# Catheter Misplacement Revealing Partial Anomalous Pulmonary Venous Return (PAPVR) in an Acute Kidney Injury Patient

## TL;DR

A patient with acute kidney injury had a dialysis catheter mistakenly placed into an unusual blood vessel, revealing a rare heart condition.

## Contribution

This case highlights the incidental detection of PAPVR during routine catheter placement in ICU settings.

## Key findings

- Catheter misplacement revealed an anomalous left pulmonary vein in an ICU patient.
- Imaging confirmed the rare condition of partial anomalous pulmonary venous return.
- CVC misplacement into PAPVR is a rare but important complication in critical care.

## Abstract

An 84-year-old patient, treated in the ICU for acute kidney injury complicating coronary artery bypass surgery, experienced an unusual event during dialysis catheter placement. First, venous blood was drawn while the catheter was inserted into the left internal jugular vein. Ultrasound confirmed the proper guidewire placement, and the dilator and catheter were inserted without difficulty. However, the blood returned from the catheter was unexpectedly bright, raising concerns for arterial placement. Transduced pressures were pulsatile, but levels were inconsistent with arterial positioning. A subsequent chest x-ray revealed the catheter extending into the left mediastinum, and CT imaging confirmed the catheter was inadvertently placed in an anomalous left pulmonary vein. Misplacement of central venous catheters (CVCs) into partial anomalous pulmonary venous return (PAPVR) has been sporadically reported. As imaging modalities, such as CT and MRI, become more prevalent in intensive care practice, incidental detection of PAPVR is expected to increase. Management typically involves removal and repositioning of the catheter, though the decision to treat the PAPVR itself remains nuanced and is based on factors such as pulmonary hypertension risk and shunt volume.