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

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.