The implanted venous catheter was placed under fluoroscopic guidance by surgeons; no static image was obtained postoperatively.

The patient received chemotherapy via this port for 8 weeks. Despite its inadvertent malposition, there had been good response to chemotherapy by the breast cancer.

Following the chest x-ray, fluoroscopy confirmed extravascular pleural course of implanted venous catheter, which was confirmed on CT. The next day, a VATS was performed and the port removed; the pleural effusion was not bloody. At that time it was confirmed that the port was in the pleural space all along and the chemotherapy was absorbed by the pleural membrane into the bloodstream effectively.

Important lesson: It is very important to ensure ports are intravascular by aspirating blood before infusing drugs.