Angiographic images through a 16 French hemostatic sheath placed via a left common femoral vein approach established a patent left common iliac vein and IVC with cranial migration of the bullet, now residing at inferior cavoatrial junction. Through the hemostatic sheath, a cloverleaf snare device was used to grasp and retract the foreign body into the left common femoral vein (Figure 4).
In our case, retrograde migration led the bullet from the right atrium to the IVC; subsequent antegrade migration resulted in the bullet residing at the inferior cavoatrial junction at the time of retrieval.
Towbin, "Cavoatrial junction
and central venous anatomy: implications for central venous access tip position," Journal of Vascular and Interventional Radiology, vol.
Descending down the anterolateral wall of SVC, it turns posteriorly as it approaches the superior cavoatrial junction
and follows in close proximity to the rightsided pulmonary veins.
Several studies mention cavoatrial junction as the preferred site10.
In some studies which have kept middle to lower parts of Superior Vena Cava as positions of choice for catheter tip along with cavoatrial junction, complication rates as high as 56% have been reported6,7.
It is then advanced proximally toward the heart through increasingly larger veins until the tip rests in the distal superior vena cava or cavoatrial junction
. The device has two openings called as lumens used to deliver medications.
Afterwards, the access was extended by an additional perpendicular incision (T-shaped diaphragmotomy) and the tourniquet was passed around the cavoatrial junction
area (Figure 3).
The 6-French catheter of the port set (Titanium Low-Profile Implantable Port, Bard Access System Inc., Salt Lake City, USA) was then inserted over the wire just as easily and without complication or kinking up to the cavoatrial junction
. A port pocket was prepared below the lateral end of the left clavicle, and the port catheter was tunnelled from the puncture side to the pocket completing the procedure as usual (Figure 3).
A chest x-ray obtained after the procedure should raise concerns if the catheter tip does not overlie the expected location of the cavoatrial junction
. Yet, plain film of the chest has substantial limitations in localizing a catheter; cross-sectional imaging and angiography are more likely to provide conclusive localization of a PICC.
Instead, the catheter was identified within the inferior vena cava, with the tip positioned at the lower cavoatrial junction
She presented for routine restaging positron emission tomography/computed tomography (PET/CT) (Figures 1(a) and2(a)2(c)) which showed an F(18) fluorodeoxyglucose (FDG) avid focus in the lower superior vena cava (SVC) just above the cavoatrial junction
adjacent to the catheter tip of her right chest wall port.