Endovascular repair of inadvertent subclavian artery perforation during cannulation for dialysis access: case report and review of the literature:

Hybrid Repair of an Iatrogenic Left Subclavian Artery Injury: A Case Report

We present the case of an iatrogenic injury to the left subclavian artery during placement of a port for chemotherapy. The artery was inadvertently accessed at its infraclavicular position, and then was perforated centrally, entering the mediastinum at the origin of the left vertebral artery. Given that the patient's posterior circulation was largely dependent on the left vertebral artery, it could not be sacrificed. To preserve her left vertebral artery and to avoid the need for a sternotomy, which would more substantially delay initiation of chemotherapy, we elected to perform a hybrid repair: an open left carotid to vertebral artery bypass with reversed great saphenous vein followed by repair of the proximal left subclavian injury with a covered stent graft, which was delivered via the left axillary artery. The patient recovered uneventfully. This case demonstrates a hybrid open and endovascular repair for a complex iatrogenic arterial injury. We were able to obtain a desirable outcome by careful assessment of the anatomic particulars of her injury and the technical constraints in proposed methods of repair, all in the context of the patient's overall goals of care.

Avoiding peripheral nerve injury in arterial interventions

Although peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or by manual compression with incidence in literature ranging from as low as 0.04% for femoral access in a large retrospective study to 9% for brachial and axillary access. Given the increasing frequency of endovascular arterial procedures and the increasing use of nontraditional access points, it is important that the interventionalist have a working knowledge of peripheral nerve anatomy and function as it relates to relevant arterial access sites to avoid injury.

[Endovascular repair of subclavian artery injury secondary to internal jugular vein catheterization: case report]

BACKGROUND AND OBJECTIVES

Ultrasound-guided internal jugular vein catheterization is a common and generally safe procedure in the operating room. However, inadvertent puncture of a noncompressible artery such as the subclavian artery, though rare, may be associated with life-threatening sequelae, including hemomediastinum, hemothorax, and pseudoaneurysm.

CASE REPORT

We describe a case of the successful endovascular repair of right subclavian artery injury in a 75-year-old woman. Subclavian artery was injured secondary to ultrasound-guided right internal jugular vein catheterization under general anesthesia for orthopedic surgery.

CONCLUSION

Under general anesthesia several factors such as hypotension can mask the signs of subclavian artery injury. This case report indicates that clinicians should be aware of the complications of central venous catheterization and take prompt action.

Endovascular repair of subclavian artery injury secondary to internal jugular vein catheterization: case report

Background and objectives

Ultrasound-guided internal jugular vein catheterization is a common and generally safe procedure in the operating room. However, inadvertent puncture of a noncompressible artery such as the subclavian artery, though rare, may be associated with life-threatening sequelae, including hemomediastinum, hemothorax, and pseudoaneurysm.

Case report

We describe a case of the successful endovascular repair of right subclavian artery injury in a 75-year-old woman. Subclavian artery was injured secondary to ultrasound-guided right internal jugular vein catheterization under general anesthesia for orthopedic surgery.

Conclusion

Under general anesthesia several factors such as hypotension can mask the signs of subclavian artery injury. This case report indicates that clinicians should be aware of the complications of central venous catheterization and take prompt action.

Successful Treatment of Iatrogenic External Iliac Artery Perforation With Covered Stent: Case Report and Review of the Literature

