An opacity in the chest following a subclavian catheterization

Internal mammary artery injury after central venous catheterization

OBJECTIVE

We describe an infrequent but potentially lethal complication: an iatrogenic injury of the internal mammary artery after central venous catheterization.

DESIGN

Report of cases.

SETTING

Pediatric intensive care unit.

PATIENTS

The first patient we report on is a 3-yr-old girl who was severely neurologically damaged and was admitted to the pediatric intensive care unit for aspiration pneumonia and septic shock. Immediately after vein cannulation on the left internal jugular vein, the patient suffered hypotension and cardiac arrest, secondary to an adequately drained massive hemothorax. Restoration of spontaneous circulation was initially achieved, and the patient was transferred to the angiographic suite. Selective angiography during cardiopulmonary resuscitation for a second cardiac arrest revealed a laceration of the internal mammary artery. Resuscitation was not successful, and the patient died. The second case reported is a 7-yr-old girl admitted for bone marrow transplantation. She was electively taken to the angiographic suite for central venous insertion. An infraclavicular approach of the right subclavian vein was attempted, but radioscopy showed the guidewire inside the pleural space. Soon thereafter, the patient became hypotensive and was in shock. Radioscopy showed a large pleural effusion and a massive hemothorax was drained. Selective angiography demonstrated an injured internal mammary artery was embolized. Hemodynamics improved, and the patient was transferred to the pediatric intensive care unit, where she was extubated 12 hrs later.

INTERVENTIONS

None.

CONCLUSIONS

Central venous catheter placement in the intrathoracic vein may cause potentially lethal complications in the form of an injury to the internal mammary artery. Hypotension during or immediately after the procedure should be a warning of a serious adverse event, such as massive hemothorax, that may compromise life. Adequate drainage of the pleural cavity may not completely relieve vascular compression if some of the bleeding from an injured internal mammary artery is extrapleural. Early diagnosis and treatment by selective embolization of the injured vessel in interventional radiology is the first therapeutic choice and may be life saving.