Delayed Superior Vena Cava Perforation: A Rare and Life-Threatening Complication of Central Venous Cannulation

Delayed Superior Vena Cava Perforation: A Rare and Life-Threatening Complication of Central Venous Cannulation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Delayed Superior Vena Cava Perforation: A Rare and Life-Threatening Complication of Central Venous Cannulation Manish Singh, Simple Gupta, Deepu Peter, Arpit Garg, Vandana Rani, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8521300/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Mar, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted 14 You are reading this latest preprint version Abstract Background - Central venous catheterization (CVC) is routinely performed in critically ill patients and is generally considered safe, particularly with ultrasound guidance. However, rare and potentially fatal delayed complications may still occur. Delayed perforation of the superior vena cava (SVC) is exceedingly uncommon and often under-recognized, especially following right-sided catheterization. Case Presentation - We report the case of a 63-year-old woman with no significant comorbidities who underwent ultrasound-guided right subclavian central venous catheterization prior to emergency surgery for small bowel obstruction. The procedure and immediate postoperative period were uneventful, and post-insertion chest radiography showed no abnormalities. Thirty hours later, the patient developed acute respiratory distress, hypotension, and oliguria. Imaging revealed a massive right-sided pleural effusion. Intercostal drainage yielded approximately 2.5 liters of clear, colorless fluid with biochemical features consistent with hydrothorax. The central venous catheter was promptly removed. Despite aggressive supportive management, the patient progressed to refractory septic shock and died on postoperative day 12. Conclusion - This case highlights delayed SVC perforation as a rare but catastrophic complication of central venous catheterization, even when performed under ultrasound guidance using right-sided access and soft catheters. Clinicians should maintain a high index of suspicion for catheter-related vascular injury in patients presenting with unexplained pleural effusion or hemodynamic instability after recent central venous access. Early recognition remains crucial, although prevention through meticulous technique and vigilant post-procedural monitoring is paramount. Central venous catheterization Superior vena cava perforation Delayed complication Hydrothorax Pleural effusion Central line–associated injury Figures Figure 1 Figure 2 Figure 3 Background Central venous catheterization (CVC) remains a cornerstone in the management of critically ill patients, allowing for administration of vasoactive drugs, parenteral nutrition, and hemodynamic monitoring. The advent of ultrasound guidance has markedly reduced the incidence of complications such as pneumothorax and arterial puncture [ 1 – 3 ]. However, rare but severe delayed complications, including superior vena cava (SVC) perforation, continue to pose diagnostic and therapeutic challenges. SVC perforation is typically associated with mechanical trauma during insertion or catheter malposition. While most reports describe early-onset complications, delayed perforation occurring more than 24 hours post-insertion is extremely uncommon and can be easily missed. The resulting fluid accumulation, whether haemothorax or hydrothorax, may mimic other postoperative complications unless a high index of suspicion is maintained. We present an unusual case of delayed right-sided SVC perforation leading to massive hydrothorax and eventual circulatory collapse in a patient who had undergone otherwise uncomplicated central venous cannulation under ultrasound guidance. Case Presentation A 63-year-old woman with no significant comorbidities presented with acute crampy abdominal pain, nausea, vomiting, fever, and abdominal distension. She was diagnosed with severe small bowel obstruction requiring emergency surgery. Prior to surgery, an ultrasound-guided right subclavian central venous catheter (7.5 Fr, triple-lumen polyurethane) was inserted by an experienced anaesthesiologist. Blood return was confirmed in all lumens, and the post-procedure chest X-ray was unremarkable. The surgery and immediate postoperative course were uneventful. However, 30 hours postoperatively, the patient developed respiratory distress, tachycardia, hypotension, and oliguria. Chest examination revealed absent breath sounds and dullness to percussion on the right side. A chest radiograph revealed a massive right-sided pleural effusion (Fig. 1 ). Diagnostic and therapeutic pleurocentesis was performed, and a 28 Fr intercostal drain was placed under sterile conditions (Fig. 2 ). Approximately 2.5 Liters of clear, colourless fluid was drained (Fig. 3). Fluid analysis revealed: protein 0.2 g/dL, LDH 34 IU/L, total cell count < 100/cumm, sodium 142 mEq/L, chloride 136 mEq/L, and pH 6.2. Microbiological studies were negative. The central venous catheter was removed immediately. Despite broad-spectrum antibiotics and supportive care, the patient deteriorated, developing septic shock requiring triple vasopressor support and mechanical ventilation. She succumbed to her illness on the 12th postoperative day. Discussion and conclusion Central venous access is integral to the care of critically ill patients, but it is not without risk. Complications may be immediate or delayed and range from benign to life-threatening (Table 1 ). Table 1 Complications of Central Venous Cannulation Immediate Complications