Accidental central venous catheter cannulation into aberrant arterial anatomy requiring endovascular intervention

Abstract

Central venous catheter placement continues to be an extremely common procedure throughout hospital systems. Although ultrasound guidance can mitigate some placement risks, misplacement of lines into neighboring structures, such as arteries, remains an unfortunate complication. In this report, we will discuss an 83-year-old female with aberrant left subclavian artery and right sided arch, which provided for successful stent graft coverage of arterial injury secondary to accidental subclavian artery cannulation with a central venous catheter with preservation of the right common carotid artery and avoidance of a potentially morbid sternotomy.

Over 5 million central venous catheters (CVCs) are placed annually across the United States.¹ The implementation of CVC placements under ultrasound guidance has lowered the incidence of mispositioned CVCs entering neighboring vessel or organ from 8.4% to 1%-3%.² However, accidental arterial puncture, even with ultrasound guidance, occurs in roughly 1% of internal jugular vein lines and 2.7% of subclavian CVCs.³ Treatment options for accidental arterial puncture involve pulling the CVC with manual pressure, percutaneous closure, endovascular stenting, or open surgical repair.⁴ Although manual pressure may be adequate for smaller caliber CVCs in accessible vessels, this strategy is often inadequate for deeper vessels and larger caliber CVCs. Percutaneous arterial closure devices, using bioabsorbable plug and suture-mediated closure mechanisms have been reported as valuable treatment options for accidental punctures of the subclavian and femoral arteries.⁵ However, these may not be feasible depending on depth of injury and the relevant path. Other endovascular interventions include stent graft placement for coverage of the arterial injury.

Open repair may be favored in sites not amenable to these less invasive techniques or for large-caliber CVCs. Hybrid approaches such as temporary balloon occlusion can be a relevant adjunct during the open exposure. Although many techniques exist, surgical judgment is necessary to delineate the best treatment for each patient, which may be influenced by patient anatomy and size and location of involved CVC injury. The patient provided informed consent to allow the publication of this report.

Case report

An 83-year-old female with a past medical history of atrial fibrillation requiring anticoagulation with apixaban, hypertension, hyperlipidemia, and type 2 diabetes mellitus, presented with a small bowel obstruction that required exploratory laparotomy with ventral hernia repair. This was complicated by abdominal wound infections requiring multiple debridements. Shortly after discharge, the patient presented to an outside hospital with fever, chills, and purulent drainage from her abdominal wounds. She was found to be septic, and a 7.5 Fr triple lumen right internal jugular vein CVC was placed at bedside. The outside imaging accompanying the patient was insufficient to determine if ultrasound guidance was utilized. Post-procedure chest X-ray demonstrated a possible arterial cannulation (Fig 1). This was followed-up with a contrasted computed tomography scan. The CVC was found to completely penetrate the right internal jugular vein, and into the right subclavian artery (RSCA), terminating in the aortic arch (Fig 2, A). On computed tomography, it was also noted that the patient had a right-sided aortic arch anatomical variant, with separate origins of the RSCA and right common carotid artery (RCCA) (Fig 2, A and B); the arch vessels had a tortuous course, with left common carotid artery (LCCA) arising from the aorta most proximally, followed by the RCCA, RSCA, then left subclavian artery (LSCA) with a Kommerel’s diverticulum (Fig 2, B). The patient was transferred to our facility for intervention.

Fig 1.

Chest X ray from outside hospital suggestive of mispositioned central venous cathether (CVC).

Fig 2.

A, Coronal view computed tomography scan showing the patient’s aberrant right common carotid artery (CCA) off the proximal aortic arch (red arrow) and the central venous cathether (CVC) within the subclavian artery (SCA) and cannulating the aortic arch (green arrow). B, Three-dimensional reconstruction with labels. IVC, Inferior vena cava.

