Title: Arterial Injury Complicating Subclavian Central Venous Catheter Insertion
Abstract: INADEQUATE PLACEMENT of a subclavian venous catheter in the subclavian artery is a well-known complication.1Mansfield P.F. Hohn D.C. Fornage B.D. et al.Complications and failures of subclavian-vein catheterization.N Engl J Med. 1994; 331: 1735-1738Crossref PubMed Scopus (721) Google Scholar, 2Eisen L.A. Narasimhan M. Berger J.S. et al.Mechanical complications of central venous catheters.J Intensive Care Med. 2006; 21: 40-46Crossref PubMed Scopus (263) Google Scholar Three cases of accidental arterial puncture occurred with the implantation of subclavian venous catheters, 2 of which involved the subclavian artery leading to percutaneous treatment; and the other involved the aortic arch, resulting in surgical management, are described. A 71-year-old man had a sigmoidectomy for sigmoid colon adenocarcinoma. Adjuvant chemotherapy was scheduled, and the insertion of a right subclavian central venous catheter (CVC) was performed without ultrasound guidance (UG). After insertion of the catheter, pulsatile red blood backflow suggested arterial misplacement. Diagnosis was not confirmed by intravascular blood pressure measurements. The patient was transferred immediately to the Vascular Interventional Radiology Unit for further management. Angiography through the subclavian catheter showed subclavian artery opacification (Fig 1). A guidewire was inserted into the subclavian artery through the catheter, allowing the misplaced catheter to be removed. A 6F Angio Seal (St Jude Medical, St Paul, MN) closure device was placed over the guidewire and was deployed correctly, leading to satisfactory hemostasis. The following day, a left subclavian CVC was inserted successfully, and chemotherapy was started thereafter. A 24-year-old woman with Hodgkin's disease was scheduled to receive a subclavian CVC for chemotherapy. The procedure was performed without UG, and no coagulation disorders were present. No adverse event was noted during the procedure; therefore, intravascular pressure was not measured. The following day, red blood backflow was noted at chemotherapy onset. A chest x-ray was performed (Fig 2) showing an unusual catheter path, and arterial misplacement was suspected. The patient was transferred to the Vascular Interventional Radiology Unit, and satisfactory hemostasis was obtained using a 6F Angio Seal device. A contralateral CVC was implanted during the procedure. A follow-up x-ray showed correct catheter placement, and no complications were noted. The patient underwent induction chemotherapy the next day. A 75-year-old woman was admitted to the gastrointestinal ward for acute pancreatitis management. Because of poor peripheral venous access, the patient underwent left subclavian CVC insertion. The procedure was performed without UG, and 3 punctures were necessary to correctly catheterize the subclavian vein because of difficult access in this obese patient. No intravascular blood pressure was measured during the procedure because no immediate abnormalities were noted. The following day, bleeding from the puncture site occurred along with local subcutaneous hematoma, hemodynamic shock, and consciousness impairment. A computed tomography (CT) scan of the brain and chest was performed immediately. The brain CT scan showed no abnormality. On the other hand, the chest CT scan showed vascular contrast blush of the horizontal part of the aortic arch at the root of the brachiocephalic arterial trunk due to a traumatic perforation of the left anterolateral side of the arch (Fig 3). This was associated with a hemomediastinum, hemothorax, and pericardial effusion. The patient underwent immediate surgical management because she suffered from consciousness impairment, acute anemia, and hemodynamic shock. Sternotomy under general anesthesia was performed, and a punctiform perforation of the left anterolateral side of the aortic arch was identified with active bleeding. A U-shaped polypropylene stitch was performed at the puncture site, and immediate hemostasis was obtained. No immediate complications occurred, and the patient was admitted to the an intensive care unit for further management of the acute pancreatitis. Complications after the insertion of subclavian CVCs are quite frequent. A previous study by Mansfield et al1Mansfield P.F. Hohn D.C. Fornage B.D. et al.Complications and failures of subclavian-vein catheterization.N Engl J Med. 1994; 331: 1735-1738Crossref PubMed Scopus (721) Google Scholar reported 9.7% of acute complications. These included catheter misplacement, arterial puncture, and pneumothorax.1Mansfield P.F. Hohn D.C. Fornage B.D. et al.Complications and failures of subclavian-vein catheterization.N Engl J Med. 1994; 331: 1735-1738Crossref PubMed Scopus (721) Google Scholar In the majority of arterial punctures or misplacements, a puncture of the subclavian artery was involved (3.7%).1Mansfield P.F. Hohn D.C. Fornage B.D. et al.Complications and failures of subclavian-vein catheterization.N Engl J Med. 1994; 331: 1735-1738Crossref PubMed Scopus (721) Google Scholar However, aortic arch injury as a complication of subclavian venous catheterization is quite rare, and only a few cases are described in the literature.3Fangio P. Mourgeon E. Romelaer A. et al.Aortic injury and cardiac tamponade as a complication of subclavian venous catheterization.Anesthesiology. 