Inadvertent carotid artery cannulation during pulmonary artery catheter insertion

Inferior thyroid artery pseudoaneurysm associated with internal jugular vein puncture: a case report

Background

Central venous catheter placement is an important aspect of patient care for the administration of fluids and medications and for monitoring purposes. However, it is still associated with significant morbidity and mortality.

Case presentation

We report a case of iatrogenic inferior thyroid artery pseudoaneurysm during the central line placement due to internal jugular vein puncture. This is a rare complication of central venous cannulation. Fortunately the pseudoaneurysm was monitored closely, diagnosed promptly and obliterated by using radiological intervention. We discuss the risk factors and management of the unintended artery puncture.

Conclusion

The pathway of the management post arterial puncture depends on the size of the needle or catheter, which is direct related to the consequence of arterial injuries. Identifying risk factors is very important to avoid the complications. However, the use of ultrasound guided venipuncture is the most important method to avoid mechanical complications.

Hybrid stent-graft repair of an iatrogenic complex proximal right common carotid artery injury

BACKGROUND

Iatrogenic carotid trauma requires early diagnosis and adequate treatment. Classic open repair may be technically challenging if trauma is in base of the neck. We present a case of an iatrogenic carotid pseudoaneurysm treated with endovascular repair.

METHODS

An 87-year-old woman presented with a pulsatile neck mass 10 days after coronary artery bypass graft surgery. A computed tomographic angiogram showed a 1.6 × 1.0 × 2.0-cm pseudoaneurysm arising from the posterior wall of the proximal right common carotid artery. Endovascular management was considered, and a percutaneous angiogram demonstrated an arteriovenous fistula in addition to the pseudoaneurysm. Through a cervical cut-down, retrograde percutaneous access was obtained through the common carotid artery, which allowed easier access to the area of trauma owing to vessel tortuosity. Subsequently, a 5 mm × 2-cm Viabahn was deployed. The postdilation angiogram showed a significant endoleak that kept filling the pseudoaneurysm. A second 6 mm × 5-cm Viabahn was placed and successfully postdilated with a 6 mm × 4-cm balloon. No endoleaks or fistulas were noted on the completion angiogram.

RESULTS

The patient remains asymptomatic after 15 months. Follow-up images showed thrombosis of pseudoaneurysm.

CONCLUSION

Endovascular treatment with self-expanding stent-grafts and open cut-down access are excellent options to treat major vessel injuries at the base of the neck, where anatomy and cumbersome access make open surgery a more difficult option.

Intraoperative vital and haemodynamic monitoring using an integrated multiple-channel monitor in rats

The aim of this study is to give a hands-on description of the successful monitoring procedure established for extended liver resections and liver transplantations in rats and to provide the typical range of data as obtained before and after a hepatobiliary surgical procedure (right median hepatic vein [RMHV] ligation) in healthy male Lewis rats. All manipulations were performed in anaesthetized (3% isoflurane in O2 1 L/min) healthy male Lewis rats (250–350 g) with an integrated multiple-channel intraoperative monitor (Powerlab® system) using a series of sensors for data acquisition. Vital parameters (body temperature, electrocardiogram, respiratory rate and heart rate), haemodynamic parameters (mean arterial blood pressure [MAP] and central venous pressure) and liver perfusion parameters (inferior hepatic venous pressure, portal vein pressure [PVP], blood flow of portal vein and inferior hepatic cava) were monitored. Catheters were placed in microsurgical technique after careful exposure guided by anatomical landmarks. Vascular incisions were closed with interrupted sutures. Complete instrumentation of animals was performed within 1 h. No specific complications occurred. Vital and haemodynamic parameters such as MAP (94 ± 16.2 mmHg) or portal pressure (9.6 ± 1.34 mmHg) were in the same range as known for humans (MAP = 100 mmHg, portal pressure = 5–10 mmHg), whereas parameters dependent on the size of the body or organ such as flow rates (portal blood flow = 16.2 ± 6 mL/min) were obviously different compared with those of humans (portal blood flow = 800 mL/min). In conclusion, the normal range for vital, haemodynamic and liver perfusion parameters was reported as reference values to allow quality control for future surgical hepatobiliary research projects. As the procedure can be easily learned, the extensive intraoperative monitoring can be used routinely.

Experience and technique for the endovascular management of iatrogenic subclavian artery injury

BACKGROUND

Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open operative approach and repair under direct vision via an infraclavicular and/or supraclavicular incision. We describe our experience and technique for endovascular management of these injuries.

METHODS

Twenty patients were identified with inadvertent iatrogenic subclavian artery cannulation. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsilateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20 min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20 min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding.

RESULTS

Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was successfully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site.

CONCLUSION

This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair.

Ultrasound-guided central venous access

Central venous catheterization is a critical component of management for the critically ill patient in the operating room and intensive care unit. When using ultrasound techniques for central venous access, access is achieved with fewer attempts, a reduced incidence of carotid artery punctures or ‘hits’, an increased success rate, and a decreased duration of procedure compared to the traditional landmark approach.

Central venous access

Central venous access plays an important role in the management of an ever-increasing population of patients ranging from those that are critically ill to patients with difficult clinical access. Interventional radiologists are key in delivering this service and should be familiar with the wide range of techniques and catheters now available to them. A comprehensive description of these catheters with regard to indications, technical aspects of catheterization, success rates, and associated early and late complications, as well as a review of various published guidelines on central venous catheter insertion are given in this article.

