Iatrogenesis Imperfecta: Stroke caused by Accidental Carotid Artery Catheterization

A systematic review of management of inadvertent arterial injury during central venous catheterisation

INTRODUCTION

Central venous catheterisation (CVC) is a technique commonly used to obtain vascular access and over five million CVCs are inserted annually. This systematic review of CVC-related arterial injury aims to compare outcomes reported with different management strategies.

METHODS

PRISMA guidelines were followed. A search of Medline, Embase, Central and CINAHL was performed. Results were limited to papers in humans and in English with duplicates removed. Details of cases including site and nature of arterial injury, use of ultrasound, methods for identifying arterial placement, management methods used, and any reported outcomes were collated from all papers. Successful management was defined as control of haemorrhage without evidence of further complications.

RESULTS

We screened 2187 abstracts and 78 full manuscripts were obtained and reviewed. Twenty-four papers were of relevance and were included in this review. Amongst the papers, 80 cases of arterial injury were reported. Successful treatment by removal and compression, endovascular methods, and open surgical repair were 5.6%, 94.6% and 100%, respectively.

DISCUSSION

Removal and compression of the arterial site is a poor management method and is associated with a high rate of complications. Endovascular approaches had a high rate of success with advantages of endovascular techniques including access to arteries which are difficult to expose surgically and avoidance of general anaesthesia. Endovascular repair might be considered depending on site of injury or local expertise though surgical repair reported the best results in this review with no complications seen.

A new infraclavicular landmark-based approach to the axillary vein as an alternative method of central venous cannulation

PURPOSE

We developed the new technique of the axillary vein catheterization, which is connected with the determination of only two anatomical points of reference for puncture site identification. The primary outcome of this study was to determine the rate of successful catheterizations and the assessment of procedure success rate, depending on cannulation side as well as physician experience. The secondary objective was to evaluate the early complication rate and to determine whether this method can be used in clinical practice.

METHODS

The methodology of this prospective, cohort study included catheterization of the axillary vein via the infraclavicular approach. All procedures were performed by the first two authors, each of whom had different levels of experience with the technique. The choice of the cannulation side was based on clinical factors, and the technique was identical on the right and left sides.

RESULTS

The cannulation success rate reached 85.6% (N = 153). The correlation between physician experience and the procedure success rate as well as between cannulation side and procedure success rate were not significant. A common early complication was a puncture of axillary artery (14.4%) with the following proper cannulation in the majority of patients (77.3%, p<0.01, exact test).

CONCLUSIONS

The procedure success rate, 85.6% (95% CI [80.0, 91.2%]), is comparable to other landmark-based techniques of the central vein cannulation. The moderately high percentage of axillary artery puncture points out that the approach should be used only as an alternative method to the central vein catheterization.