2002; 96: 1520-1522Crossref PubMed Scopus (23) Google Scholar, 4Seleem M.I. Al-Hashemy A.M. Al-Naemi A. Ectopic intra-aortic insertion of a subclavian central venous catheter: Case report and review of the literature.J Thorac Cardiovasc Surg. 2004; 127: 1515-1516Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5Forauer A.R. Dasika N.L. Gemmete J.J. et al.Pericardial tamponade complicating central venous interventions.J Vasc Interv Radiol. 2003; 14: 255-259Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 6Hatfield M.K. Zaleski G.X. Kozlov D. et al.Angio-seal device used for hemostasis in the descending aorta.AJR Am J Roentgenol. 2004; 183: 612-614Crossref PubMed Scopus (15) Google Scholar, 7Patel S.J. Venn G.E. Redwood S.R. Percutaneous closure of an iatrogenic puncture of the aortic arch.Cardiovasc Intervent Radiol. 2003; 26: 407-409Crossref PubMed Scopus (8) Google Scholar, 8Leijdekkers V.J. Go H.L. Legemate D.A. et al.The use of a percutaneous closure device for closure of an accidental puncture of the aortic arch: A simple solution for a difficult problem.Eur J Vasc Endovasc Surg. 2006; 32: 94-96Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In the first 2 cases, percutaneous management was chosen. Several percutaneous management techniques are possible when the catheter is still inserted in the artery, such as with percutaneous closure devices (Angio seal), transthoracic percutaneous injection of glue or thrombin, stent grafting, or embolization. Each case is different, and there are no recommendations concerning the use of such percutaneous management. In these cases, the use of an Angio Seal closing device was chosen. The Angio Seal consists of a self-closing device using an endoluminal anchor to close off the intraluminal part of the puncture hole associated with an extraluminal collagen plug (all parts are biodissolvable). The use of this device necessitates an experienced physician because it is not without risk (eg, hematoma, misplacement, vascular parietal damage).9Chemelli A.P. Wiedermann F. Klocker J. et al.Endovascular management of inadvertent subclavian artery catheterization during subclavian vein cannulation.J Vasc Interv Radiol. 2010; 21: 470-476Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar A few case reports describing the use of self-closing devices for closure of an accidental subclavian artery puncture have been reported in the literature.10Fraizer M.C. Chu W.W. Gudjonsson T. et al.Use of a percutaneous vascular suture device for closure of an inadvertent subclavian artery puncture.Catheter Cardiovasc Interv. 2003; 59: 369-371Crossref PubMed Scopus (31) Google Scholar, 11Wallace M.J. Ahrar K. Percutaneous closure of a subclavian artery injury after inadvertent catheterization.J Vasc Interv Radiol. 2001; 12: 1227-1230Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Each time, the catheter was still inserted in the subclavian artery, making percutaneous management possible. In the 3rd case, surgical management was chosen. Percutaneous management was not possible because the aortic arch injury was diagnosed late after the procedure, and no immediate percutaneous access to the aortic bleeding puncture site was available at the time of diagnosis. The use of an aortic stent graft was not possible because the puncture site was located near the left carotid artery ostium; exclusion of the tear by a covered stent could obstruct the carotid artery. Embolization was excluded because the authors believed that catheterization of the aortic tear might enlarge it. Transthoracic percutaneous injection of glue or thrombin appeared inappropriate because of the high risk of migration due to a constant flow of the leak seen on CT images. Case reports describing aortic arch injury after CVC with percutaneous management previously have been reported in the literature3Fangio P. Mourgeon E. Romelaer A. et al.Aortic injury and cardiac tamponade as a complication of subclavian venous catheterization.Anesthesiology. 2002; 96: 1520-1522Crossref PubMed Scopus (23) Google Scholar, 4Seleem M.I. Al-Hashemy A.M. Al-Naemi A. Ectopic intra-aortic insertion of a subclavian central venous catheter: Case report and review of the literature.J Thorac Cardiovasc Surg. 2004; 127: 1515-1516Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5Forauer A.R. Dasika N.L. Gemmete J.J. et al.Pericardial tamponade complicating central venous interventions.J Vasc Interv Radiol. 2003; 14: 255-259Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 6Hatfield M.K. Zaleski G.X. Kozlov D. et al.Angio-seal device used for hemostasis in the descending aorta.AJR Am J Roentgenol. 2004; 183: 612-614Crossref PubMed Scopus (15) Google Scholar, 7Patel S.J. Venn G.E. Redwood S.R. Percutaneous closure of an iatrogenic puncture of the aortic arch.Cardiovasc Intervent Radiol. 2003; 26: 407-409Crossref PubMed Scopus (8) Google Scholar, 8Leijdekkers V.J. Go H.L. Legemate D.A. et al.The use of a percutaneous closure device for closure of an accidental puncture of the aortic arch: A simple solution for a difficult problem.Eur J Vasc Endovasc Surg. 2006; 32: 94-96Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar; however, immediate complications such as cardiac tamponade, hemodynamic instability, or strong pulsatile red blood backflow were present. In some of these cases, successful percutaneous management (Angio Seal) was performed. Each time, the catheter was still in place in the vessel, and no life-threatening complications occurred.6Hatfield M.K. Zaleski G.X. Kozlov D. et al.Angio-seal device used for hemostasis in the descending aorta.AJR Am J Roentgenol. 