Inadvertent direct pulmonary artery catheterization complicating the effort for subclavian venous cannulation and central venous catheter placement: A case report and review of the literature

Abstract

Subclavian access is commonly used in the intensive care unit (ICU) for central venous catheterization. Many complications have been reported during the placement of central venous catheters including pneumothorax, hemothorax, hematoma, and bleeding. The direct, through the thoracic wall, catheterization of pulmonary artery is a very rare one with only three previous reports in the literature. We report a patient who was catheterized for subclavian venous catheter placement, but the imaging techniques (chest X-ray and computed tomography with reconstruction of the images) revealed the direct positioning of the catheter into the pulmonary trunk, fortunately without other adverse events for the patient. Our case report in accordance with recent review of the literature strongly emphasizes the benefits of performing ultrasound-guided interventions in ICU.

INTRODUCTION

In the past, many interventions in the intensive care units (ICUs) were performed with the guidance of anatomic landmarks. The broad use of ultrasound and computed tomography (CT) made imaging of vessels and solid organs easily accessible in everyday clinical practice even by nonradiologists (intensivists, surgeons, and internal medicine physicians). Intensive care medicine has a long-standing history of experience in their use which made interventions in ICU safer and diagnosis of complications that follow these procedures easier.[1]

One usual procedure for ICU patients is a central venous catheter (CVC) placement. Many complications that follow this medical intervention have been reported in the literature. Common complications include arterial injury, venous injury, bleeding, hematoma, pneumothorax, catheter malposition, arrhythmia, and infection, while other complications such as pneumomediastinum, chylothorax, tracheal injury, injury to the recurrent laryngeal nerve, air embolus, cardiac tamponade, and cardiac arrest are more rare and life-threatening due to difficulty in diagnosis and confrontation.[2] We report a very rare complication of direct catheterization of the pulmonary artery through the thoracic wall, which could easily have been overlooked. Our case report with the review of the literature that we performed focuses on the reduction of the occurrence of these events and the early identification of them with the use of imaging methods that every intensivist should become familiar with.

CASE REPORT

A 52-year-old woman nonsmoker, nonalcoholic, with negative medical and family history was hospitalized due to serositis (pleural and pericardial effusion) and cerebral hemispheric leukoencephalopathy in magnetic resonance imaging of the brain, resulting in reduced level of consciousness (Glasgow Coma Scale: 8/15, eye-opening response: 1, verbal response: 3, and motor response: 4). Her vital signs were temperature body 36°C, heart rate: 60 beats/min, respiratory rate: 16 breaths/min, and arterial blood pressure: 110 systolic, 60 diastolic, and 77 mean (in millimeters of mercury). No etiology was recognized after extensive clinical, laboratory, and imaging investigation/workup. She was finally admitted to our ICU following intubation for airway protection.

Due to progressive hemodynamic compromise, our patient required administration of vasopressors and subsequently the placement of a CVC. Her body mass index (BMI) was 23.8. She was intubated, receiving proper doses of analgesia and sedation for endotracheal tube tolerance and small doses of noradrenaline (0.02 mcg/kg/min) for the distributive shock that sedatives caused. Left subclavian CVC placement was attempted using anatomic landmarks. The procedure was performed by a resident physician under the direct supervision of an ICU consultant. The patient was placed in a supine position with the feet elevated (Trendelenburg). The area was cleaned liberally with chlorhexidine solution, scrubbed vigorously for 60 s, and allowed to dry for 30 s. Sterile procedures were followed for the preparation of the CVC kit, the physician (mask, bonnet, sterile gown, and gloves) and the isolation of the body area that would undergo the procedure. ten milliliter of 1% lidocaine was injected for local anesthesia. The index finger was placed in the sternal notch, while the thumb was used to identify the middle third of the clavicle. The introducer needle was inserted with negative pressure, approximately 1 cm inferior to the junction of the middle and medial third of the clavicle, at 10° angle to the skin, aiming toward the sternal notch and with an effort to remain parallel to the floor while advancing. Three efforts were performed. In the first and second attempts, the subclavian vein was not accessed despite the use of the above mentioned anatomic landmarks. Fatigue, frustration from the two unsuccessful efforts, and the physician's anxiety to accomplish central venous access for the patient made the third attempt laborious. Anatomic landmarks were not carefully followed. The effort finally led to aspiration of dark blood that was conceived as nonpulsatile. The procedure was completed without further difficulties and a chest X-ray followed with no abnormal findings observed.

