of detection, complications during procedure, and patient outcomes.

Results: Sixty-six articles including 75 cases across 20 countries were included. The patient's age ranged from 19 to 90 years. The left internal jugular vein was most frequently associated with severe malpositions, including the perforation of the left brachiocephalic vein, mediastinal haematoma, and aberrant cannulation of the left internal mammary, accessory hemizygous and peri-cardio-phrenic veins. Malpositions occurred despite ultrasound guidance in many of the cases. Anatomical variants such as persistent left superior vena cava, anomalous pulmonary venous connections, and right-sided aortic arch were implicated but were often unrecognised. Chest radiograph was the primary detection method but was found insufficient in many cases, requiring computed tomography or trans-oesophageal echocardiography. There were six deaths which were directly attributed to malposition and predominantly occurred from delayed recognition of the complication.

Conclusion: To conclude, CVC malposition is a frequent, multifactorial complication with significant patient safety implications. Multimodal prevention strategies (e.g., ultrasound guidance, appropriate guidewire selection, vigilance during the procedure, and routine post-procedure imaging) can significantly reduce the incidence of CVC malposition and morbidity. Awareness of anatomical variants and technical pitfalls is essential for the procedure.