Case Reports: Case Report
Two case reports by Varelmann and Hilberath1 and by Fukugasako et al.2 underscore the challenges of central venous catheter (CVC) insertion in surgical patients with complex conditions. A third case report by Dave and Giglio3 highlights the potential complications of removing a normally functioning intravascular catheter when its use is no longer indicated.
In the Varelmann and Hilberath case report,1 the patient’s very low cardiac output understandably complicated flow-directed pulmonary artery catheter (PAC) placement. This case report highlights an additional challenge of central venous access in patients with heart failure: the fact that these patients frequently have an implantable cardioverter-defibrillator for either primary or secondary prevention of arrhythmia. Patients with refractory heart failure may have up to 3 leads (atrial, right ventricular, and coronary sinus) for cardiac resynchronization therapy. Entanglement of wires and catheters, dislodgement of preexisting implantable cardioverter-defibrillator leads, and access failure due to thrombosis or reduced vascular diameter are all potential hazards of CVC placement in patients with end-stage heart failure. The authors correctly point out that additional vigilance is required during assembly and placement of CVCs in these patients. Transesophageal echocardiography (TEE) may have been useful for visualization of the introducer wire in the right atrium and correct placement of the PAC.
The second case report, by Fukugasako et al.,2 describes an instance of introducer wire perforation and entanglement during an attempted dual central venous catheterization of the right internal jugular vein. Using a single, larger introducer catheter with ports for titrated infusion, rapid infusion, and PAC placement would have eliminated the need for a dual wire and catheter technique. Should a dual catheter technique be preferred, TEE in either the bicaval or the 4-chamber midesophageal view allows the operator to confirm wire placement in the right atrium before placement of the second wire begins. In this case, TEE visualization could have prevented the wire puncture by the second introducer needle.
In the third case report by Dave and Giglio,3 a transvenous coronary sinus catheter was placed to administer cardioplegia during minimally invasive aortic valve surgery. Although the catheter was correctly inserted and cardioplegia solution was effectively administered, the coronary sinus catheter tip was sheared or fractured from the remainder of the catheter during removal, possibly due to incomplete deflation of the balloon. In such cases, removal of the catheter fragment with additional surgical or interventional procedures may be necessary. However, TEE examination did not reveal any foreign body in the right atrium or ventricle, and the 11F introducer appeared intact. Subsequent close visual inspection of all components of the coronary sinus catheter system revealed that the broken tip was entirely contained within the lumen of the introducer.
These case reports emphasize the need for monitoring for complications of CVC insertion and removal, with heightened awareness when multiple wires and/or devices are present in or near the targeted vein. Furthermore, the cases highlight unique uses of TEE for visualization of wires and catheters during CVC insertion and removal.
Annemarie Thompson, MD
Department of Anesthesiology Duke University School of Medicine Durham, North Carolina
1. Varelmann DJ, Hilberath JN. Misplacement of a pulmonary artery catheter. A & A Case Reports. 2014;3:127–9
2. Fukugasako H, Mishima Y, Ito A, Kozasa Y, Ushijima K. A significant complication that occurred during the insertion of dual guidewires into the right internal jugular vein for central venous catheterization. A & A Case Reports. 2014;3:133–5
3. Dave B, Giglio NM. Identification and management of a coronary sinus catheter fracture. A & A Case Reports. 2014;3:130–2