Insertion of a central venous catheter (CVC) is a routine technique in the intensive care unit to monitor central venous pressure and establish an intravenous line to deliver nourishment and medication that cannot be safely pumped into peripheral veins. Patients with major surgery or severely ill who need close supervision and a high dose of inotropic and vasopressor medications benefit from this technique. However, problems such as artery puncture, hematoma, pneumothorax, hemothorax, catheter infections, and thrombosis may result from inserting a CVC. Here we report a case of hemothorax due to attempts at CVC insertion into the subclavian veins in a patient with ST-segment elevation myocardial infarction (STEMI) with new-onset atrial fibrillation on triple antithrombotic therapy after the primary PCI procedure.
A 62-year-old man arrived at the emergency department with unstable typical chest pain. For the last 6 h before admission, he looked anxious and diaphoretic. He denied a history of hypertension or diabetes mellitus. He has been a heavy smoker for the past 30 years.
On initial evaluation, his blood pressure was 89/50 mm Hg, heart rate was 32 bpm. with an irregular pulse, respiratory rate was 24 times per minute, O2 saturation was 98% without oxygen supplementation, and the temperature was 35.6°C. There were no audible murmurs upon cardiac auscultation, no rales in lung auscultation, and his other physical examinations were unremarkable. An electrocardiogram (ECG) revealed sinus arrest with junctional escape rhythm of 40 bpm. and multiple premature ventricular complex, ST-segment elevation at inferior extremity lead (leads II, III, and aVF), right precordial lead (v3r-v5r), and posterior precordial lead (lead v7-v9). He was then diagnosed with Killip IV inferior-RV-posterior STEMI and sinus arrest with junctional escape rhythm. An intravenous pump of Norepinephrine and Dopamine was given for hemodynamic support. Dual antiplatelet loading doses of Aspirin 300 mg and Ticagrelor 180 mg were given as recommended in the recent ESC Guideline of STEMI. The patient was sent to the cardiac catheterization laboratory for primary percutaneous coronary intervention (PPCI). The temporary transvenous pacemaker was placed before the procedure. Diagnostic coronary angiography revealed a culprit of critical stenosis at proximal right coronary artery and significant 90% stenosis at mid-right coronary artery. PPCI procedure was undergone with stent placement at proximal and mid-right coronary artery with thrombolysis in myocardial infarction flow 3 as the result.
The patient was then transferred to intensive cardiovascular care unit for close observation. Chest pain has relieved, and the vital sign was stable. Blood pressure was 110/60 mm Hg, heart rate was 80 bpm. with an irregular pulse, respiratory rate was 20 times per minute, and O2 saturation was 99% with 3 liters per minute of nasal cannula. Laboratory data which came up later revealed elevated levels of cardiac troponin-I (84.92 ng/mL; normal <0.1 ng/mL), serum creatinine (2.15 mg/dL; normal 0.7–1.2 mg/dL), and uncompensated metabolic acidosis from arterial blood gas analysis (pH 7,19; pCO2 25 mmHg; pO2 98 mm Hg; HCO3 9.5 mmol/L; BE ‐18.7 mmol/L; SO2 96%). Another lab result was unremarkable. A CVC was then placed at the right subclavian vein as intravenous access for metabolic acidosis correction with sodium bicarbonate. Several puncture attempts were needed before CVC was correctly placed at the right subclavian vein. Repeated ECG at intensive cardiovascular care unit revealed atrial fibrillation rhythm with a moderate ventricular response of 75 bpm on average. For this new onset of atrial fibrillation (CHA2DS2-VASc score: 1; HAS-BLED score: 2), we give warfarin as an oral thromboembolic prophylactic anticoagulant was given as proposed in the recent ESC Guideline of Atrial Fibrillation. and Amiodarone as an anti-arrhythmic agent. On day 2 of admission, chest X-ray evaluation post-CVC insertion revealed a normal appearance [Figure 1]. Echocardiographic examination revealed mildly reduced left ventricle ejection fraction of 49% with hypokinetic at inferior, inferoseptal, posterior, and septal segments. On day 3 of admission, the patient’s symptoms improved. Vital signs were stable without vasopressor or inotropic support. Blood gas analysis revealed a normal value which indicated that prior metabolic acidosis had been corrected. The patient was then transferred to the low-care room.
On day 4 of admission, the patient complained about general weakness and shortness of breath. Physical examination revealed decreased vascularity of the right lung in auscultation and dullness in lung percussion. Laboratory evaluation revealed a significant drop of hemoglobin (from 12.7 mg/dL at admission and 9.6 mg/dL at present). Vital signs were still stable, and ECG evaluation was still in atrial fibrillation rhythm with moderate ventricular response. Chest X-ray evaluation was planned for the suspicion of hemothorax. The result confirmed a hemothorax that filled up to half of the right hemithorax [Figure 1]. Thorax drain was then inserted by the cardiothoracic surgeon with an initial blood drain of 140cc. Ticagrelor, as one of the prior dual antiplatelet therapies, was switched to clopidogrel, and warfarin as anticoagulant thromboembolic prophylactic at atrial fibrillation was stopped as proposed in ESC’s recent guideline of dual antiplatelet therapy. Reverse anti-coagulation was not given because international normalized ratio evaluation is just 1.08.
On day 5 of admission, the patient’s symptoms improved. ECG evaluation revealed a rhythm has converted to normal sinus rhythm. Thorax drain production was 250cc of blood at 24 h. Three days later, there was no more production of blood from the thorax drain. Chest X-ray evaluation revealed a clear lung without residual hemothorax [Figure 2]. Then the thorax drain was pulled out on day 8 of admission with a total production of 460cc blood. The patient started to mobilize with no complaint. The vital sign was stable. The patient was then discharged later on the day, and a follow-up medical appointment at the cardiology outpatient clinic was scheduled.
