Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 64

When choosing the internal jugular or subclavian veins for CVCs, postprocedure films and fluoroscopy are useful in confirming catheter placement and tip location. These, however, are not foolproof, as evidenced by this case, where admission chest x-ray failed to recognize the arterial location of the catheter. In cases of internal jugular vein CVCs, intraarterial misplacement may not be apparent in routine x-rays when the CVC is in the ascending aorta because of overlap of the superior vena cava and the aorta. Anatomic vascular anomalies such as a right-sided aortic arch may also make radiographic recognition difficult. Fluoroscopic confirmation after a tunneled hemodialysis catheter insertion has the same limitation unless contrast is used to see actual blood flow (1). Upon recognition of an intraarterial placement of a CVC, it should be left in place until further advice and management from surgery or interventional radiology is obtained. Rare but life-threatening complications include hematoma formation enough to compromise airway, hemorrhage with or without hemothorax, cerebrovascular accidents from thromboembolism, Horner’s syndrome, pseudoaneurysm or arteriovenous fistula formation, arterial occlusion, and even death (2, 3, 7). Removal of large-bore hemodialysis catheters requires careful consideration and extensive operator experience. Treatment options vary from extrinsic compression if the artery is accessible (although this risks brain ischemia), to surgical removal of the catheter with repair of the arterial defect, to endovascular repairs with or without stent placement (1). Due to the associated significant morbidity and mortality of CVC arterial puncture and catheter misplacement, prevention is key, and the best preventive strategies are adequate patient and operator preparation and use of real-time ultrasound-guided cannulation. 1. 2. 3. 4. 5. 6. 7. Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. Br J Anaesth 2013;110(3):333–346. Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg 2007;204(4):681–696. Choi YS, Park JY, Kwak YL, Lee JW. Inadvertent arterial insertion of a central venous catheter: delayed recognition with abrupt changes in pressure waveform during surgery—a case report. Korean J Anesthesiol 2011;60(1):47–51. Schwab SJ, Beathard G. The hemodialysis catheter conundrum: hate living with them, but can’t live without them. Kidney Int 1999;56(1):1–17. Vats HS. Complications of catheters: tunneled and nontunneled. Adv Chronic Kidney Dis 2012;19(3):188–194. Aydin Z, Gursu M, Uzun S, Karadag S, Tatli E, Sumnu A, Ozturk S, Kazancioglu R. Placement of hemodialysis catheters with a technical, functional, and anatomical viewpoint. Int J Nephrol 2012;2012:302826. Göksel OS, El H, Onalan A, Alpagut U. Successful removal of a malpositioned hemodialysis catheter into the aortic arch. J Vasc Access 2012;13(4):543. Avocations Spring flowers. Photos copyright © Rolando Solis, MD. Dr. Solis is an interventional cardiologist practicing at Baylor Medical Center at Garland and the Heart Hospital Baylor Plano (e-mail: [email protected]). 138 Baylor University Medical Center Proceedings Volume 27, Number 2