Looping of a central venous catheter during pediatric cardiac surgery

Although several complications with central venous catheters have been discussed extensively, intravascular migration is uncommon and often goes unrecognized during surgery. We present a case of central venous catheter looping into the left innominate vein after cardiopulmonary bypass during pediatric cardiac surgery. The clinical signs of a lack of backflow from the central venous catheter and different catheter tip positions on transesophageal echocardiography should alert clinicians to the possibility of intravascular migration.