Delayed Complications Bleeding Infection Arterial puncture Venous thrombosis, pulmonary embolism Arrhythmia Venous stenosis Air embolism Catheter malfunction Thoracic duct injury Catheter migration Catheter malposition Catheter embolization Pneumothorax or hemothorax Myocardial perforation, nerve injury Among the most serious yet rarely reported delayed complications is superior vena cava (SVC) perforation. Though typically associated with catheter malposition or direct trauma during insertion, delayed perforation occurring more than 24 hours post-cannulation is exceptionally uncommon, especially with right-sided, ultrasound-guided approaches. While left-sided catheter placements are more frequently implicated due to the acute angle between the catheter and the SVC wall [ 4 – 6 ], this case illustrates that delayed SVC perforation can occur even with optimal conditions, including right-sided access, polyurethane catheters, confirmed blood return, and unremarkable initial imaging. The pathogenesis in such delayed cases likely involves subtle mechanical irritation of the vessel wall, compounded by patient movement or changes in intrathoracic pressure over time. Clinically, the presentation of delayed SVC perforation is often nonspecific and insidious, potentially masquerading as pulmonary, infectious, or cardiac complications. In this case, massive pleural effusion and hemodynamic compromise developed over 30 hours following catheter insertion, with pleural fluid characteristics suggesting hydrothorax rather than haemorrhage. The absence of infection and the rapid accumulation of clear fluid with low protein content should prompt suspicion of catheter-related venous perforation, especially when no other source is evident. Radiographic signs such as the “curved-tip sign” on lateral chest X-ray may serve as early warnings [ 7 ] but are often absent or missed in real-time. Prompt diagnosis and immediate removal of the catheter are essential, but as this case demonstrates, even timely intervention may not prevent poor outcomes once catastrophic sequelae have set in. Delayed perforation of the superior vena cava is a rare but potentially fatal complication of central venous catheterization, even when performed under ultrasound guidance using right-sided access and soft catheters. This case highlights the critical need for clinicians to maintain a high index of suspicion for delayed SVC injury in patients who develop unexplained pleural effusion, respiratory distress, or hemodynamic instability after recent central venous cannulation. Early recognition and prompt catheter removal are key to mitigating harm, but preventive strategies—including vigilant catheter tip positioning, secure fixation, and close post-procedure monitoring—remain the best defense. As this case tragically illustrates, even well-placed lines can result in delayed complications, reinforcing the importance of ongoing vigilance beyond the procedural moment. Abbreviations CVC Central venous catheterization SVC Superior vena cava LDH Lactate dehydrogenase Declarations Ethics approval and consent to participate - Not applicable. Consent for publication - Written informed consent for publication was obtained from the patient’s legally authorized representative. Funding - No external funding was received for this study. Authors’ contributions - MS, SG and DP conceptualized the study, drafted the manuscript and contributed to clinical management and critical revision. AG, VR, and SS reviewed the literature and revised the manuscript. All authors read and approved the final manuscript. Author Contribution MS, SG and DP conceptualized the study, drafted the manuscript and contributed to clinical management and critical revision. AG, VR, and SS reviewed the literature and revised the manuscript. All authors read and approved the final manuscript. Acknowledgement The authors thank the intensive care and nursing staff involved in the patient’s management. Availability of data and materials - Not applicable. Competing interests - The authors declare that they have no competing interests. References Taylor RW, Palagiri AV. Central venous catheterization. Crit Care Med. 2007;35:1390–6. https://doi.org/10.1097/01.CCM.0000260241.80346.1B . Nelson BP, Noble VE, editors. Vascular access. In: Manual of Emergency and Critical Care Ultrasound. 2nd edition. Cambridge: Cambridge University Press; 2011. pp. 273–96. https://doi.org/10.1017/CBO9780511734281.017 Abboud P-AC, Kendall JL. Ultrasound guidance for vascular access. Emerg Med Clin North Am. 2004;22:749–73. https://doi.org/10.1016/j.emc.2004.04.003 . Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth. 2000;85:188–91. https://doi.org/10.1093/bja/85.2.188 . Barton BR, Hermann G, Weil R. Cardiothoracic emergencies associated with subclavian hemodialysis catheters. JAMA. 1983;250:2660–2. Booth SA, Norton B, Mulvey DA. Central venous catheterization and fatal cardiac tamponade. BJA: Br J Anaesth. 2001;87:298–302. https://doi.org/10.1093/bja/87.2.298 . Tocino IM, Watanabe A. Impending catheter perforation of superior vena cava: radiographic recognition. AJR Am J Roentgenol. 1986;146:487–90. https://doi.org/10.2214/ajr.146.3.487 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Mar, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 06 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviews received at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviews received at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers invited by journal 29 Jan, 2026 Editor assigned by journal 07 Jan, 2026 Submission checks completed at journal 07 Jan, 2026 First submitted to journal 05 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":33905,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePortable chest radiograph showing right sided pleural effusion and right sided subclavian central line insitu.