Management of Subclavian Arterial Injuries following Inadvertent Arterial Puncture during Central Venous Catheter Placement

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1 Management of Subclavian Arterial Injuries following Inadvertent Arterial Puncture during Central Venous Catheter Placement Nadine Abi-Jaoudeh, MD, Ulku C. Turba, MD, Bulent Arslan, MD, Klaus D. Hagspiel, MD, John F. Angle, MD, Worthington G. Schenk, MD, and Alan H. Matsumoto, MD Subclavian artery injuries after central venous catheter placement constitute a rare but potentially fatal complication. In this case series, the authors describe several endovascular treatment options in the management of iatrogenic subclavian arterial injuries resulting from inadvertent arterial placement of central catheters. J Vasc Interv Radiol 2009; 20: CENTRAL venous catheters are commonly placed at the bedside in critically ill patients based on anatomic landmarks and without imaging guidance. Inadvertent subclavian arterial puncture is a rare but potentially fatal complication (1 4). The majority of subclavian artery injuries are caused by blunt or penetrating trauma and are usually managed by surgery or endovascular techniques (5). There are a few case reports in the literature on iatrogenic subclavian arterial injuries during central catheter placement and their management (6). Herein the authors describe a compilation of various endovascular treatment options used at a single institution in the management of inadvertent puncture of a subclavian artery during central catheter placement. From the Departments of Radiology (N.A.J., U.C.T., B.A., K.D.H., J.F.A., A.H.M.) and Surgery (W.G.S.), University of Virginia Health System, Box , Lee Street, Charlottesville, VA Received February 1, 2008; final revision received November 30, 2008; accepted December 7, Address correspondence to U.C.T.; uct5d@virginia.edu None of the authors have identified a conflict of interest. SIR, 2009 DOI: /j.jvir MATERIALS AND METHODS After institutional review board approval was received, a retrospective review of our Hi-IQ database (Conexys, Providence, Rhode Island) was undertaken based on the key term vascular artery repair. The database search revealed six cases of subclavian arterial injury after central venous catheter placement between 1996 and One patient was excluded from this series because he was treated with open surgery. Five patients underwent endovascular therapy to treat iatrogenic trauma to the subclavian artery. RESULTS Patient data and outcomes are summarized in Table 1. Case 1 A 53-year-old woman with amyloidosis of the liver, small bowel ileus, retroperitoneal hematoma, and sepsis was admitted to the intensive care unit. The patient underwent attempted placement of a subclavian central venous catheter by the surgery team during the hospitalization, but pulsatile, bright red blood was seen coming from the catheter. The catheter was removed immediately and the puncture site bleeding was controlled with manual pressure. However, 2 weeks later, the patient reported a pulsatile mass that had appeared suddenly at her right lower neck area. The patient was in hemodynamically stable condition. A computed tomographic (CT) angiogram was obtained to confirm the clinical diagnosis of a pseudoaneurysm and its relation to subclavian branches for treatment planning. The interventional radiology service was consulted for management. The CT angiogram of the neck revealed a right subclavian artery pseudoaneurysm with a wide neck. The pseudoaneurysm was located beneath the clavicle, precluding external pressure. The neck of the pseudoaneurysm was large; therefore, thrombin injection was thought to be risky. As a result, the operator decided to treat the pseudoaneurysm with a covered stent. Via the right common femoral artery, the right subclavian artery was catheterized and a selective right subclavian angiogram was obtained. It demonstrated a pseudoaneurysm at the previous central catheter insertion site. The patient was treated with a 5-mm-diameter, 15-mmlong handmade balloon-expanded Palmaz stent (Cordis, Miami Lakes, Florida) with a polytetrafluoroethylene covering (Impra; Bard Peripheral Vascular, Tempe, Arizona), which was deployed via a brachial artery cutdown. The stent was postdilated to 6 mm. The manufacturer of the balloon catheter 396

2 Volume 20 Number 3 Abi-Jaoudeh et al 397 Table 1 Inadvertent Subclavian Artery Injury: Procedure and Outcome Summary Pt. No. Age (y)/ Sex Side Catheter Status 1 53/F R Already explanted Catheter Size (F) Imaging Findings Procedure 2 41/M L In situ 9 Contrast agent extravasation 3 54/F R In situ 8 Contrast agent extravasation and dissection in the vertebral artery 4 66/M R In situ 8 Contrast agent extravasation along tract after catheter pulled back 5 55/M L In situ 7 Catheter in the artery without evidence of extravasation or pseudoaneurysm Incidental Vessel Finding Outcome Unknown Pseudoaneurysm Covered stent None No complications; exclusion of pseudoaneurysm Failed closure device attempt followed by covered stent Failed closure device attempt followed by covered stent Nonocclusive