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Arterial Placement of Central Venous Catheters: Beyond
Prevention to Management
Benjamin T. Wierstra, MD, FRCP© Kenton L. Rommens, MD, FRCSC, Paul M. Cantle, MD, FRCSC, and Selena Au, MD, FRCP©
About the Authors
Benjamin Wierstra and Selena Au are Internists and Critical Care physicians at the University of Calgary. Paul Cantle and Kenton
Rommens are vascular surgeons at the University of Calgary.
Corresponding author: bt.wierstra@me.com
Submitted: October 7, 2019. Accepted: November 26, 2019. Published: August 27, 2020 DOI: 10.22374/cjgim.v15i3.398
Abstract
Arterial misplacement of central venous catheters can often be avoided with the use of real-
time ultrasound-guided procedural competency. However, misplacement can still occur and
is more likely to occur when the internal jugular vein is located directly above the common
carotid artery. The resultant injury to the common carotid artery occurs through the posterior
wall of the internal jugular vein. Arterial injury may also occur when the subclavian vein is
attempted in a non-ultrasound-guided fashion. Optimal management requires a coordinated
evaluation of the catheter misplacement by Interventional Radiology and Vascular Surgery to
ensure maximum patient safety during catheter removal. This article reviews the literature on
this topic and provides a summary of the best approach to safely remove the misplaced catheter.
Resume
Le mauvais positionnement artériel des cathéters veineux centraux peut souvent être évité grâce
à l’utilisation de compétences procédurales guidées par ultrasons en temps réel. Cependant,
un mauvais positionnement peut toujours se produire et est plus susceptible de se produire
lorsque la veine jugulaire interne est située directement au-dessus de l’artère carotide commune.
La lésion de l’artère carotide commune qui en résulte se produit à travers la paroi postérieure
de la veine jugulaire interne. Une lésion artérielle peut également se produire lorsque la veine
sous-clavière nest pas guidée par un ultrason. Une gestion optimale nécessite une évaluation
coordonnée du mauvais positionnement du cathéter par la radiologie interventionnelle et la
chirurgie vasculaire afin de garantir une sécurité maximale au patient lors du retrait du cathéter.
Cet article passe en revue la littérature sur ce sujet et fournit un résumé de la meilleure approche
pour retirer en toute sécurité le cathéter mal placé.
Case Presentation
A 62-year-old man with viral myocarditis and acute renal failure
had a 14 French (Fr) left internal jugular dialysis line placed
for renal replacement therapy. Following the insertion of the
dialysis line, the resident assessed the transduced waveform
and correctly identified that it was an arterial pattern. Arterial
cannulation of the carotid artery was further supported by
blood gas analysis and chest x-ray (Figure 1). A CT angiogram
confirmed that the catheter had been placed into the proximal
left common carotid artery within the patients thoracic cavity
posterior to the clavicle and that the arterial cannulation had
been through the posterior wall of the left internal jugular vein.
Vascular Surgery and Interventional Radiology were consulted
urgently. Endovascular options including the use of an arterial
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closure device or the placement of a covered stent combined
with venous balloon tamponade options were considered, but,
ultimately, an open surgical repair in a hybrid operating room
with conventional surgical supplies and endovascular supplies
readily at hand was felt to be the safest approach. The surgery
was delayed by 48 hours because the patient had been on
Apixaban before hospitalization and was felt to be at increased
risk of bleeding complications. A heparin infusion was initiated
and continued until the surgical intervention. The open surgery
successfully removed the catheter without complications and did
not require the utilization of the hybrid approach.
Many critically ill patients require the placement of a
central venous catheter (CVC) during the course of their
hospitalization. Complications associated with internal jugular
(IJ) and subclavian vein CVC insertion include pneumothorax
(0.1–3%), hematoma (0.1–2.1%), arterial puncture (3.1–9.4%),
arterial cannulation (<1%) and guide-wire embolism (<0.1%).
1
The potential consequences of these complications include
permanent neurologic disability from cerebral ischemia, airway-
threatening hematoma, tension pneumothorax, uncontrolled
hemorrhage, emergent cardiovascular surgical interventions
requiring general anesthesia, and death. Recognizing that
complications from CVC insertion are inevitable despite the
procedural competence of the operator necessitates a clear
approach to managing these events so that further iatrogenic
harm to patients can be minimized.
The traditional means of averting arterial line misplacement
include operator attentiveness to the colour and pulsatility of the
blood coming from the needle after cannulation but these methods
are frequently unreliable in isolation.
2
Real-time ultrasound-
guidance is associated with improved success in correct CVC
placement with fewer complications (relative risk 0.22 [95% CI:
0.1 to 0.45] and 0.53 [95% CI: 0.41 to 0.69] for IJ and subclavian
veins respectively).
3–5
Newer echogenic cannulation needles
further improve procedural safety by optimizing distal needle tip
visualization during the procedure.
6
Despite the improved safety
associated with employing ultrasound-guided procedures, when
the common carotid artery is located underneath the IJ vein,
operators may still puncture through the posterior wall of the
vein resulting in arterial injury or cannulation.