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8521300/v1/4064e365a9b367dc88e2c9c4.jpeg"},{"id":100399674,"identity":"f4e59fca-017f-4c00-b8a2-1fdb755a55be","added_by":"auto","created_at":"2026-01-16 11:57:31","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":110258,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePortable chest radiograph showing intercostal drainage insitu and resolution of right sided pleural effusion and removal of right subclavian central line.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8521300/v1/4b77aa903be6d54cab3e5d2d.jpeg"},{"id":100399858,"identity":"6aff8c7d-502c-4ac2-9a7f-3ea0158fb98e","added_by":"auto","created_at":"2026-01-16 11:57:40","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":63186,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eClear drained fluid from right sided pleural effusion.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8521300/v1/b4628fd7472111514e1fe853.jpeg"},{"id":104739320,"identity":"ab98483e-9a28-4e02-92a6-4eaf54e87171","added_by":"auto","created_at":"2026-03-16 16:01:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":746140,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8521300/v1/385867c9-ce48-44a2-8852-e6ddb02f9ae4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDelayed Superior Vena Cava Perforation: A Rare and Life-Threatening Complication of Central Venous Cannulation\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eCentral venous catheterization (CVC) remains a cornerstone in the management of critically ill patients, allowing for administration of vasoactive drugs, parenteral nutrition, and hemodynamic monitoring. The advent of ultrasound guidance has markedly reduced the incidence of complications such as pneumothorax and arterial puncture [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, rare but severe delayed complications, including superior vena cava (SVC) perforation, continue to pose diagnostic and therapeutic challenges.\u003c/p\u003e \u003cp\u003eSVC perforation is typically associated with mechanical trauma during insertion or catheter malposition. While most reports describe early-onset complications, delayed perforation occurring more than 24 hours post-insertion is extremely uncommon and can be easily missed. The resulting fluid accumulation, whether haemothorax or hydrothorax, may mimic other postoperative complications unless a high index of suspicion is maintained.\u003c/p\u003e \u003cp\u003eWe present an unusual case of delayed right-sided SVC perforation leading to massive hydrothorax and eventual circulatory collapse in a patient who had undergone otherwise uncomplicated central venous cannulation under ultrasound guidance.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e \u003c/p\u003e \u003cp\u003eA 63-year-old woman with no significant comorbidities presented with acute crampy abdominal pain, nausea, vomiting, fever, and abdominal distension. She was diagnosed with severe small bowel obstruction requiring emergency surgery. Prior to surgery, an ultrasound-guided right subclavian central venous catheter (7.5 Fr, triple-lumen polyurethane) was inserted by an experienced anaesthesiologist. Blood return was confirmed in all lumens, and the post-procedure chest X-ray was unremarkable. The surgery and immediate postoperative course were uneventful. However, 30 hours postoperatively, the patient developed respiratory distress, tachycardia, hypotension, and oliguria. Chest examination revealed absent breath sounds and dullness to percussion on the right side. A chest radiograph revealed a massive right-sided pleural effusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDiagnostic and therapeutic pleurocentesis was performed, and a 28 Fr intercostal drain was placed under sterile conditions (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eApproximately 2.5 Liters of clear, colourless fluid was drained (Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eFluid analysis revealed: protein 0.2 g/dL, LDH 34 IU/L, total cell count \u0026lt; 100/cumm, sodium 142 mEq/L, chloride 136 mEq/L, and pH 6.2. Microbiological studies were negative. The central venous catheter was removed immediately. Despite broad-spectrum antibiotics and supportive care, the patient deteriorated, developing septic shock requiring triple vasopressor support and mechanical ventilation. She succumbed to her illness on the 12th postoperative day.\u003c/p\u003e "},{"header":"Discussion and conclusion","content":"\u003cp\u003eCentral venous access is integral to the care of critically ill patients, but it is not without risk. Complications may be immediate or delayed and range from benign to life-threatening (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications of Central Venous Cannulation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmediate Complications\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelayed Complications\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial puncture\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVenous thrombosis, pulmonary embolism\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrhythmia\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVenous stenosis\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAir embolism\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatheter malfunction\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic duct injury\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatheter migration\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheter malposition\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatheter embolization\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumothorax or hemothorax\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyocardial perforation, nerve injury\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAmong the most serious yet rarely reported delayed complications is superior vena cava (SVC) perforation. Though typically associated with catheter malposition or direct trauma during insertion, delayed perforation occurring more than 24 hours post-cannulation is exceptionally uncommon, especially with right-sided, ultrasound-guided approaches.