Background: Central venous catheterization is frequent during the intra-operative period. Despite the physician's experience, technique-associated complications may occur, such as pneumothorax, arterial puncture, hydrothorax and gaseous embolism. Late complications may also occur, such as sepsis, cardiac tamponade and vascular erosion.
Vascular erosion may occur, generally 48h after the central catheter placement, but there are also reports of complications up to 2 months later.
Case report: 78 year-old female, ASA III, diagnosed with gastric neoplasia, presented for subtotal gastrectomy. In the intra-operative period, catheterization of the right internal jugular vein was attempted, but the internal carotid artery was punctured with formation of a hematoma. The left internal jugular vein was then catheterized. The technique was uneventful. The chest x-ray showed a well-positioned catheter.
On the 3rd day post-operative, patient developed respiratory failure.
Pulmonary embolism was suspected and the patient was admitted to an ICU, where mechanical ventilation was initiated. Breath sounds were absent on the right thorax and the chest x-ray showed pleural effusion. Chest drain was placed and 500ml of glycosylated fluid were drained. The central venous catheter was then removed and the patient's clinical status improved dramatically. She was extubated shortly after. 24 hours later the patient was transferred to the surgical ward, from where she was discharged.
Discussion: Superior vena cava erosion secondary to central venous catheter placement is a rare but potentially lethal complication, with a mortality rate of up to 74%. As it is a late complication, with an unspecific presentation, diagnosis is often very difficult.
Left internal jugular approach has as increased risk of this complication - the increased distance to the right atrium increases the risk of positioning the catheter tip against the superior vena cava wall.
1. POLDERMAN, KH et al. Central venous catheter use - Part 1: Mechanical complications.
Intensive Care Medicine 2002;28:1-17
Learning points: Central venous catheterization presents early and late complications, even on experienced hands. Confirmation of the correct placement of the catheter is mandatory.
Although rare, vascular erosion may occur after well-succeeded catheterization, so an elevated suspicion is needed to avoid worse complications.