Central venous cannulation is associated with numerous complications of various etiologies.1–4 The most common mechanical complications are arterial puncture, hematoma, and pneumothorax.1 The rare but potentially fatal complication of hemothorax has been reported during right internal jugular vein (IJV) catheterization.5–11
Here, we report the perforation of the brachiocephalic vein during ultrasound-guided catheterization of the right IJV in a patient with tortuous right carotid artery, which led to massive hemothorax.
Written informed consent for publication of this case report was obtained from the patient.
An 80-year-old woman (height 1.48 m; weight 40.6 kg) with a history of hypertension was diagnosed with a thrombosed Stanford type A aortic dissection. A contrast-enhanced computed tomographic (CT) examination demonstrated an increase in the size and flow in the false lumen; therefore, the patient was scheduled for elective hemiarch replacement surgery. Preoperative laboratory investigations revealed a hemoglobin level of 10.0 g/dL, normal renal function, and absence of any coagulation disorders.
Right radial arterial catheter insertion, anesthetic induction, and endotracheal intubation proceeded uneventfully. A pulsating vessel in the right supraclavicular region was detected. Ultrasound imaging identified a tortuous common carotid artery (CCA) and right IJV. We planned to insert the sheath from the right IJV under ultrasound guidance. The operator had previously inserted more than 50 central venous lines.
The patient was placed in the Trendelenburg position. Under ultrasound visualization, the introducer needle was guided through the skin into the vessel. An iE33 ultrasound machine with L11-3 transducer (Philips Electronics Japan, Tokyo, Japan) was used. Without considering the orientation of the tip, the J-tip guidewire was inserted smoothly from the right IJV by using the thin-wall introducer needle technique. Ultrasound guidance was not used during guidewire insertion but was used to confirm that the guidewire was in the IJV. The guidewire was inserted 10 to 11 cm. After making an incision at the site of wire entrance at the skin to facilitate dilator and sheath insertion, a 9-Fr introducer sheath (Arrow 9.0 Fr 10 cm, sheath introducer kit, Teleflex Medical Japan, Tokyo, Japan) was placed over the dilator, which was fully inserted with ease; we did not to check for free sliding of the guidewire during the advancement of the sheath dilator. The guidewire was advanced further into the IJV during insertion. After removing the dilator and guidewire without any resistance, we could not aspirate blood from the sheath. Ultrasound visualization showed that the sheath was in the right IJV. We suspected that the sheath entrance was sealed against the vein wall. The sheath was retracted by 2 cm, and dark blood was subsequently aspirated. The sheath, however, could no longer be advanced. The sheath was removed, and manual pressure was applied to stop the bleeding. Suddenly, the patient’s blood pressure decreased to as low as 43/30 mm Hg. Norepinephrine, fluids, and erythrocyte concentrates were administered. A transesophageal echocardiography (TEE) probe was inserted, which revealed an empty and hyperdynamic left ventricle, and no left ventricle wall asynergy or progression of the aortic dissection. Pressure-controlled tidal volume decreased and right-sided breath sounds were dampened. The patient’s vital signs sufficiently recovered to allow chest radiography, which showed a massive right-sided hemothorax (Figure 1). At that time, we noticed that the removed guidewire was bent. A chest tube was inserted; however, the hemothorax was not fully drained. The endotracheal tube was exchanged for a double-lumen tube, and thoracoscopic surgery was performed to remove the hematoma. Intraoperative videothoracoscopic imaging showed an injured right brachiocephalic vein, but the bleeding had already stopped completely (Figure 2). The total amount of blood loss was 2360 mL. The patient was transferred to the intensive care unit and extubated uneventfully 8 hours after the surgery without major complications.
After surgery, we reconstructed the preoperative 3-dimensional CT angiography scan, which showed the tortuous right CCA (Figures 3 and 4).
Brachiocephalic vein perforation can lead to communication between the vein and pleural space, resulting in life-threatening hemothorax. Abnormal vessel anatomy is 1 of the risk factors for this complication,5 and this likely contributed to the accident in our case.
We have identified 9 cases in the literature, including our own, of brachiocephalic vein or superior vena cava (SVC) perforation during right IJV catheter insertion in adult patients.5–11 No other case of right IJV catheter insertion under ultrasound guidance has been reported. In previous cases of brachiocephalic vein perforation through right IJV access, patients developed sudden onset of hypotension or volume loss of unknown origin that was detected 10 minutes after the completion of the procedure,6 during surgery,7,8 soon after the surgery,5 or upon arriving in the cardiac intensive care unit.9 Only in the present case and in 4 other cases, patients were successfully resuscitated.5,8,10,11 In the present case, as cardiac surgery was planned, qualified medical personnel and blood transfusions were available. These circumstances all contributed to the favorable outcome in our patient.
