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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]).
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Volume 27, Number 2