Central venous internal jugular vein (IJV) catheterization is frequently used in the operating room and intensive care unit. The majority of mechanical complications associated with central line placement produce vascular and pleural injury, including carotid artery puncture, hemothorax, and pneumothorax.1 The incidence of the aforementioned varies widely, but appears to be decreasing with increased use of ultrasonography (US). However, complications have been reported even when the procedure is guided with US.2,3 We present a patient who sustained a massive left hemothorax despite using US during insertion of a left IJV catheter.
Written authorization was obtained from the patient before publication of this case.
An 82-year-old, 73-kg man, with a history of a pre-existing infrarenal abdominal aortic aneurysm (AAA) and previous Endograft stent placement, emergently presented with a type 1 endovascular leak and ruptured juxtarenal AAA. The patient was taking warfarin and clopidogrel for atrial fibrillation and a drug-eluting stent, respectively.
After an uneventful induction of general anesthesia via an existing peripheral IV line, the left neck was prepped for placement of a 13-French dialysis catheter. A large, patent left IJV was clearly evident with US and punctured with an 18-gauge needle under direct visualization. A guidewire passed without resistance. The guidewire was confirmed to be in the venous system with US. While avoiding full insertion, 2 dilators of increasing size were passed through the skin and subcutaneous tissue, again without resistance. The dialysis catheter was threaded in a modified Seldinger method. Given the emergent nature of this case, the mobility of the guidewire was not ensured at all points of the procedure. Aspiration of blood from all ports was noted, and they were subsequently flushed with saline.
Over the next several minutes, the patient became progressively hypotensive. High on the differential diagnosis was worsening of the aneurysmal rupture. Rather than proceed with left lateral decubitus positioning, as originally planned, the surgeon prepared for an urgent supine midline abdominal incision. Large-volume resuscitation with packed red blood cells and crystalloid was immediately started via the newly placed central line. Hypotension worsened and the patient was unresponsive to bolus doses of vasopressor and inotrope injected via the newly placed line. The bolus of an inotrope via the peripheral IV line produced immediate improvement in hemodynamics. Malposition of the left internal jugular venous catheter was now suspected as the cause of the hemodynamic deterioration. Increased airway pressures and decreased arterial saturation prompted placement of a thoracostomy tube to treat a presumed tension hemothorax. A large volume of fluid, comparable to that administered via the central line, was relieved on insertion of the tube. All hemodynamic parameters including airway pressures subsequently improved. A portable chest radiograph (Figure 1) was taken to ensure re-expansion of the lung and appropriate thoracostomy tube placement.
After consultation with the surgeon, another line of the same type was placed using the same technique into the right IJV and the misplaced catheter was also removed. In an attempt to promote lung re-expansion and tamponade the low-pressure venous bleeding that occurred after extraction of the catheter, positive pressure ventilation with large tidal volumes and positive end-expiratory pressure were used for the duration of the case.
At the conclusion of the AAA rupture repair, output from the chest tube continued at a rate of 300 mL/h. A contrast venogram via the left basilic vein was performed showing extension of contrast from the left brachiocephalic vein into the pleural cavity (Figure 2). The thoracostomy tube, with its tip at the apex of the left lung, was pulled back several centimeters and a subsequent contrast venogram was performed resulting in a much smaller volume of extravasation into the left pleural cavity. The venogram was repeated twice at an interval of 30 minutes. There appeared to be a hematoma that had formed near the perforation site without continued extravasation of contrast, and there was minimal drainage of blood from the chest tube (Figure 3).
Previous experience in these cases with mechanical occlusion of right IJV catheters prompted the decision to place a line into the left IJV. A 13-French dialysis catheter provided not only adequate access for aggressive intraoperative volume resuscitation, but also a temporary access point for hemofiltration in the intensive care unit given the risk of postoperative renal failure.
In this case, it was difficult to explicitly define the mechanism of the vessel injury. US identification of the left IJV and insertion of the guidewire were uneventful. However, left-sided catheters pose a particular risk for dilator-related vascular injury. This is because the left IJV forms a nearly perpendicular angle with the brachiocephalic vein. There is a presumption that if the guidewire passes smoothly into the vein, it will successfully guide the dilator through the vessel.4 In this case, the guidewire likely passed the nearly perpendicular angle into the brachiocephalic vein. However, as the dilator was advanced along the guidewire, the guidewire may have become “trapped” against the inferior wall of the brachiocephalic vein. Under this hypothesis, perforation of the brachiocephalic vein and subsequent violation of the pleural space resulted. It should be noted that the mobility of the wire was not ensured at all points of the procedure given the emergent nature of this case. However, on removal of the guidewire from the distal port of the catheter, no exaggerated bend or any damage was seen.