left vertebral artery origin calcified plaque Nonocclusive right vertebral artery dissection flap noted before stent No complications; exclusion of injured arterial segment No complications; patient died of unrelated reasons 9 days later; exclusion of injured arterial segment Tract embolization None No complications; successful closure of leaking artery Gradual sheath downsizing None No complications; closure of arteriotomy without further incident was not available from the medical records. Angiography after stent placement revealed exclusion of the pseudoaneurysm without compromise of the vertebral artery or the thyrocervical trunk. The patient tolerated the procedure well without complications. Of note, commercially available covered stents were not widespread at that time. Case 2 A 41-year-old man had burns of approximately 30% of his body surface area, affecting mainly his face, upper chest, and upper extremities. While hospitalized, the patient had an upper airway infection causing sepsis and requiring intravenous antibiotics. Placement of a left subclavian central venous catheter was attempted at the bedside by the clinical team. However, pulsatile blood return was noticed from the catheter. The clinical team consulted the interventional radiology team for removal of the 9-F sheath. Femoral artery access was gained and selective angiography of the right subclavian artery was performed. After defining the location of the catheter entry site into the left subclavian artery, a decision was made to treat the subclavian artery puncture site with a closure device. A wire was placed through the sheath. The central catheter and sheath were removed and a suture-mediated closure device (Perclose; Guidant, Menlo Park, California) was advanced over the guide wire. Proper blood backflow from the device side port was not achieved. Because we had guide wire access, we elected to deploy a second device; however, the second device also failed to seal the arteriotomy. Follow-up selective subclavian angiography demonstrated persistent contrast medium extravasation through the arteriotomy (Fig 1). A 10-mm-diameter, 40-mm-long self-expanding covered stent (Fluency; Bard Peripheral Vascular) was deployed and postdilated with an 8-mm balloon catheter (UltraThin Diamond, Boston Scientific; Natick, Massachusetts). After stent deployment and postdilation, the subclavian arteriotomy site was successfully excluded. Clinical follow-up 3 months later revealed that the patient was doing well. Case 3 A 54-year-old woman with a history of subarachnoid hemorrhage presented with sudden onset of severe headache. Further clinical and imaging investigation revealed two distinct cerebral aneurysms, one of which had ruptured. Both aneurysms were treated with coils. The patient s hospital course was complicated by posterior fossa circulation vasospasm and Takotsubo cardiomyopathy. The clinical team s attempted placement of a central venous catheter resulted in inadvertent placement of an 8-F sheath into the right subclavian artery. The interventional radiology service was consulted for evaluation and removal of the subclavian arterial sheath. Femoral artery access was gained, and a selective right subclavian arteriogram demonstrated an 8-F central venous catheter situated in the right subclavian artery with its tip extending to the ostium of the vertebral artery, and a nonocclusive dissection flap at the origin of the vertebral artery. Because there was a short subcutaneous tract, a decision was made to seal the subclavian arteriotomy with a closure device. However, the guide wire could not be advanced through the catheter. At this time, follow-up angiography showed a small amount of contrast medium extravasation, with the catheter partially tamponad-

3 398 Management of CVC-related Subclavian Artery Injuries March 2009 JVIR Figure 1. Images from a 41-year-old man with inadvertent placement of a 9-F venous catheter into the left subclavian artery: (a) An aortic arch angiogram demonstrates that the central catheter enters the left subclavian artery (arrow) just distal to the thyrocervical trunk and the tip of the catheter extends a short distance into the proximal subclavian artery. There is also a filling defect at the origin of the left vertebral artery (arrowhead), likely resulting from a calcified atherosclerotic plaque. A guide wire has been advanced through the central catheter into the descending thoracic aorta. (b) A selective left subclavian arteriogram better defines the calcified atherosclerotic plaque (arrow). Contrast medium extravasation is noted from the subclavian artery along the puncture tract (arrowheads) after a failed attempt to place a closure device over the previously placed guide wire. (c) A 10-mm 4-cm covered stent was placed in an off-label application to successfully exclude the bleeding site in the left subclavian artery. ing the tract. Through the existing femoral access, an 8-mm-diameter, 2-cm-long self-expanding covered stent (Viabahn; W.L. Gore & Associates, Flagstaff, Arizona) was deployed to cover the subclavian artery arteriotomy site. The stent was dilated with an 