Keywords
central venous cannulation - computed tomography angiography - imaging - vascular
injury - sternotomy
A 22-year-old male with underlying end-stage renal failure was referred to our center
for a malpositioned dialysis catheter. He has been on regular continuous ambulatory
peritoneal dialysis via a Tenckhoff's catheter; however, suspicion of a blocked catheter
necessitated its removal.
Right internal jugular dialysis catheter (size, 16 French) was inserted via an anatomical
landmark technique.
After insertion, pulsatile flow, as well as an appearance of oxygenated blood, raised
suspicion of an inadvertent arterial injury. No obvious hematoma was clinically observed,
and the patient did not report neurological or obstructive symptoms. He was clinically
stable.
An urgent computed tomography angiography (CTA) revealed the catheter puncturing through
the medial aspect of the right internal jugular vein, and entering the right subclavian
artery (black arrow, [Fig. 1]), and passing retrograde into the brachiocephalic trunk, where the tip was seen
(white arrow, [Fig. 1]). Minimal hematoma was observed. A cardiothoracic surgery referral was sought.
Fig. 1 Computed tomography angiography image, in coronal section, showing the course of
the malpositioned dialysis catheter, after puncturing through the internal jugular
vein (medial aspect). The catheter is seen to course through the right subclavian
artery (black arrow), with the tip within the brachiocephalic trunk (white arrow).
A partial sternotomy, exploration of the subclavian and jugular vessels and surgical
catheter removal were done. Intraoperatively, the catheter was seen exiting the right
internal jugular vein at its medial aspect, penetrating the right subclavian artery
at its superior aspect. The catheter could be felt within the right subclavian artery
and the brachiocephalic trunk. The catheter was then removed, and the right subclavian
artery was clamped both proximally and distally. The injured vessels were repaired
using prolene 5/0. No overt hematoma was seen.
The patient recovered well postoperatively and was discharged on day 3. Postoperative
radiograph did not show any complications ([Fig. 2]).
Fig. 2 Postoperative frontal chest radiograph on outpatient follow-up was normal.
Central venous catheters are used routinely in clinical practice for a multitude of
reasons as follows: venous access, prolonged antibiotics administration, nutritional
support, as well as in managing perioperative fluid status. However, insertion of
these catheters poses associated risks, among them being inadvertent arterial puncture,
which can occur in up to 6% of patients when using external landmark techniques.[1] Complications that may accompany arterial injuries include hematoma formation, stroke,
fistula, development of pseudoaneurysms, and death.
Central venous catheter insertion via ultrasound guidance has been shown in multiple
studies to reduce catheter-related complications by up to 71%.[2] However, this technique, albeit preferable, is not routinely practiced at this patient's
referring center.
When arterial injuries do occur, management has to be tailored on a case-by-case basis,
taking into account the expertise and services available in a particular institution.
The catheter is secured to prevent movement or dislodgment, followed by cross-sectional
imaging via CT or magnetic resonance imaging, to better delineate the position of
the catheter, guiding subsequent treatment approach.
In our center, the cardiothoracic surgery service is readily available, hence the
surgical approach was conducted.
An alternative technique would be via an endovascular approach, utilizing covered
stents, balloon tamponade, or vascular closure devices.[3]