A few days later, a new chest X-ray [Figure 1] was more carefully examined raising questions about the position of the catheter. In fact, a more careful observation revealed that the point from which the catheter entered our patients' body was not typical as well. It was between the first and the second ribs of the patient at the lever of the parasternal line. A CT of the thorax was performed. The axial and oblique reformatted images [Figure 2a and b] and the three-dimensional volume-rendered images [Figure 3a and b] revealed the direct placement of the catheter into the pulmonary trunk, with no damage caused at the surrounding anatomic structures and vital organs (heart, pericardium, pulmonary parenchyma, visceral and parietal pleura, and large vessels of the area other than the pulmonary artery). The pulmonary artery itself was affected in no way other than the presence of the catheter. After thoracic surgery consultation, in the ICU, but ready for immediate surgical intervention if necessary, the catheter was removed uneventfully. A new one was placed at the right jugular vein by another physician under ultrasound guidance. Our patient died 22 days later due to severe cerebral edema and brain stem herniation.

Figure 1.

Chest X-ray performed 3 days after the insertion with inadvertent positioning of the catheter

Figure 2.

(a and b) Postcontrast computed tomography of the thorax with an axial-oblique reformatted image (a) and a coronal-oblique reformatted image using maximum intensity projection technique (b), portraying the course of the catheter (arrow 1) as well as the tip ending into the pulmonary trunk (arrow 2)

Figure 3.

(a and b) Three-dimensional volume rendered images showing the course of the catheter (arrow 1) entering the thoracic cavity from the first intercostal space anteriorly (a), passing medially to the left superior pulmonary lobe in contact with the parietal pleura (b), ending into the pulmonary trunk (arrow 2)

DISCUSSION

Placing of CVCs is an everyday necessity in ICUs. Their widespread use has made the occurrence of resulting complications a common phenomenon that has to be prevented with every possible measure due to its catastrophic consequences. Placement sites for CVCs include the internal jugular, the femoral, and the subclavian vein.

Subclavian CVC placement, the access initially used for our patient, is associated with lower infection and thrombosis rate than the other two sites and better patient comfort. A catheter can be placed quickly using anatomic landmarks, and this site is often preferred in trauma patients with cervical collars. However, the most significant disadvantage of this access is the risk of pneumothorax due to the anatomic proximity to the lung. In addition, due to its proximity to the clavicle in case of inadvertent arterial puncture, it is difficult to effectively compress the subclavian artery. Those disadvantages can be left aside with the use of ultrasound, which has made subclavian venous access, an even more appealing choice. The procedure is safer with ultrasound guidance, the possibilities of arterial puncture are minimized and the technique is more easily learned by inexperienced operators compared to the traditional landmark approach.

Another procedure performed in ICUs for hemodynamic monitoring of patients is pulmonary artery catheterization (PAC). It is used for the evaluation or diagnosis of pulmonary hypertension and for the assessment of right-sided cardiac chamber filling pressures, cardiac output, intracardiac shunt, valvular studies, and vascular resistance. Complications that follow this procedure include the ones already mentioned after the catheterization of internal jugular, femoral or subclavian vein, and moreover arrhythmias, thromboembolic events, air embolism, pulmonary infraction, endocarditis, right bundle branch block, knotting of the catheter, damage to the valves, and pulmonary artery rupture. Another category of complications are those that follow the direct, through the thoracic wall, catheterization or puncture of the pulmonary artery.

The review of the literature reveals only three similar reports of direct PAC in the international literature[3,4,5] and a few others regarding only puncture, without cannulation of the vessel [Table 1].[6,7,8,9] Fortunately, none of the adverse events (hemothorax and cardiac tamponade) that were observed at the reports 3, 4, 6-9 occurred at our patient. The catheter passed through the second intercostal space and the mediastinum directly at the pulmonary artery, leaving the lung parenchyma, the pleura, and the pericardium intact [Figure 2a and b]. The close anatomic relationship of the pulmonary artery with vital structures and organs and its different trajectories from the subclavian vein make direct PAC without further complication a very rare and worth-mentioning case. Only one similar report[5] without implications for the patient is referred in the literature [Table 1].

Table 1.

