Right subclavian catheter perforation of the aorta due to an incorrect external landmark-guided insertion technique
Case Reports
From the Departments of *Cardiothoracic Surgery and †Anaesthesia, University Hospital of Wales, Cardiff, United Kingdom, and the ‡Department of Cardiothoracic Surgery, Trondheim University Hospital, Trondheim, Norway
CJEM 2007;9(1):43-45
Abstract
Emergency placement of a right subclavian triple lumen silastic catheter in an obese, unstable postoperative patient caused a perforation of the aorta, resulting in sudden cardiac tamponade. Because this complication was immediately recognized and surgical decompression with suturing of the perforation in the aorta was performed, the patient survived. A standardized approach for all central venous line insertions should be emphasized for all clinicians. Use of ultrasound guidance whenever feasible is encouraged.
Résumé
L'installation d'urgence d'un cathéter à triple lumière en silastic dans la veine sous-clavière droite chez une patiente obèse en phase postopératoire dans un état instable a causé une perforation de l'aorte, entraînant une tamponnade cardiaque soudaine. Cette complication ayant été reconnue immédiatement et la décompression chirurgicale ayant été effectuée grâce à la suture de la perforation de l'aorte, la patiente survécut. On devrait insister pour que tous les cliniciens adoptent une conduite thérapeutique standardisée pour toutes les insertions de cathéters veineux centraux. Le recours à l'échoguidage est encouragé lorsque c'est possible.
Introduction
Central venous catheter insertion for diagnostic and therapeutic purposes is a common and indispensable clinical procedure. Although the incidence of catheter-related complications has been reported to be as high as 10%,1 serious or fatal events are fortunately rare.2,3 We report a near fatal complication following aortic puncture from an attempted insertion of a central venous line by incorrect application of the landmark technique.
Case report
A 55-year-old obese woman who had undergone laparoscopic cholecystectomy developed biliary peritonitis 2 weeks postoperatively. Percutaneous drains were inserted into the abdominal cavity under ultrasound guidance. Attempting to use the external landmark-guided technique, a junior physician on call decided to insert a right subclavian line for fluid resuscitation and as an aid in hemodynamic monitoring. According to the patient notes, the right subclavian fossa was palpated, a local anesthetic drug was infiltrated subcutaneously and a 16-gauge needle was introduced to puncture the right subclavian vein. Upon aspiration of blood, a guide wire was inserted, the track was dilated and the triple lumen catheter was introduced over the guide wire. At this time the patient suddenly developed bradycardia and subsequently circulatory shock. The catheter was immediately removed and advanced life support initiated.
A plain chest x-ray showed evidence of gross widening of the mediastinum, supporting the suspicion of a cardiac tamponade. An urgent transthoracic echocardiogram showed a 2-3-cm pericardial effusion with diastolic collapse of both the right and left ventricles, indicative of a cardiac tamponade. The investigation also raised a suspicion of a tear at the junction between the superior vena cava and the right atrium with a persistent leak of fluid somewhere inside the pericardial cavity.
Immediate surgical exploration of the mediastinum was performed via a median sternotomy. Prior to the incision we noticed the puncture site of the central line catheter to be located closer to the midline of the chest than what is normally advised. There was an extensive extra-pericardial hematoma, and on opening the pericardium blood gushed out under pressure. Following evacuation of the hemopericardium, an immediate improvement in both the systemic blood pressure and the arterial oxygen saturation were observed. A puncture hole was seen on the right side of the ascending aorta, which was sutured with a 4-0 pledget monofilament polypropylene suture (PROLENE; Ethicon, Inc., Somerville, NJ). Surgical hemostasis was secured, and the sternotomy wound was closed with a standard technique using sternal wires. The mechanism of the subclavian catheter injury is illustrated in Figure 1.
Fig. 1. Mechanism of aortic wall puncture due to inadvertent percutaneous catheter transgression of the right subclavian vein because of an incorrect landmark technique.
Postoperatively, the patient was managed in the intensive care unit for the first 2 days and later transferred to the general surgical ward. She made a steady recovery and was fully ambulatory at the time of discharge, 4 weeks following her emergency surgery.
Discussion
Insertion of a central venous line, like all invasive manoeuvres, carries a range of complications. The most common complication of subclavian catheterization is pneumothorax, with an incidence of about 2.7%.4 Vascular complications are most often related to injury of the subclavian vein.1-8 Cardiac tamponade is the most lethal complication associated with central line insertion, with a mortality rate between 65%-90%.1-8 It occurs when the venous access device perforates into the pericardial cavity through the wall of a vascular structure (i.e., a vein, artery or the heart). In our case the aorta may have been punctured after the catheter had transgressed out through the subclavian vein. A similar case of ascending aortic puncture from a central venous line insertion was previously reported.6 Unfortunately, this case had a fatal outcome and the diagnosis was made at postmortem examination.
A difficult case, such as our patient, coupled with the inexperience of a junior physician, facilitated an incorrect external land-mark guided technique. The skin puncture site was more medial and caudal than is generally recommended. On the other hand the occurrence of central line insertion complications is extremely low in centres where this procedure is performed more frequently.
Inexperience in this procedure, when compounded by complicated anatomy in obese and unstable patients, can increase the possibility of complications. However, this should not be an excuse for errors while performing treatment modalities with a potential fatal outcome.9 Ultrasound guidance to aid vascular access has been shown to increase the success rate and reduce complications.10,11 In an extensive meta-analysis, ultrasound guidance significantly reduced internal jugular and subclavian placement failure (relative risk [RR] 0.32; 95% confidence interval [CI] 0.18-0.55), decreased complications during catheter placement (RR 0.22; 95% CI 0.18-0.55) and lowered the need for multiple catheter placement attempts (RR 0.6; 95% CI 0.45-0.79) when compared with the standard landmark placement technique.12 Use of this procedure for central line placement generally requires 2 operators: one to hold the transducer and the other to guide the needle. Recently a randomized clinical trial tested the effectiveness of a single-operator technique and compared it with the standard 2-operator technique for placement of internal jugular central lines. Cannulation success rate was similar for the 2 groups (96% v. 95%) with a 90% probability that the success rates of these 2 groups differed by less than 10% of each other.13
Conclusions
Insertion of a central venous line should be carried out under ultrasound guidance, especially in high-risk patients, thereby minimizing the risk of a serious adverse event as seen in the present case. Ultrasound guidance will probably be of even more benefit when central line insertion is performed by physicians not as familiar with the procedure. When used for vessel location and catheter placement in real-time, ultrasound guidance improves success rates and reduces the complications associated with internal jugular and subclavian venous catheter placement. A proper training program to teach ultrasound-guided insertion techniques should be completed before unsupervised practise in order to reduce potential complications.4,9 Moreover, a single-operator technique of placement is feasible and reliable and should be implemented in emergency departments and intensive care units.
References
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- Christensen KH, Nerstrom B, Baden H. Complications of percutaneous catheterization of the subclavian vein in 129 cases. Acta Chir Scan 1967;133:615-20.
- Ng WS. The subclavian vein. In: Latto IP, Ng WS, Jones PL, et al, editors. Handbook of percutaneous central venous catheterisation. 3rd ed. London: W. B. Saunders; 2000. p. 91-134.
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- Randolph AG, Cook DJ, Gonzales CA, et al. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053-8.
- Milling T, Holden C, Melniker L, et al. Randomized controlled trial of single-operator vs. two-operator ultrasound guidance for internal jugular central venous cannulation. Acad Emerg Med 2006;13:334-6.