2004; 183: 612-614Crossref PubMed Scopus (15) Google Scholar, 7Patel S.J. Venn G.E. Redwood S.R. Percutaneous closure of an iatrogenic puncture of the aortic arch.Cardiovasc Intervent Radiol. 2003; 26: 407-409Crossref PubMed Scopus (8) Google Scholar, 8Leijdekkers V.J. Go H.L. Legemate D.A. et al.The use of a percutaneous closure device for closure of an accidental puncture of the aortic arch: A simple solution for a difficult problem.Eur J Vasc Endovasc Surg. 2006; 32: 94-96Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar It has been shown that ultrasound guidance decreases the complications associated with subclavian CVC placement12Randolph A.G. Cook D.J. Gonzales C.A. et al.Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature.Crit Care Med. 1996; 24: 2053-2058Crossref PubMed Scopus (735) Google Scholar, 13Girard T.D. Schectman J.M. Ultrasound guidance during central venous catheterization: A survey of use by house staff physicians.J Crit Care. 2005; 20: 224-229Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar and has become a standard technique. Unfortunately, UG is not always available (emergency cannulation and ultrasound availability), which increases the SVC complication rate. This is shown in the 3 cases presented here because none was performed under UG. Although all procedures were performed by senior physicians, the teams in the authors' institution at the time of the procedure were not familiar with UG and the central line-associated bloodstream (CLAB) prevention protocol. This should alert clinicians to the necessity of performing CVC under UG whenever the patient's condition allows it. If UG is not available at the time of the procedure, it might be advisable to delay the procedure until UG is present. In the 3 cases presented, there was no critical condition justifying cannulation without UG. Moreover, arterial misplacement was suggested by the appearance of pulsatile red blood backflow in the first 2 cases and by the appearance 24 hours after the procedure of severe consciousness disorder in the 3rd. The presence of red blood pulsatile backflow can suggest arterial misplacement, but this is an unreliable marker of the exact arterial location of a catheter and should not be used as confirmation of position. In the present cases, further radiologic investigations led to diagnosis. Manometry was not used to confirm arterial misplacement. To the authors' knowledge, there are no recommendations concerning the management of this frequent complication. Guilbert et al14Guilbert M.C. Elkouri S. Bracco D. et al.Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm.J Vasc Surg. 2008; 48: 918-925Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar proposed a management algorithm concerning arterial trauma during CVC, but no management of aortic arch injury was mentioned. Therefore, the present authors attempted to describe 2 possible strategies of treatment of inadvertent arterial injury after CVC depending on the complication type. In cases of catheter misplacement with the catheter still in place, it probably is advisable not to remove it because percutaneous management might be possible, avoiding surgical treatment. This is all the more true when the misplacement involves the subclavian artery. This was clearly shown in the two first reports, which are in agreement with other case reports in the literature.10Fraizer M.C. Chu W.W. Gudjonsson T. et al.Use of a percutaneous vascular suture device for closure of an inadvertent subclavian artery puncture.Catheter Cardiovasc Interv. 2003; 59: 369-371Crossref PubMed Scopus (31) Google Scholar, 11Wallace M.J. Ahrar K. Percutaneous closure of a subclavian artery injury after inadvertent catheterization.J Vasc Interv Radiol. 2001; 12: 1227-1230Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar In cases of intra-aortic catheterization, previous case reports have shown that the use of percutaneous closure devices also are possible.6Hatfield M.K. Zaleski G.X. Kozlov D. et al.Angio-seal device used for hemostasis in the descending aorta.AJR Am J Roentgenol. 2004; 183: 612-614Crossref PubMed Scopus (15) Google Scholar, 7Patel S.J. Venn G.E. Redwood S.R. Percutaneous closure of an iatrogenic puncture of the aortic arch.Cardiovasc Intervent Radiol. 2003; 26: 407-409Crossref PubMed Scopus (8) Google Scholar, 8Leijdekkers V.J. Go H.L. Legemate D.A. et al.The use of a percutaneous closure device for closure of an accidental puncture of the aortic arch: A simple solution for a difficult problem.Eur J Vasc Endovasc Surg. 2006; 32: 94-96Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Nevertheless, in this situation, a multidisciplinary approach seems necessary (radiologists, surgeons, and anesthesiologists) to determine the best possible treatment (surgical v percutaneous). On the other hand, when confronted with arterial injury with active bleeding without the catheter in place, surgical management is the only treatment possible. The 3rd case shows this as the patient underwent immediate thoracic surgery after aortic injury diagnosis. Inadvertent arterial puncture complicating CVC can be a critical condition, especially when it concerns the aortic arch. Depending on the presence or absence of a catheter still in place, several treatment options ranging from a percutaneous closure device to surgical repair are available. In each case, multidisciplinary management is necessary in order to obtain the best possible treatment. Ultrasound guidance has proven to significantly reduce the risk of arterial puncture during CVC and should be used as often as possible in order to avoid inadvertent arterial puncture.