7,8
This recurring
complication pattern of injury reinforces the importance of
visually confirming the position of the wire in both the cross-
sectional and longitudinal ultrasound planes before dilation of
the tract before catheter placement.
Management of arterial injuries from attempted CVC
placement depends on the extent of the injury, location of the
injury, and clinical status of the patient. The incidence of arterial
needle puncture during CVC placement is estimated at 3.7 to
12% and is usually promptly recognized and managed with
removal of the needle followed by direct manual compression
to the cannulation site.
9
While unproven, smaller gauge needles
(use of a micropuncture technique) may decrease the risk of
Figure 1. Chest x-ray showing arterial cannulation of the carotid artery.
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complications from an unintentional arterial puncture during
CVC placement.
10,11
More significant arterial injury following
tract dilation or catheter placement is estimated to occur at a
frequency of 0.1 to 1% and necessitates a more comprehensive
workup including specialist consultation due to the higher rates
of neurologic or hemorrhagic complications associated with
inattentive management of this situation.
9
Many experienced clinicians believe that misplacement of
smaller gauge catheters (7Fr triple lumen catheters) can be
safely managed with a “pull-pressure” strategy (characterized
by “pulling” the catheter out and applying “pressure” for 5–20
minutes) while acknowledging that larger bore catheters require
removal with definitive open or endovascular repair. Published
literature supports that patients have better outcomes when larger
devices are left in situ so that surgical and endovascular expertise
can be consulted to determine an optimal removal plan. A 2008
case series and review
12
described 30 cases where accidental
large-bore (7Fr) cervicothoracic arterial cannulation patients
were treated with the “pull-pressure” method (n =17) compared
to immediate removal by surgery (n=13). Eight (47%) of the
pull-pressure” patients experienced complications including
hematoma, airway obstruction, false aneurysm, stroke, and death.
No complications occurred within the surgical management
group. A 2017 systematic review
9
identified 80 case reports of
inadvertent arterial injury. Twenty-two percent of these patients
were treated with a “pull-pressure” approach resulting in a high
proportion of patients (94.6%) experiencing severe complications
such as failure to control hemorrhage, embolic stroke, or death.
Comparatively, 95% of the patients treated with endovascular
interventions experienced favorable outcomes and all 37 patients
treated with primary surgical repair resulted in good neurologic
outcomes. Strong data is supporting surgical or endovascular
repair options for large-bore common carotid arterial injuries.
Management of inadvertent injury to the subclavian artery
is complicated by the technical difficulty of accessing the region
for primary surgical repair. Injuries to the subclavian artery,
proximal carotid artery behind the clavicle, or innominate artery
can be intra-thoracic and may require surgical interventions that
require clavicular resection, a thoracotomy, or a sternotomy. A
variety of covered stents, closure devices (e.g., Angio-seal and
Perclose
), and tamponade products have been described to treat
complications from CVC insertion resulting in subclavian artery
cannulation.
13,14–16
However, closure devices are contraindicated if
the injury site involves a branch or there is evidence of underlying
arterial dissection and may have limitations such as a maximum
French size or puncture site depth in which they can be used.
The use of closure devices in this setting is also considered off
label. These injuries require urgent CT angiography so that
adequate procedural planning may occur to determine the safest
approach to remove the misplaced catheter. As institutional
resources and skillsets vary, arterial cannulation events should
be discussed with the local vascular surgical specialists. This is
especially true for cannulations of 7Fr, non-compressible sites,
and patients on anticoagulation. Surgeons capable of vascular
injury repair should be involved in the development of local
policies and procedures regarding the surgical or endovascular
treatment approach to iatrogenic vascular injuries. Hybrid
operating rooms with fluoroscopy capabilities permit the use
of combined open surgical and endovascular approaches and
act as an ideal setting for bailout options if an initial operative
strategy is unsuccessful.
Time to the removal of the misplaced catheter is another
factor that confers a safety profile in favor of surgical removal.
If greater than 4 hours have transpired since the vessel was
cannulated there are fewer complications when catheters are
removed surgically. This is because distal embolization events
from thrombus build-up on cannulas can be minimized in the
surgical setting via distal vascular control or surgical embolectomy
if required. However, there is no timeframe for non-surgical
removal that is considered completely “safe” so endovascular
or surgical removal should always be a consideration.
9
Inadvertent cervicothoracic artery cannulation during
CVC placement is a rare complication that carries a high risk of
morbidity and mortality. Addressing the risk of this event begins
with prevention strategies that include operator attentiveness
and the use of real-time ultrasound guidance. Whenever a
catheter is inadvertently placed within an adjacent artery,
a time-efficient and expedited management plan should be
initiated that includes consultation for surgical removal instead
of an uncontrolled “pull-pressureremoval technique. Arterial
cannulation with catheters 7Fr necessitates rapid consultation
between the attending team and the most appropriate surgical
service (vascular, neurosurgery, general surgery depending on
practice setting). Arteriotomy sites that are not easily amenable to
surgical exposure may be candidates for newer techniques using
endovascular products to improve patient safety. Achieving the
goal of safely removing a misplaced catheter requires the timely
collaboration of services and should be guided by non-emergent
plan development within individual institutions to improve
patient safety during this high-risk period.
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