Characteristics of accidental pulmonary artery catheterization/puncture incidents regarding predisposing factors, diagnosis, complications, evolution, and prevention practice

Reference/year	Age/sex	Pulmonary artery catheterization/puncture	Predisposing factors	Method used for diagnosis	Further complication	Evolution	Suggestion for ultrasonography use
1977[6]	36 years/female	Puncture	Τethering of the apex of the left lung by adhesions/anticoagulation/pulmonary hypertension	Thoracotomy	Hemothorax	Resolution	NO
1980[7]	69 years/female	Puncture	Mild pulmonary hypertension	Thoracotomy	Hemothorax	Resolution - Death due to sepsis	NO
1984[8]	56 years/female	Puncture	None reported	Thoracotomy	Cardiac tamponade	Resolution - Discharge	NO
1984[3]	46 years/female	Catheterization	Increased BMI	Chest radiography with contrast administration/right heart catheterization	Cardiac tamponade	Resolution - Discharge	NO
2008[4]	6 months/male	Catheterization	Cardiac malformation/previous operations	Thoracotomy	Hemothorax	Not specified	YES
2009[9]	63 years/female	Puncture	Increased BMI	Thoracotomy	Hemothorax	Resolution - Discharge	YES
2012[5]	79 years/male	Catheterization	Limited experience of the operator/low BMI/pulmonary hypertension	Chest radiography with contrast administration	No further complication	Death from other cause	YES

BMI: Body mass index

Another thing worth noticing about our case is the absence of predisposing factors. The review of the literature reveals that direct pulmonary artery puncture or catheterization is associated with BMI >30 or lower than 20, pulmonary hypertension, cardiac malformation/previous operations, prior catheterization, surgery or radiotherapy at the site of puncture, congenital anatomic variations, and inexperience of the operator [Table 1].[3,4,5,6,7,8,9] Our patients' BMI was normal and she had no history, signs or echocardiographic findings compatible with congenital or acquired heart disease and pulmonary hypertension and had no prior catheterization, radiotherapy, or surgery at the site of the puncture. It seems that less experience of the physician is enough for the occurrence of the complication. In only one of the previous reports, no predisposing factors related to the patient are mentioned.[8]

The retrospective analysis of the incident suggested that a more careful evaluation of X-rays following such interventions is mandatory. We observed that something unusual could have happened 3 days after the placement of the catheter as the patient's stability misled us. In most of the cases, early identification is crucial due to the severity of the resulting complications.[3,4,6,7,8,9] When a patient becomes unstable after such a procedure, fast diagnostic workup is absolutely necessary and can be proved lifesaving. However, even if a patient is clinically stable like in our case, careful evaluation after every interventional procedure is absolutely necessary for the avoidance of delayed recognition of complications.

The incident motivated us to change the procedures regarding both trainings of our residents and placing of CVCs. More specifically, residents receive intensive theoretical and practical training in interventional procedures. They start with anatomical models for realistic and safe exercise and follow training courses and conferences to expand their knowledge and experience. The placing of CVCs by residents is performed with active participation of consultants. Ultrasound guidance is strongly encouraged in accordance with international literature.[10,11] Attention is drawn to factors associated with the performer of the procedure. Knowing that the number of attempted insertions is linked to complication occurrence when a physician has three unsuccessful attempts, he or she is encouraged to abandon the procedure and let someone else to carry on. When predisposing factors for complications are present, experienced physicians are preferred. CVCs are placed with a strict protocol, following strict indications and unnecessary placements are avoided. Peripherally inserted central catheters are used occasionally when indicated. Every interventional procedure performed with ultrasound guidance is recorded in a database to be able to evaluate the performance of our department, detect possible mistakes/malpractices, and promote improvement.

CONCLUSION

Our case stresses out the usefulness of new imaging techniques. In the hands of experienced radiologists, they facilitate recognition and diagnosis of complications leading to avoidance of more interventional procedures such as digital subtraction angiography or thoracotomy. Not only diagnosis but also prevention of complications is facilitated by imaging techniques. Review of the current literature, especially recent reports,[1,4,5,9,10] supports the use of ultrasound for making our interventions in the ICU safer. The use of ultrasound-guided CVC placement should be adopted in everyday clinical practice at the environment of the ICU so that the prevalence of such complications is minimized in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. The patient's family signed the consent form for her clinical information and images to be reported and potentially published. The patient's family understands that the patient's name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (applicable reporting guideline for case reports [CARE] was followed). The authors also attest that this clinical investigation was determined to require the Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is 76 (09/02/2019).