8-mm-diameter angioplasty balloon (UltraThin Diamond; Boston Scientific). After stent placement and angioplasty, angiography demonstrated no further extravasation of contrast medium. The small dissection at the origin of the right vertebral artery was not flow-limiting and therefore was not treated. The patient died 9 days later of liver failure, adult respiratory distress syndrome, and septic shock. Case 4 A 66-year-old man with a small-cell lung carcinoma was transferred from another hospital to our institution after placement of a central venous catheter. By report, during placement of the central catheter, bright red, pulsatile blood flow was noted. The catheter was secured in place and the patient was transferred to the interventional radiology department. With a common femoral approach, selective right subclavian angiography demonstrated the tip of the central catheter in the subclavian artery, extending to the aortic arch (Fig 2). The distance between the skin entry site of the catheter and the vessel entry site was approximately 7 8 cm. The distance from the skin to the arteriotomy was thought to be too long for safe use of a closure device. We decided to remove the catheter while embolizing the tract under close angiographic observation, with consideration for immediate treatment with a covered stent if necessary. A 100-cm catheter (Vert; Cook, Bloomington, Indiana) was positioned at the origin of the subclavian artery. The central catheter was pulled back slowly during contrast agent injection. When the tip of the catheter was outside the right subclavian artery and in the subcutaneous tract, three pledgets of Gelfoam (Pharmacia & Upjohn, Kalamazoo, Michigan) were pushed with a guide wire and deployed on the abluminal side of the subclavian artery. With the central catheter pulled back approximately 3 cm outside of the right subclavian artery, a control angiogram was obtained, which demonstrated no evidence of active extravasation. The central catheter was then removed. Immediate and 30-minute control subclavian angiograms showed no evidence of vessel injury, intimal flap, extravasation, or pseudoaneurysm. Three days later, the patient was doing well and underwent placement of a left chest port catheter via the left internal jugular vein. Case 5 A 55-year-old man was transferred from an outside hospital after a motor

4 Volume 20 Number 3 Abi-Jaoudeh et al 399 Figure 2. Images from a 66-year-old man who underwent an attempt at placement of a tunneled right subclavian central venous catheter. However, pulsatile, brisk arterial flow from the catheter was noted. Removal of the catheter and management of the arterial puncture site was requested. (a) A preprocedural chest radiograph demonstrated the skin entry site of the catheter, marked with a hemostat. (b) Contrast medium was injected through the catheter and a digital subtraction angiogram was obtained. The angiogram shows the entry location of the catheter through the skin (arrow) and the entry site of the catheter into the subclavian artery (arrowhead). (c) The catheter was withdrawn approximately 2 3 cm under fluoroscopic guidance while contrast medium was injected and the skin entry site was marked (arrow). Contrast medium is noted along the catheter tract (arrowheads), without evidence of active bleeding. When the catheter was outside of the subclavian artery but within the tract, three pledgets of Gelfoam were introduced into the tract through the catheter to embolize the subcutaneous tract. (d) Immediate and 30-minute follow-up angiograms revealed no evidence of a pseudoaneurysm, vessel injury, or contrast medium extravasation. The patient did well, without evidence of any bleeding. vehicle accident that resulted in head trauma and a cardiac contusion leading to atrial-ventricular block. During placement of a left subclavian central venous catheter at the bedside, arterial flow was noted from the catheter. The interventional radiology service was consulted for evaluation and management. Common femoral artery access was obtained and a selective left subclavian arteriogram revealed a 7-F central catheter in the left subclavian artery without evidence of extravasation or a pseudoaneurysm. A decision was made to remove the central catheter by gradual downsizing of the catheter. The patient was in the intensive care unit for trauma and was being followed closely with physical examinations and laboratory studies for potential bleeding from groin access and catheter placement sites during sheath downsizing. Use of a covered stent was kept as an alternative treatment option. Closure devices were not available at that time. Over a inch guide wire, the 7-F catheter was exchanged for a 6-F catheter. An angiogram from the groin confirmed no extravasation. Twelve hours later, the 6-F catheter was downsized to a 5-F catheter. A repeat angiogram from a femoral approach confirmed the absence of extravasation. Another 12 hours later, the 5-F catheter in the left subclavian artery was exchanged for a 3-F catheter, with a follow-up angiogram confirming lack of extravasation. Finally, 12 hours later, the 3-F catheter was removed without inci-