The patient was brought to our hybrid operating room for a planned endovascular intervention of central arterial stent graft placement via open brachial access. To accommodate the 8 Fr sheath size of our planned intravascular ultrasound catheter and stent graft, we performed a right brachial artery cutdown, systemically heparinized with 5000 units of unfractionated heparin, and gained access using a modified Seldinger technique. Intravascular ultrasound and angiography were used to identify the origin of the vertebral artery from the subclavian artery, and its proximity to the CVC (Fig 3); the vertebral artery origin was approximately 11 mm in centerline distance from the CVC entry site. Imaging suggested a suitable landing zone for placement of a stent graft into the RSCA with line-associated injury coverage without vertebral artery coverage. We therefore deployed an 11 × 29 mm Gore VBX stent graft (WL Gore & Associates, Flagstaff, AZ) within the proximal subclavian artery to a nominal diameter of 11 mm over a .035 wire. The proximal portion appeared to overhang into the aortic arch about 3 mm. After initial deployment of the stent graft to nominal size, we pulled the CVC out from between the stent graft and arterial wall. To ensure full apposition of the stent graft in the vessel wall for seal and to flare the stent graft slightly at the subclavian origin, additional balloon angioplasty with a 14 × 40 mm balloon was performed. Completion angiogram revealed no contrast extravasation (Fig 3). The patient was extubated and observed in the surgical intensive care unit with a 500 unit/hr flat-rate heparin infusion immediately postoperatively and transitioned to her home anticoagulant (apixaban) on postoperative day (POD) #2. She was transferred to the floor on POD #1 and was discharged on POD #7 on apixaban and aspirin therapy with oral doxycycline and cefpodoxime for antibacterial coverage per infectious disease recommendations. Arterial duplex at 1-month follow-up was normal, and medication regimen was transitioned to apixaban monotherapy to minimize bleeding risk.

Fig 3.

Intraoperative angiogram showing cannulation of the right subclavian artery (SCA) with the central venous catheter (CVC) (red arrow) just proximal to the vertebral artery takeoff (A). Postoperative angiogram of the left SCA showing no extravasation of contrast (B).

Discussion

Multiple randomized studies demonstrate lower complication rates with ultrasound-guided CVC placements.⁶ However, line placements continue to carry a small risk of accidental arterial cannulation (up to 5% of cases)⁷ and associated hematoma, hemothorax, pseudoaneurysm, stroke, or arteriovenous fistula complications8, 9, 10, 11, 12; accidental damage to the carotid arteries has been specifically linked to higher risk of strokes.

The patient’s aberrant anatomy of a type II right aortic arch with aberrant LSCA with Kommerel’s diverticulum had the RCCA originating from the proximal aortic arch, coursing anterior to the RSCA. The incidence of right aortic arches in the general population ranges from 0.1% to 0.5%.^13,14 The lack of a true innominate artery led to an uncompromised carotid artery and was likely protective from stroke risk associated from CVC misplacement. Multiple case reports of patients developing strokes from accidental cannulation of the carotid arteries with CVCs exist,^15,16 with common etiology noted of direct damage to the arterial intima, leading to thrombus formation, with cerebral embolization. The ability to stent graft without coverage of the vertebral takeoff also was also protective from stroke risk in her case, though her contralateral vertebral was also patent.

Among misplaced CVC removal options, the location of the arterial puncture prohibited direct pressure as a safe treatment strategy. Even with an endovascular treatment strategy, we were concerned about the ability to get rapid proximal control if a percutaneous closure device failed, and the intrathoracic depth and course of the vessel injury suggested risk for additional trauma with the deployment mechanisms of some of our facility’s available closure devices. Techniques of using percutaneous closure devices in cerebrovascular and upper extremity vessels has been established, however, with Bechara et al reporting good perioperative and early postoperative (1 month) outcomes of 12 patients with inadvertent carotid artery cannulation where six required open exploration with primary repair and the remaining six were closed percutaneously.¹⁷ Regarding accidental SCA cannulations, direct pressure, or percutaneous closure are often favored over other methods due to the vessel’s proximity to the skin.18, 19 The patient’s comorbidities, in combination with the systemic infection, led us to believe open surgical repair would be poorly tolerated. Regardless of the abundance of treatment options, there remains a need for case-by-case decision-making regarding retrieval techniques and an appreciation for alternative strategies for hemorrhage control in the central vessels, such as temporary balloon occlusion and availability of procedural supplies and teams for emergent sternotomy. In this case, key anatomic factors that led to successful treatment result included lack of a true innominate artery, which provided a longer proximal landing zone, avoidance of need for RCCA manipulation or cannulation, and adequate distal seal zone to avoid vertebral artery coverage.

Conclusion

Although ultrasound-guided access has improved the safety of central venous catheter placement, accidental arterial puncture remains prevalent in approximately 1% to 3% of upper extremity central venous catheter placements. Dedicated imaging of CVC course in cases of misplaced lines can help identify aberrant vascular anatomy, which may aid in the choice of treatment options for safe CVC removal with hemorrhage prevention or control. Although a rare variant, the patient’s right sided aortic arch and aberrant right subclavian artery assisted in the successful treatment of this patient’s arterial injury.