As demonstrated by this case, successful aspiration of blood from all ports does not exclude malposition of a central venous catheter. In this case, the aspirated blood may have originated from the enlarging collection in the pleural cavity secondary to the vessel injury. Alternatively, an insufficient volume may have been aspirated and led to a false-positive conclusion with regard to correct catheter placement.
To avoid a complication whereupon the wall of a central vein may become compromised, a few simple maneuvers can be considered. First, the dilator should not be inserted beyond the approximate depth traversed by the introducer needle (18-gauge needle). Doing so increases the chance of vessel wall injury. Had there been a transesophageal echocardiogram in place, utilization of the bicaval view would provide confirmation of the guidewire in the superior vena cava and thus a good tract for the catheter to follow toward the cavoatrial junction.5 Similarly, given the prevalence of ultrasonography, direct visualization of the right atrium by way of a transthoracic echocardiogram is an effective and efficient method in confirming correct guidewire and central line placement. Studies have suggested that US visualization of bubbles (seen as opacification) in the right atrium after injection of 10 mL of agitated normal saline via the most distal catheter port confirms proper positioning of the catheter tip. Overall, when considering the thoracic vessels for cannulation, the right side should be given the higher preference, because there is an increased incidence of malposition when access is from the left.7
The literature on the management of central venous catheter malposition is mixed whether to reposition, replace, or remove as soon as it is deemed practical.6 In this case removal of the catheter had a few shortcomings. The bleeding may have been exaggerated because the patient was taking both warfarin and clopidogrel. It may have been worthwhile to administer fresh frozen plasma and platelets. Uncertainty as to the location of the body or tip of catheter meant the removal could have resulted in life-threatening arterial hemorrhage. The literature appears to be consistent in recommending that an inappropriately placed catheter should remain in situ until a workup can be completed, especially when direct external compression is not possible.7
The literature provides several suggestions on how to manage iatrogenic central vein injury when direct compression of an injured vessel cannot be provided. Saseedharan et al7 reported a hemodialysis catheter that penetrated the wall of the brachiocephalic vein entering the anterior mediastinum. Under fluoroscopic guidance, the misplaced catheter was removed in a staged manner with a balloon catheter in place to tamponade if a hemorrhage scenario resulted. Kuzniec et al8 reported a case of video-assisted thoracoscopic surgery in the management of a mediastinal venous perforation, allowing for direct compression of the perforation site. Iwańczuk et al9 reported on a right subclavian vein perforation with resulting hemothorax after subclavian vein cannulation with a hemodialysis catheter. Emergent thoracotomy allowed for reconstruction of the damaged vein wall. Finally, endovascular repair of central venous injury using an endoprosthesis has been reported,10 but this method involves the definitive implant of intravascular synthetic material that may have long-term obstructive implications. In addition, there is an inherent risk of worsening the injury in reaccessing the venous system that was already injured.
Fortunately, the ease of use and overall increased availability of the US device may positively impact first-attempt success rates for the placement of central venous catheters. US has been invaluable in targeting the site of entry, especially for the vessels located in the neck. When comparing landmark versus US guidance, many studies have shown a clear advantage of ultrasound guidance for the cannulation of the IJV. Troianos et al11 describes an improvement as an overall success rate from 96% to 100% with the use of US. More importantly, the first-attempt success rate improved from 54% to 73%, the number of needle advances decreased from 2.8 to 1.4 attempts, the time to cannulation decreased from 117 to 61 seconds, and the number of arterial punctures decreased from 8.43% to 1.39%. Probe placement on the thorax itself may help ensure both adequate guidewire and central catheter tip placement.11
Iatrogenic perforation of the brachiocephalic vein is a serious and potentially fatal complication that may occur after left IJV insertion of a large-bore catheter. It is important to understand that US guidance can facilitate the identification of vessels but cannot guarantee proper central line placement within a large vessel.
Management of a misplaced central depends on the extent of the injuries, general status of the patient, and efficiency of the clotting system. If only a needle puncture has occurred, the problem is usually not critical. However, if large-bore catheter penetration and fluid injection are involved, aggressive monitoring and consultation with a thoracic surgeon, vascular surgeon, and/or an interventional radiologist should be sought. The misplaced catheter should be left in situ until suitable imaging is obtained and a plan is devised to control any bleeding that might result at the time of removal.
Name: Lindsay R. Wetzel, MD.
Contribution: This author helped write and edit the manuscript, and with visualization.
Name: Priyesh R. Patel, MD.
Contribution: This author helped write and edit the manuscript, and with visualization.
Name: Nicholas L. Pesa, MD.
Contribution: This author helped conceive and design the case report.
This manuscript was handled by: Raymond C. Roy, MD.
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