5 400 Management of CVC-related Subclavian Artery Injuries March 2009 JVIR Table 2 Literature Review of Management Options of Iatrogenic Carotid and Subclavian Arterial Injury During Central Venous Catheterization (1 4,6,7,9,11 15) Study, Year No. of Pts. Anatomic Location Management Options Technical Success (%) Berlet et al (9), Subclavian Closure devices 100 Wheeler et al (11), Subclavian Covered stents 100 Nicholson et al (7), Subclavian, n 8; carotid, n 1 Balloon tamponade, n 2; covered stents, n 3; closure device, n 4 Kapadia et al (1), Subclavian, n 1; Covered stents 100 carotid, n 1 Hilfiker et al (12), Subclavian Covered stents 100 Schoder et al (13), Subclavian Covered stents 100 Finlay et al (14), Subclavian Covered stent 100 Kang et al (15), Subclavian Thrombin injection 100 Jeganathan et al (2), Subclavian Thrombin injection 100 McConnell et al (6), Subclavian Thrombin injection 100 Kemmerer et al (4), Subclavian Thrombin injection dent. Three hours later, a final angiogram via the femoral access confirmed no vessel injury, contrast medium extravasation, or pseudoaneurysm. At that time, the femoral sheath was removed without complications. DISCUSSION Bedside, non image-guided central venous catheter placement is a common procedure in critically ill patients. The reported incidences of inadvertent arterial puncture during central venous catheter placement are between 2% and 9.3% (1,7), and these incidents have even been reported despite the use of ultrasound guidance (8). Most inadvertent arterial punctures are recognized immediately because of the bright red, pulsatile backflow of blood from the access needle or the catheter. However, problems such as distal emboli, brachial plexus injury, pseudoaneurysm formation, vessel rupture, and/or frank bleeding may arise if the arterial puncture is not recognized and inadvertent placement of the catheter into the artery occurs (1,4,9). Risk factors for injury to an artery during central catheter placement include obesity, previous radiation therapy or surgery in the region of catheter placement, multiple needle passes, and operator inexperience (7). In the present case series, most of the problems occurred in patients in the intensive care unit, where the catheters were placed without image guidance by operators with limited experience. Although surgery was the treatment of choice in the past for the management of this complication, with recent technical and device advancements, most cases can now be treated with endovascular techniques (3,6,7,10). Imaging plays a critical role in the evaluation of vascular injuries related to central catheter placement. With highresolution, multidetector CT angiography, the vascular anatomy can be outlined and the injury defined to allow treatment planning. Catheter-based angiography is primarily used during the treatment process to demonstrate effective exclusion of the vascular injury. A variety of applications of various devices such as stents, closure devices, and balloon tamponade have been described to treat complications related to inadvertent subclavian arterial injuries that arise during central venous catheter placement (Table 2) (1 4,6,7,9,11 15). Each device or treatment option is tailored to each patient. Depending on the situation and the exact location of the arterial injury, a covered stent, vascular closure device, tract embolization, or gradual downsizing of transarterial catheters can be used. The treatment method will depend on a variety of factors. The Angioseal (St. Jude Medical, St. Paul, Minnesota) and Perclose (Abbott Vascular, Redwood City, California) devices are indicated by their manufacturers only in femoral arterial punctures (16,17). There is no specific recommendation regarding the longest tract from the skin to the arteriotomy for a long tract puncture. However, the footplates from the device hub to the proximal closure are 8 cm for the Perclose device and 10 cm for the Angioseal device, which might be considered the limit. Evidently, use of an arterial puncture closure device might be considered as long as the length of the tract from the skin entry site to the arteriotomy is less than 8 cm. There should not be branch vessel involvement, an underlying arterial dissection, or a pseudoaneurysm. In case 2, the subcutaneous tract was longer than 8 cm and the use of a closure device (Perclose; Abbott Vascular) was unsuccessful. However, there are case reports of successful off-label use of arterial closure devices in this application (7,9). The successful use of covered stents to treat subclavian artery injuries related to central catheter placement has been previously reported (1,7,11 14). Use of a covered stent is especially attractive in cases in which the subclavian artery is dissected, there is a pseudoaneurysm, or there is persistent bleeding from the injury site. When choosing a covered stent, the advantage of a balloon-expandable stent is very controlled deployment and flexible sizing, as the stent can be further expanded with the use of larger balloons. In addition, covered stents 5 6 mm in diameter can be inserted though a 6-F guide sheath and