\u003c/p\u003e\u003cp\u003eWhile left-sided catheter placements are more frequently implicated due to the acute angle between the catheter and the SVC wall [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], this case illustrates that delayed SVC perforation can occur even with optimal conditions, including right-sided access, polyurethane catheters, confirmed blood return, and unremarkable initial imaging. The pathogenesis in such delayed cases likely involves subtle mechanical irritation of the vessel wall, compounded by patient movement or changes in intrathoracic pressure over time.\u003c/p\u003e\u003cp\u003eClinically, the presentation of delayed SVC perforation is often nonspecific and insidious, potentially masquerading as pulmonary, infectious, or cardiac complications. In this case, massive pleural effusion and hemodynamic compromise developed over 30 hours following catheter insertion, with pleural fluid characteristics suggesting hydrothorax rather than haemorrhage. The absence of infection and the rapid accumulation of clear fluid with low protein content should prompt suspicion of catheter-related venous perforation, especially when no other source is evident.\u003c/p\u003e\u003cp\u003eRadiographic signs such as the “curved-tip sign” on lateral chest X-ray may serve as early warnings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] but are often absent or missed in real-time. Prompt diagnosis and immediate removal of the catheter are essential, but as this case demonstrates, even timely intervention may not prevent poor outcomes once catastrophic sequelae have set in.\u003c/p\u003e\u003cp\u003eDelayed perforation of the superior vena cava is a rare but potentially fatal complication of central venous catheterization, even when performed under ultrasound guidance using right-sided access and soft catheters. This case highlights the critical need for clinicians to maintain a high index of suspicion for delayed SVC injury in patients who develop unexplained pleural effusion, respiratory distress, or hemodynamic instability after recent central venous cannulation.\u003c/p\u003e\u003cp\u003eEarly recognition and prompt catheter removal are key to mitigating harm, but preventive strategies—including vigilant catheter tip positioning, secure fixation, and close post-procedure monitoring—remain the best defense. As this case tragically illustrates, even well-placed lines can result in delayed complications, reinforcing the importance of ongoing vigilance beyond the procedural moment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral venous catheterization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSVC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSuperior vena cava\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLactate dehydrogenase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate -\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication -\u003c/strong\u003e \u003cp\u003e Written informed consent for publication was obtained from the patient\u0026rsquo;s legally authorized representative.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding -\u003c/h2\u003e \u003cp\u003eNo external funding was received for this study.\u003c/p\u003e \u003cp\u003e \u003cem\u003eAuthors\u0026rsquo; contributions -\u003c/em\u003e MS, SG and DP conceptualized the study, drafted the manuscript and contributed to clinical management and critical revision. AG, VR, and SS reviewed the literature and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMS, SG and DP conceptualized the study, drafted the manuscript and contributed to clinical management and critical revision. AG, VR, and SS reviewed the literature and revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the intensive care and nursing staff involved in the patient\u0026rsquo;s management.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials -\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCompeting interests -\u003c/em\u003e The authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTaylor RW, Palagiri AV. Central venous catheterization. Crit Care Med. 2007;35:1390\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.CCM.0000260241.80346.1B\u003c/span\u003e\u003cspan address=\"10.1097/01.CCM.0000260241.80346.1B\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson BP, Noble VE, editors. Vascular access. In: Manual of Emergency and Critical Care Ultrasound. 2nd edition. Cambridge: Cambridge University Press; 2011. pp. 273\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/CBO9780511734281.017\u003c/span\u003e\u003cspan address=\"10.1017/CBO9780511734281.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbboud P-AC, Kendall JL. Ultrasound guidance for vascular access. Emerg Med Clin North Am. 2004;22:749\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.emc.2004.04.003\u003c/span\u003e\u003cspan address=\"10.1016/j.emc.2004.04.