The patient described in this case had a tortuous CCA, which has been detected in up to 5% of carotid angiograms obtained in symptomatic patients.12 Pulsation in the lower right cervical region beneath the sternomastoid muscle may be related to a tortuous CCA.13 Although the exact mechanism of injury is uncertain, we believe that the perforation was caused by the dilator when it was advanced over the guidewire, which was trapped against a vessel wall after misplacement (Figure 5).2 Generally, the right IJV continues straight into the SVC, and the guidewire is easily advanced to the SVC–atrial junction. We suspect that the tortuous CCA displaced the right IJV, and the guidewire was easily introduced into the subclavian vein, following which the stiff dilator then penetrated the brachiocephalic vein wall. This theory is further supported by the fact that the removed guidewire was bent, suggesting malposition of the guidewire.7 The patient was elderly, of small stature, and with fragile tissues, which might have resulted in reduced resistance of the vessel wall.
Several technical points should be considered to prevent this complication. First, if we had inserted the guidewire to more than 11 cm, we may have encountered resistance, and this would have alerted us to the malpositioning of the guidewire. In 1 study, the authors suggested inserting the guidewire at least 15 cm in adult patients.14 In surgeries where this is a feasible option, it is recommended that TEE be used to visualize the guidewire advancing to the SVC–atrial junction in order to prevent dilatation of the wrong vessel or perforation of the vessel wall.4,5,14 Real-time fluoroscopy can also be used to identify the anatomic location of the guidewire.4,10,14 Second, the dilator should not be inserted all the way; rather, the dilator tip should be advanced only until it has entered the vessel and established sufficient dilation of the track to allow insertion of the flexible catheter.3 It has previously been recommended to avoid inserting the dilator more than 10 cm, because in most patients, an insertion depth of 8 cm is sufficient for adequate tissue dilation.6 It is unnecessary to dilate the vessel past the entry point into the vessel.6 The excessive insertion of the dilator can cause vascular injury. In our case, the tip of the sheath dilator perforated the brachiocephalic vein and entered the right pleural cavity. Third, ensuring free sliding of the guidewire within the dilator during advancement of the dilator has also been recommended to ensure that the dilator tip is not trapped against the vein wall.7,11 Moreover, soon after removing the dilator and guidewire, we should have checked whether the guidewire tip was bent, which would have allowed more rapid detection of the complication.
If blood cannot be aspirated through the sheath, the possibility of a vascular perforation should be kept in mind. In such case, surgeons and anesthesiologists should ensure that there is no sheath kinking and that the sheath is not subcutaneous, extrapleural, or intrapleural.5,8 We could have injected agitated saline through the sheath while visualizing the right atrium via TEE or transthoracic echocardiography. The absence of the agitated saline in the right atrium would have suggested that the catheter tip was not in a central vein. Clinical suspicion of an intrathoracic injury should prompt imaging to locate the site of injury and plan surgical or endovascular treatment.10 The catheter position cannot be confirmed within a vessel on a radiograph, as this is a 2-dimensional projection of 3-dimensional objects. A CT scan would be required to definitely confirm the catheter in the vessel.
Tension pneumothorax is a common differential diagnosis for cardiovascular collapse after central line placement. In addition to radiography, surface ultrasonography is useful in diagnosing hemothorax5,11 and tension pneumothorax.15 Pneumothorax could have been excluded with surface ultrasound with high specificity.15
In conclusion, anesthesiologists should consider the possibility of guidewire malposition, which can result in a risk of devastating complications during right IJV catheterization, particularly in patients with a tortuous CCA.
Name: Atsushi Kainuma, MD.
Contribution: This author was the attending anesthesiologist during surgery and helped write the manuscript.
Name: Keiichi Oshima, MD.
Contribution: This author was the attending anesthesiologist during surgery and helped collect the data.
Name: Chiho Ota, MD.
Contribution: This author was the supervising anesthesiologist during the surgery and helped prepare the manuscript.
Name: Yu Okubo, MD.
Contribution: This author helped collect and interpret the intraoperative videothoracoscopic imaging.
Name: Naoto Fukunaga, MD.
Contribution: This author helped collect and interpret the 3-dimensional computed tomographic angiography
Name: Soon Hak Suh, MD.
Contribution: This author helped supervise the case report.
This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.
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