Inadvertent Dialysis Catheter—An Interventional Bailout!

Here is a 38-year-old male patient who presented in the emergency with complaints of severe abdominal pain, vomiting since 4 days, and breathlessness since 2 days. On clinical examination, the patient was drowsy, with dyspnea and moderate dehydration. Blood evaluation showed elevated lipase (63,365 U/L), amylase (2,457 U/L), and total count (17,000 cells/µL of blood). Imaging was suggestive of acute necrotizing pancreatitis. The patient developed secondary renal and respiratory failure for which the patient was shifted to the intensive care unit (ICU) for ventilatory support. Because of rising serum creatinine levels, central venous access was planned for hemodialysis.

Right internal jugular access was planned by the ICU intensivist. The procedure was performed by Seldinger technique using 16G needle without any ultrasound guidance. After the initial backflow, the needle was blindly advanced further, and a wire was introduced, following which a 6F central vein catheter was placed. No free backflow was observed, and the radiologist was called to perform a Doppler scan.

Check radiography was acquired, which showed the catheter to be positioned slightly off center ([Fig. 1]). Because of the patient's condition, contrast-enhanced computed tomographic (CT) angiography was performed, which revealed the central venous catheter to be malpositioned with the catheter traversing the right subclavian artery (first part of subclavian artery distal to the origin of the thyrocervical trunk) and surrounded by a localized hematoma. The catheter tip was in the posterior pleural cavity with associated lung contusion and hemothorax ([Figs. 2], [3]).

Fig. 1 Scanogram showing laterally placed central vein catheter.

Fig. 2 Contrast-enhanced CT. (A) Axial section and (B, C) reformatted coronal and sagittal sections show the central vein catheter (yellow arrow head) traversing the right subclavian artery with surroundings hematoma and right hemothorax.

Fig. 3 Volume-rendered image showing the malpositioned catheter placement.

The patient was referred to the interventional radiology team to evaluate the condition and take the appropriate interventional step required to bail out the patient from this situation. Both options of covered stent and balloon occlusion were explained to the patient, and covered stent placement was considered over balloon occlusion as balloon occlusion is a temporary technique that can be associated with a risk of re-bleed or increase in the rent size.

The patient was taken up for angiography. Right femoral access using a 5F sheath (Cordis) under ultrasound guidance was achieved. Right innominate artery angiogram was performed using a 100-cm Cobra catheter, which revealed that the central venous catheter had traversed the subclavian artery. However, there was no contrast leak across the puncture site that was likely due to the tamponade effect between the arterial wall and the catheter. Next, a wire was placed across the innominate artery, and the focus was shifted to the central vein catheter. A small volume of contrast was injected as the catheter was withdrawn, and a subclavian angiogram was seen once the side holes of the catheter were within the intraluminal portion of the artery ([Fig. 4]). It was decided to place a stent graft across the through and through puncture site. However, as the site was in proximity to the right vertebral artery (origin is 2.8 cm away), a decision of sacrifice of the right vertebral artery was made after evaluating the patency and caliber of the left vertebral artery. The 5F sheath was replaced by a 6F sheath, and a 40- × 8-mm stent graft (iCAST; Atrium Medical) was placed and deployed across the puncture site after pulling out the central vein catheter. Check angiogram images were acquired, which was suggestive of an excellent hemodynamic outcome ([Fig. 5]). Dual-antiplatelet (aspirin 75 mg and clopidogrel 150 mg) medication was initiated on day 2. The patient showed improvement in his condition during the postprocedure period.

Fig. 4 Angiography images. (A) Anteroposterior projection. (B) Oblique projection showing a filling defect within the right subclavian artery.

Fig. 5 Angiographic images. Anteroposterior projection. (A) Subclavian artery angiogram from pulled back catheter. (B) Stent graft placed across the subclavian artery rent.

Discussion

Central vein catheterization is a very commonly performed procedure in an intensive care setting. However, it can be associated with complications that need to be addressed immediately and managed effectively. Complications can be either immediate or delayed in nature. Immediate complications include pulmonary, cardiac, vascular, and placement related, and delayed complications include infection and dysfunction of a device. The use of ultrasound assistance has reduced immediate procedure-related complication significantly down to 4 to 7%.[1] [2] [3] However, the use of ultrasound does not eliminate the possibility of an inadvertently placed catheter into the arterial system.[4] [5] [6]

Arterial injury has been seen in less than 1% of cases.[7] Arterial injury involving femoral artery is more common when compared with subclavian artery.[8] On reviewing the literature, multiple case reports and case series have been found with an inadvertently placed catheter or arteriovenous (AV) fistula formation or pseudoaneurysm development. Our case is unique as the catheter went through and through the subclavian artery prompting for an endovascular approach by the interventional radiology team.

Various devices such as stents, closure devices, and balloons are used to treat complications associated with subclavian artery injury. Based on the location and type of injury, the treatment is tailored specifically to the situation.

A covered stent has been found to be very successful in the management of subclavian artery injury secondary to central vein catheter.[9] [10] [11] [12] [13] [14] Two forms of covered stents are available: (1) balloon expandable and (2) self-expanding covered stent. The advantage of balloon-expandable stents is that first, they have a very controlled deployment and second the option of flexible sizing. The long-term outcome of these stents has, however, not been documented.[15] Use of a covered stent is not always possible, especially in cases when the subclavian artery injury is in proximity to important branch vessels, for example the vertebral artery.