Retroperitoneal hemorrhage from iliac artery injury is a potentially serious complication of vascular interventional procedures leading to hemorrhagic shock and death if not diagnosed early and treated promptly. We report a 70-year-old male admitted to our facility with non-ST-elevation myocardial infarction, whose heart catheterization revealed left anterior descending artery (LAD) with 80% proximal, 95% mid and 100% distal disease. The left circumflex and right coronary arteries were 100% occluded proximally and received collaterals from the LAD. The patient declined coronary artery bypass surgery; therefore, the decision was made to perform high-risk percutaneous coronary intervention (PCI) of the LAD with Impella left ventricular assist device support. Left femoral artery angiogram revealed severely tortuous and calcified aorta, left external iliac and left common iliac arteries, and was accessed with 14-inch Impella sheath. He developed groin pain with mild hypotension thought to be due to sedation, which responded to intravenous fluids and dopamine. He underwent successful rotational atherectomy of the proximal and mid LAD with deployment of drug-eluting stents. Following PCI, he suffered acute profound hypotension necessitating intravenous fluids and vasopressor support with epinephrine. Emergency transthoracic echocardiogram did not reveal any pericardial effusion, and showed normal left ventricle and right ventricle systolic function. The Impella device was removed and selective left common iliac angiogram from the right femoral access revealed a vascular injury site with shift of the bladder to the right indicative of retroperitoneal hematoma. A digital subtraction angiogram revealed extravasation of blood at the vascular injury site. An 8.0 × 59 mm iCAST covered stent was deployed to the left external iliac artery with successful sealing of the perforation. The Impella device site was closed with two Perclose devices. The patient required 4 units of packed red blood cell transfusion. His hospital course was complicated by transient acute kidney injury, with return of his renal function to baseline at discharge 10 days later. This case underscores the importance of prompt recognition and treatment of vascular complications associated with interventional procedures, and highlights some of the risk predictors of such complications, which should be anticipated and planned for prior to intervention.

Iatrogenesis Imperfecta: Stroke caused by Accidental Carotid Artery Catheterization

Purpose

Central venous catheterization is a commonly used procedure to gain access to the central circulation. Although ultrasound guidance decreases the complication rates, arterial puncture may still occur. Failure to recognize this early may lead to devastating complications such as thrombosis and embolic stroke. We discuss the factors associated with increased risk of arterial puncture, techniques to detect them early and the management of established carotid artery cannulation.

Methods

We report a case of internal jugular catheterization complicated by carotid artery puncture leading to embolic stroke.

Result

Arterial catheterization in the patient went unrecognized for 2 days. During this period, the patient developed catheter-related thrombus in the carotid artery, ultimately resulting in embolic stroke. Emergent open surgical repair of the vessels with thrombectomy was performed.

Conclusion

Even with ultrasound-guided central venous catheterization, it is essential to remain vigilant for the early detection of vascular complications. Clinical suspicion combined with diagnostic modalities such as chest radiograph, transduction and manometry can increase the detection rates.

A multicenter evaluation of a compact, sterile, single-use pressure transducer for central venous catheter placement

BACKGROUND

Inadvertent arterial placement of a large-bore catheter during attempted placement of a central venous catheter (CVC) occurs at a rate of 0.1% to 1.0% and may result in hemorrhage, pseudoaneurysm, stroke, or death. Ultrasound guidance or observation of color and pulsatility of blood are not reliable methods for avoiding this serious complication. Measurement of pressure in the needle or short plastic catheter before insertion of the guidewire has been shown to be highly reliable; however, traditional pressure measurement methodology is cumbersome. Recently a compact, sterile, single-use pressure transducer with an integrated digital display has become available. In this study, we evaluated the performance of this new device (Compass® Vascular Access).

METHODS

In this prospective, observational study at 4 academic medical centers 298 CVCs were placed. Pressure was measured using the Compass transducer before and after guidewire insertion. Other details of the procedure were at the discretion of the clinician. Data describing the CVC placement and any complications were collected.

RESULTS

Trainees placed 279 of 298 CVCs. Ultrasound guidance was used for 286 of 298 CVCs. Seven of the CVC placements occurred in the intensive care unit, with the balance occurring in the operating room. Ten of the CVCs were placed in a subclavian vein, with the balance being internal jugular vein. Two hundred seventy-four of 298 CVCs were placed on the right side. Venous pressure measured before and after guidewire insertion was 7.2 ± 4.3 (SD) and 6.5 ± 4.3 (SD) mm Hg respectively (P = 0.03). The satisfaction score recorded by the physician performing the procedure was 8.0 ± 2.1 (SD; visual analog scale 1-10, 10 being most satisfying). There were 5 inadvertent arterial punctures (1.7%). Ultrasound guidance was used in all 5 cases of arterial puncture. All of the arterial punctures were recognized before guidewire insertion by measurement of arterial pressure with the Compass transducer. No guidewires or CVC catheters were placed in arteries.

CONCLUSION

The Compass pressure transducer for CVC placement performed as intended in 298 cases from 4 academic medical centers. There were 5 inadvertent arterial punctures despite the use of ultrasound guidance, all of which were correctly identified by pressure measurement using the Compass. The device was easily used by trainees, and users expressed a positive level of satisfaction.