Approximately 8% of hospitalized patients require central venous access, making it a frequently done procedure. Every year, more than 5 million CVCs are placed in Americans. The published rates of cannulation success and complications vary by anatomic site, use of ultrasound guidance, and operator expertise. A 6-month observational cohort analysis of 385 consecutive CVC placements found that mechanical problems occurred in 33% of those placements, with a hemothorax frequency of less than 1%.
In this patient, we placed a CVC at the right subclavian vein with the indication for administration access of continuous pump vasopressor and sodium bicarbonate. Right-sided subclavian access techniques are frequently preferred by right-handed operators. The lower pleural apex and lack of the thoracic duct in the right subclavian anatomy theoretically reduce the problems. However, compared to left-sided access, right-sided subclavian access is more frequently linked with catheter malposition and vascular damage.
The bleeding complication in this patient, as manifested by hemothorax, may be caused by multiple attempts of punctures. When insertion was attempted more than three times, as opposed to successful insertion on the first try, mechanical complications were six times more likely to occur, according to a prospective cohort study.
Hemothorax can occur as the complications of subclavian or jugular venous access. Chest cavity drainage using a 32 or 36 Fr tube thoracostomy in adults is the standard therapy for these patients. Surgical intervention is rarely needed but may be necessary with large hemothorax exceeding 1500 mL at the time of insertion or persistent bleeding greater than 200 mL/h over four hours indicative of injury to significant structures.
The bleeding complication in this patient may also be triggered by the patient’s condition on triple antithrombotic therapy (aspirin, ticagrelor, and warfarin). In a situation of a patient with significant bleeding complications while on triple antithrombotic therapy, it was recommended to switch to a less potent antiplatelet (i.e., from ticagrelor to clopidogrel) and consider oral anticoagulant discontinuation or even reversal until bleeding is controlled, unless very high thrombotic risk (i.e., mechanical heart valves, cardiac assist device, or CHA2DS2-VASc>4).
Even though a prompt treatment of bleeding complications in CVC access is mandatory, prevention in the first place is also crucial. Therefore, strategies to prevent bleeding complications should be considered before placing a CVC access.
The operator’s knowledge and skill, the patient’s anatomy (e.g., known venous occlusion, presence of lymphedema), placement risks (e.g., coagulopathy, pulmonary disease), access needs (e.g., the patient’s needs and duration of catheter use), and device type (e.g., tunneled catheter, implanted port) all played a role in choosing the most suitable site for CVC access. Although it can be tempting to stick with a favorite common site and method, it is important to be familiar with access procedures at a variety of anatomic locations in order to suit patient needs while maintaining patient safety. The femoral veins may be favored in the presence of coagulopathy over subclavian and jugular access sites because they can deliver direct pressure. Overall, infection problems were more common with femoral catheterization.
An appropriate experienced operator is also an essential factor. In one prospective cohort study, operators who had previously placed more than 50 CVCs were more likely to be successful and have less difficulties when inserting future CVCs. Using ultrasound to guide catheter placement is also recommended to reduce the number of access attempts and may reduce other complications as well.
Hemothorax, as one of bleeding complications secondary to CVC insertion, could be associated with significant morbidity and mortality, especially in patients with triple antithrombotic therapy. Prompt treatment is mandatory to save a patient’s life, including immediate identification and treatment such as thorax drain insertion and triple antithrombotic adjustment.
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1. Androlov H, Shmilev T. Complications of central venous catheterization. Pediatriya 2009;49:1123-33
2. Wetzel LR, Patel PR, Pesa NL. Central venous catheter placement in the left internal jugular vein complicated by perforation of the left brachiocephalic vein and massive hemothorax: A case report. A A Case Rep 2017;9:16-9
3. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2018;39:119-77
4. Hindricks G, Potpara T, Dagres N, Bax JJ, Boriani G, Dan GA, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021;42:373-498
5. Ju P, Germany AK, France GM, Germany FN, Steg PG, Luis J. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg 2018. 213-54
6. Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: Internal jugular versus subclavian access—A systematic review. Crit Care Med 2002;30:454-60
7. Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF. Mechanical complications of central venous catheters. J Intensive Care Med 2006;21:40-6
8. Leonard RJ. The clinical anatomy of several invasive procedures: American association of clinical anatomists, educational affairs committee. Clin Anat 1999;12:43-54
9. Britt RC, Novosel TJ, Britt LD, Sullivan M. The impact of central line simulation before the ICU experience. Am J Surg 2009;197:533-6
10. Broderick SR. Hemothorax: Etiology, diagnosis, and management. Thorac Surg Clin 2013;23:89-96, vi
11. Timsit JF. Central venous access in intensive care unit patients: Is the subclavian vein the royal route?. Intensive Care Med 2002;28:1006-8
12. Al-Jawder SE, Hameed AA. Complications of femoral venous catheterization in critically ill patients. Saudi Med J 2004;25:240-1
13. Tsotsolis N, Tsirgogianni K, Kioumis I, Pitsiou G, Baka S, Papaiwannou A, et al. Pneumothorax as a complication of central venous catheter insertion. Ann Transl Med 2015;3:1-10
14. Bouaziz H, Zetlaoui PJ, Pierre S, Desruennes E, Fritsch N, Jochum D, et al. Guidelines on the use of ultrasound guidance for vascular access. Anaesth Crit Care Pain Med 2015;34:65-9