Catheter malposition leading to superior vena cava perforation: A rare but serious complication of hemodialysis access.

BACKGROUND: Central venous catheterization through the internal jugular vein is a standard procedure for hemodialysis access in end-stage renal disease (ESRD). Although generally safe, serious and life-threatening complications can occur. CASE PRESENTATION: We present a rare case of superior vena cava (SVC) perforation during tunneled dialysis catheter (PermCath) insertion in a patient with chronic renal failure. The injury led to mediastinal hematoma, bilateral hemothoraces, and hemorrhagic shock, requiring emergency thoracotomy and surgical repair. DISCUSSION: Perforation of the SVC is an exceptionally rare but critical complication of central venous catheterization. Early symptoms are often nonspecific, making diagnosis challenging. Imaging modalities such as ultrasonography and urgent computed tomography (CT) are vital for detecting extravascular catheter placement and associated mediastinal bleeding. CONCLUSION: Early recognition and coordinated management were crucial in stabilizing the patient. Following emergency thoracotomy and surgical repair, the patient achieved hemodynamic recovery and was successfully weaned from ventilatory support. This case highlights the importance of high clinical vigilance, appropriate imaging, and multidisciplinary coordination in the early recognition and management of catheter-related vascular injuries.