The Accuracy of the Central Landmark Used for Central Venous Catheterization of the Internal Jugular Vein

We simulated needle paths based on the central landmark used for central venous catheterization of the internal jugular vein. We obtained ultrasound images to quantify the landmark's accuracy (precision and bias) in 107 subjects placed in Trendelenburg position with their heads turned 30-35 degrees. We also determined the frequency of simulated carotid artery puncture. The simulated needle path missed the middle 80% of the lumen of the internal jugular vein in 34% of subjects (95% confidence interval [CI], 25% to 44%) and traversed the carotid artery in 26% of subjects (95% CI, 18% to 35%). Both events occurred in 20% of subjects (95% CI, 13%-29%). The landmark had a medial bias of 3.7 mm (95% CI, 2.7 to 4.8); it was more often (77 of 104 subjects) medial to the center of the right internal jugular vein (P < 0.001). The landmark was more likely to miss the internal jugular vein (odds ratio, 3.11; P < 0.016) and intersect the carotid (odds ratio, 3.03; P < 0.024) in obese patients. The central landmark should not be expected to yield frequent success on first needle pass without risk of carotid puncture because of its imprecision and bias. The measured bias should be considered when the central landmark is used for central venous catheterization.

Arterial misplacement of large-caliber cannulas during jugular vein catheterization: case for surgical management

BACKGROUND

Accidental placement of a large sheath or catheter in an artery during central venous cannulation, though rare, is a potentially devastating complication. The present study reviews our 14-year experience with this complication to determine appropriate role of surgical management.

STUDY DESIGN

Review was conducted of all cases involving patients treated by the vascular surgery service from July 1989 to June 2003 for accidental placement of a large-caliber cannula (>or= 7 F) in an artery during catheterization of the jugular vein. Two management techniques were used during this period: removal of cannula followed by application of local pressure; and surgical exploration, removal of cannula under direct vision, and repair of artery.

RESULTS

Eleven patients (5 men, 6 women) aged 35 to 73 years (mean age 56 years) were treated for cannulas placed accidentally in an artery. In nine patients, the cannula entered the carotid artery, and in two patients it entered the subclavian artery. Three patients had undergone placement of 8.5-F sheaths for monitoring cardiac hemodynamics, and 8 patients had triple-lumen catheters for fluid infusion or parenteral nutrition. Eight patients (three sheath, five catheter) were asymptomatic at the time of cannula removal. In three patients, the correct diagnosis was missed initially and infusion was started. All three developed neurologic symptoms. In two patients, the cannula (sheath) was pulled and pressure applied. One of them developed a stroke and the other developed a pseudoaneurysm that was treated surgically. Nine patients in whom the sheath or catheter was removed by surgical exploration had no new complications related to surgery.

CONCLUSIONS

Surgical management seems to be the most effective and safe treatment of arterial misplacement of cannulas during jugular vein catheterization. Further study is needed to determine the optimum management of this potentially devastating complication.

Radiology in the intensive care unit (Part I)

The increasing complexity of the intensive care patient combined with the recent advances in imaging technology has generated a new perspective on intensive care radiology. The purpose of this 2-part review article is to describe the contribution of radiology to the management of these critically ill patients. The first article will discuss the impact of picture archiving and communication system (PACS) on critical care management and utility of the portable chest radiograph in the detection and evaluation of pulmonary disease with correlation to computed tomography (CT). The second article describes in more detail the increasing role of CT in diagnosis and therapeutic procedures. In particular, the implementation of CT pulmonary angiography in the evaluation of pulmonary emboli and the introduction of the new multislice detector CT scanners that allow even the most dyspneic patient to be evaluated. Pleural complications in the intensive care unit and image-guided intervention will also be discussed.

Complications of invasive monitoring

Invasive monitoring in anesthesiology is relatively safe. Arterial catheterization in particular has an extremely low rate of serious complications. Radial, brachial, and femoral artery catheterization sites appear to have similar and low complication rates. CVP and PA catheters are more dangerous and entail potentially fatal complications. The most troublesome complication with CVP catheters is perforation of the heart or cava, which should be avoidable under most circumstances if care is taken to position the catheter properly, outside the heart. Chest radiography should be used to specifically ascertain that the catheter is not in a dangerous location. The most troublesome complication with PA catheters is perforation of the pulmonary artery. This is probably a sporadic problem, and it is not necessarily avoidable by adherence to particular techniques. It should be assumed that hemoptysis in a patient with a PA catheter is caused by perforation of the pulmonary artery until proven otherwise, and it should be treated aggressively.

Complications of hemodynamic monitoring

The uses of the pulmonary artery catheter have been expanded from its original use, helping to assess the cardiac output and left ventricular filling pressure of patients with cardiac disease, to include the management of patients with trauma, septic shock, respiratory failure, and those undergoing high-risk surgeries. Although more than 1 million pulmonary artery catheters are inserted each year in the United States, clear evidence establishing that they improve outcome remains hard to find. This article discusses the complications of invasive hemodynamic monitoring.

Cerebral infarct following central venous cannulation

Inadvertent carotid artery puncture is a well-known complication of internal jugular vein cannulation. A case of cerebral infarct subsequent to carotid artery puncture during internal jugular vein cannulation is reported.

Transesophageal echocardiographic identification of a retrograde dissection of the ascending aorta caused by inadvertent cannulation of the common carotid artery

Retrograde aortic dissections can be a complication of vascular procedures. We describe a case of an inadvertent cannulation of the right common carotid artery during an attempt at inserting a pulmonary artery catheter. This resulted in dissection of the right common carotid, subclavian, and innominate arteries. Transesophageal echocardiography was able to visualize a retrograde dissection extending back into the ascending aorta.