Subclavian stents demonstrate a primary patency rate of 77 to 92% and a secondary patency rate of 92 to 96%.[16] [17] [18]

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) in their guidelines for vascular interventions have recommended that (1) ultrasound screening should be performed on the target vessel to assess the optimal patient position and locate the most appropriate anatomical site for central vascular access and (2) both short- and long-term venous access should be performed under real-time ultrasound guidance rather than ultrasound assistance.[19] The American Society of Anesthesiologists (ASA) strongly recommends the use of ultrasound and also recommends (1) confirmation of the catheter position can be done using ultrasound, manometry, pressure-waveform analysis, or venous blood gas measurement; (2) in case of unsure wire or catheter tip, confirmation can be done using ultrasound, fluoroscopy, continuous electrocardiography, or transesophageal ultrasound; and (3) in case of inadvertent cannulation of an arterial vessel, the catheter should be left in place and an intervention radiologist/surgeon should be consulted.[20]

 

MissingLinkText

Conclusion

A standard central vein catheterization can be associated with several avoidable complications when adhered to guidelines laid down by EFSUMB or ASA.

The guidelines also state the appropriate approach in case of an in-advent arterial catheterization. Endovascular approach is preferred in the management of cases that are surgically challenging.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

None.

• Reference

• 1 Schnabel KJ, Simons ME, Zevallos GF. et al. Image-guided insertion of the Uldall tunneled hemodialysis catheter: technical success and clinical follow-up. J Vasc Interv Radiol 1997; 8 (04) 579-586
• 2 Funaki B, Szymski GX, Hackworth CA. et al. Radiologic placement of subcutaneous infusion chest ports for long-term central venous access. AJR Am J Roentgenol 1997; 169 (05) 1431-1434
• 3 Peris A, Zagli G, Bonizzoli M. et al. Implantation of 3951 long-term central venous catheters: performances, risk analysis, and patient comfort after ultrasound-guidance introduction. Anesth Analg 2010; 111 (05) 1194-1201
• 4 Zimmerman P, d'Audiffret A, Pillai L. Inadvertent great vessel arterial catheterization during ultrasound-guided central venous line placement: a potentially fatal event. J Vasc Surg 2009; 53: 74
• 5 Parsons AJ, Alfa J. Carotid dissection: a complication of internal jugular vein cannulation with the use of ultrasound. Anesth Analg 2009; 109 (01) 135-136
• 6 Thompson C, Barrows T. Carotid arterial cannulation: removing the risk with ultrasound?. Can J Anaesth 2009; 56 (06) 471-472
• 7 Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment. J Cardiothorac Vasc Anesth 2014; 28 (02) 358-368
• 8 McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348 (12) 1123-1133
• 9 Kapadia S, Parakh R, Grover T, Agarwal S, Yadav A. Endovascular covered stent for management of arterial pseudoaneurysms after central venous access. J Cardiothorac Vasc Anesth 2007; 21 (01) 99-102
• 10 Nicholson T, Ettles D, Robinson G. Managing inadvertent arterial catheterization during central venous access procedures. Cardiovasc Intervent Radiol 2004; 27 (01) 21-25
• 11 Wheeler SC, Zinn KM, Hughes TW. Endovascular covered stent repair of an iatrogenic subclavian artery-to-pulmonary artery fistula and pseudoaneurysm. J Vasc Interv Radiol 2007; 18 (06) 775-779
• 12 Hilfiker PR, Razavi MK, Kee ST, Sze DY, Semba CP, Dake MD. Stent-graft therapy for subclavian artery aneurysms and fistulas: single-center mid-term results. J Vasc Interv Radiol 2000; 11 (05) 578-584
• 13 Schoder M, Cejna M, Hölzenbein T. et al. Elective and emergent endovascular treatment of subclavian artery aneurysms and injuries. J Endovasc Ther 2003; 10 (01) 58-65
• 14 Finlay DJ, Sanchez LA, Sicard GA. Subclavian artery injury, vertebral artery dissection, and arteriovenous fistulae following attempt at central line placement. Ann Vasc Surg 2002; 16 (06) 774-778
• 15 Abi-Jaoudeh N, Turba UC, Arslan B. et al. Management of subclavian arterial injuries following inadvertent arterial puncture during central venous catheter placement. J Vasc Interv Radiol 2009; 20 (03) 396-402
• 16 Brountzos EN, Petersen B, Binkert C, Panagiotou I, Kaufman JA. Primary stenting of subclavian and innominate artery occlusive disease: a single center's experience. Cardiovasc Intervent Radiol 2004; 27 (06) 616-623
• 17 Rodriguez-Lopez JA, Werner A, Martinez R, Torruella LJ, Ray LI, Diethrich EB. Stenting for atherosclerotic occlusive disease of the subclavian artery. Ann Vasc Surg 1999; 13 (03) 254-260
• 18 Patel SN, White CJ, Collins TJ. et al. Catheter-based treatment of the subclavian and innominate arteries. Catheter Cardiovasc Interv 2008; 71 (07) 963-968
• 19 Jenssen C, Brkljacic B, Hocke M. et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part VI—Ultrasound-Guided Vascular Interventions. Ultraschall Med 2016; 37 (05) 473-476
• 20 Rupp SM, Apfelbaum JL, Blitt C. et al; American Society of Anesthesiologists Task Force on Central Venous Access. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012; 116 (03) 539-573