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth. 2000;85:188\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bja/85.2.188\u003c/span\u003e\u003cspan address=\"10.1093/bja/85.2.188\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarton BR, Hermann G, Weil R. Cardiothoracic emergencies associated with subclavian hemodialysis catheters. JAMA. 1983;250:2660\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBooth SA, Norton B, Mulvey DA. Central venous catheterization and fatal cardiac tamponade. BJA: Br J Anaesth. 2001;87:298\u0026ndash;302. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/bja/87.2.298\u003c/span\u003e\u003cspan address=\"10.1093/bja/87.2.298\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTocino IM, Watanabe A. Impending catheter perforation of superior vena cava: radiographic recognition. AJR Am J Roentgenol. 1986;146:487\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2214/ajr.146.3.487\u003c/span\u003e\u003cspan address=\"10.2214/ajr.146.3.487\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Central venous catheterization, Superior vena cava perforation, Delayed complication, Hydrothorax, Pleural effusion, Central line–associated injury","lastPublishedDoi":"10.21203/rs.3.rs-8521300/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8521300/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground -\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCentral venous catheterization (CVC) is routinely performed in critically ill patients and is generally considered safe, particularly with ultrasound guidance. However, rare and potentially fatal delayed complications may still occur. Delayed perforation of the superior vena cava (SVC) is exceedingly uncommon and often under-recognized, especially following right-sided catheterization.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase Presentation -\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe report the case of a 63-year-old woman with no significant comorbidities who underwent ultrasound-guided right subclavian central venous catheterization prior to emergency surgery for small bowel obstruction. The procedure and immediate postoperative period were uneventful, and post-insertion chest radiography showed no abnormalities. Thirty hours later, the patient developed acute respiratory distress, hypotension, and oliguria. Imaging revealed a massive right-sided pleural effusion. Intercostal drainage yielded approximately 2.5 liters of clear, colorless fluid with biochemical features consistent with hydrothorax. The central venous catheter was promptly removed. Despite aggressive supportive management, the patient progressed to refractory septic shock and died on postoperative day 12.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion -\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis case highlights delayed SVC perforation as a rare but catastrophic complication of central venous catheterization, even when performed under ultrasound guidance using right-sided access and soft catheters. Clinicians should maintain a high index of suspicion for catheter-related vascular injury in patients presenting with unexplained pleural effusion or hemodynamic instability after recent central venous access. Early recognition remains crucial, although prevention through meticulous technique and vigilant post-procedural monitoring is paramount.\u003c/p\u003e","manuscriptTitle":"Delayed Superior Vena Cava Perforation: A Rare and Life-Threatening Complication of Central Venous Cannulation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 08:52:35","doi":"10.21203/rs.3.rs-8521300/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-06T22:35:39+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"65884210559451375907226541719960304801","date":"2026-02-06T01:30:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T18:05:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46931057210742784300708907116671786894","date":"2026-02-02T03:14:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323521514470457316659853068110273470780","date":"2026-02-01T14:40:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T20:09:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313658268518323213031386606287976970407","date":"2026-01-29T19:08:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T07:29:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304644522604539222546226661421797846866","date":"2026-01-29T07:11:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102040986772157852516619613269696296904","date":"2026-01-29T07:10:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T06:46:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-07T07:34:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T07:31:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2026-01-05T12:02:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0bf3d32c-8de5-4602-8c8b-cb257ea12a44","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:01:08+00:00","versionOfRecord":{"articleIdentity":"rs-8521300","link":"https://doi.org/10.1186/s12245-026-01168-3","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2026-03-14 15:58:05","publishedOnDateReadable":"March 14th, 2026"},"versionCreatedAt":"2026-01-16 08:52:35","video":"","vorDoi":"10.1186/s12245-026-01168-3","vorDoiUrl":"https://doi.org/10.1186/s12245-026-01168-3","workflowStages":[]},"version":"v1","identity":"rs-8521300","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8521300","identity":"rs-8521300","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}