6 Volume 20 Number 3 Abi-Jaoudeh et al 401 stents as large as 12 mm in diameter can be inserted through an 8-F sheath. Very short (16 mm) balloon-expandable stents are also available (eg, icast; Atrium Medical, Hudson, New Hampshire). Self-expanding covered stents are made of nitinol. Therefore, they are MR imaging compatible. However, these stents require the use of larger sheaths approximately 7 11 F depending on stent diameter and the shortest length is 2.5 cm (Viabahn; W.L Gore & Associates; and Fluency; Bard Peripheral Vascular). Long-term outcomes of covered stents for the treatment of subclavian injuries are not well documented. Also, if the arterial injury site is at the thoracic inlet/outlet, there is a risk of stent collapse and/or fracture as a result of extrinsic compression. Moreover, use of a stent is not always possible because of the proximity of the subclavian artery injury to the origin of critical branch vessels, such as the vertebral artery. It is not desirable to place stents in patients with sepsis. Although thrombin injection into a pseudoaneurysm has also been successfully used to treat this problem in the femoral artery, thrombin should be used with extreme caution in vessels in close proximity to arteries to the spinal cord and brain (4,6,15). We used alternative treatment techniques in cases 4 and 5 in the form of safe puncture tract embolization with Gelfoam (Pharmacia & Upjohn) and gradual sheath downsizing. With these treatment methods, we monitored the patient angiographically and with direct inspection to ensure the absence of ongoing bleeding or contrast agent extravasation. In our limited experience, both techniques appear to be safe. However, attention should be paid to prevent Gelfoam from embolizing into the subclavian artery lumen during tract embolization. In addition, although we did not perform balloon angioplasty during Gelfoam embolization, inflating an angioplasty balloon across the arterial injury may minimize the risk of Gelfoam migration into the artery, while at the same time controlling any bleeding that might occur from the injured artery. The technique of gradual catheter downsizing necessitates some patience and prolonged common femoral arterial access for angiographic evaluation at the time of each downsizing procedure. However, this treatment method obviates a permanent implant and may be more beneficial in cases of bacteremia. Overall, it is important to recognize when an inadvertent subclavian arterial catheterization has occurred during central catheter placement, and the potential severity of a complication. Adequate manual compression of the subclavian artery to obtain hemostasis is often not possible because of the interposing subcutaneous tissue and bony structure, as well as the lack of structural support around the subclavian artery (1,7). A patient in very stable condition can quickly become unstable and die of massive bleeding and/or an expanding hemothorax (18,19) if the complication is not well managed. When the diagnosis is suspected or made, a diagnostic CT angiogram can be very useful for treatment planning or for confirmation of a suspected diagnosis. Inadvertent catheterization of the subclavian artery during central catheter placement can be managed with endovascular techniques. Catheter-based angiography remains a mainstay in guiding and insuring the success of the treatment. With the availability of a variety of covered stents, their use will likely be considered the first treatment option, especially in the presence of a pseudoaneurysm or if the underlying injured subclavian artery has an associated dissection. However, in very young patients or those with sepsis, or when significant branch vessels may be compromised by a covered stent, other management techniques can be employed. Use of arterial closure devices can be attempted, especially when the distance from the skin to the artery tract is less than 5 cm and access to the artery is still available. Tract embolization with Gelfoam can be employed. Angiographic and clinical monitoring during any of these treatment methods is recommended so that, if they fail, control of the injured artery can be maintained until an alternative treatment option can be devised. In general, after a diagnosis of iatrogenic subclavian artery is made, imaging was obtained to define the exact injury, its relation to other vessels, and presence of complications such as dissection, pseudoaneurysm, and active extravasation. If the artery is still accessed, the subcutaneous tract is short, and there are no complications, a closure device might be used. If a narrow-necked pseudoaneurysm is the only finding, thrombin injection might be considered. The presence of subclavian arterial dissection, active extravasation, or a pseudoaneurysm with a wide neck may necessitate the use of a covered stent. If sepsis, major branch vessels, or proximity of the arteriotomy to the thoracic outlet precludes the use of the aforementioned methods, Gelfoam embolization or gradual sheath downsizing might be used. 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