Percutaneous catheterization is a frequently-used technique to gain access to the
central venous circulation. Inadvertent arterial puncture is often without consequence,
but can lead to devastating complications if it goes unrecognized and a large-bore
dilator or catheter is inserted. The present study reviews our experience with these
complications and the literature to determine the safest way to manage catheter-related
cervicothoracic arterial injury (CRCAI).
We retrospectively identified all cases of iatrogenic carotid or subclavian injury
following central venous catheterization at three large institutions in Montreal.
We reviewed the French and English literature published from 1980 to 2006, in PubMed,
and selected studies with the following criteria: arterial misplacement of a large-caliber
cannula (>/=7F), adult patients (>18 years old), description of the method for managing
arterial trauma, reference population (denominator) to estimate the success rate of
the therapeutic option chosen. A consensus panel of vascular surgeons, anesthetists
and intensivists reviewed this information and proposed a treatment algorithm.
Thirteen patients were treated for CRCAI in participating institutions. Five of them
underwent immediate catheter removal and compression, and all had severe complications
resulting in major stroke and death in one patient, with the other four undergoing
further intervention for a false aneurysm or massive bleeding. The remaining eight
patients were treated by immediate open repair (six) or through an endovascular approach
(two) for subclavian artery trauma without complications. Five articles met all our
inclusion criteria, for a total of 30 patients with iatrogenic arterial cannulation:
17 were treated by immediate catheter removal and direct external pressure; eight
(47%) had major complications requiring further interventions; and two died. The remaining
13 patients submitted to immediate surgical exploration, catheter removal and artery
repair under direct vision, without any complications (47% vs 0%, P = .004).
During central venous placement, prevention of arterial puncture and cannulation is
essential to minimize serious sequelae. If arterial trauma with a large-caliber catheter
occurs, prompt surgical or endovascular treatment seems to be the safest approach.
The pull/pressure technique is associated with a significant risk of hematoma, airway
obstruction, stroke, and false aneurysm. Endovascular treatment appears to be safe
for the management of arterial injuries that are difficult to expose surgically, such
as those below or behind the clavicle. After arterial repair, prompt neurological
evaluation should be performed, even if it requires postponing elective intervention.
Imaging is suggested to exclude arterial complications, especially if arterial trauma
site was not examined and repaired.