Central venous catheterization is an essential and

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1 Iatrogenic vertebral artery pseudoaneurysm due to central venous catheterization Janneth Momiy, MD, and Jay Vasquez, MD Central venous lines have become an integral part of patient care, but they are not without complications. Vertebral artery pseudoaneurysm formation is one of the rarer complications of central line placement. Presented is a rare case of two pseudoaneurysms of the vertebral and subclavian artery after an attempted internal jugular vein catheterization. These were successfully treated with open surgical repair and bypass. Open surgical repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudoaneurysms has been described with promising outcomes, but long-term results are lacking. Ultimately, the best treatment of these iatrogenic injuries should start with prevention. Well-documented techniques to minimize mechanical complications, including inadvertent arterial puncture, should be practiced and taught in training programs to avoid the potentially devastating consequences. Central venous catheterization is an essential and commonly used procedure in the acutely ill patient. Central venous catheter use was fi rst described by Aubaniac in 1952 (1). Now 7 million central venous catheters are placed each year in the United States (2, 3). Central venous lines are commonly placed for volume resuscitation, hemodynamic monitoring, and administration of vasoactive drugs. The procedure is relatively safe but not completely without complications. The incidence of serious complications from venous access varies from 0.4% to 9.9% (4). Complications include local hematoma, pneumothorax, hemothorax, hydrothorax, central venous thrombosis, air embolism, and cardiac tamponade due to perforation of the superior vena cava or right side of the heart. Inadvertent arterial puncture, which occurs in approximately 5% of all central venous catheter placements (5), can lead to arterial dissection, arteriovenous fistula formation, hematoma, pseudoaneurysms, and even stroke. Arterial puncture occurs more often with internal jugular vein catheterization attempts than with the subclavian vein approach (3% vs 0.5%) (6). The artery most commonly injured is the carotid artery (7, 8). Thus, iatrogenic injury of the vertebral artery via central venous catheterization is a rare complication with less than 30 reported cases. Most injuries to the vertebral artery occur with internal jugular vein catheterization. Injuries include dissection, thrombosis, formation of arteriovenous fi stulas, and pseudoaneurysms Figure 1. CT angiogram of the chest and abdomen showing the hematoma over the right subclavian artery and vertebral artery. (9, 10). Among these injuries, pseudoaneurysm of the vertebral artery as a complication of central venous catheterization is very rare, with only five reported cases in the literature. We report a case of two pseudoaneurysms, one of the vertebral artery and one of the subclavian artery, after attempted internal jugular vein catheterization. This is the first described case report of two concurrent pseudoaneurysms after a central venous catheterization attempt. CASE REPORT A 48-year-old hypertensive woman presented in September 2007 with acute onset of midback pain and a blood pressure of 210/129 mm Hg. An internal jugular vein catheterization was attempted in the emergency department for hemodynamic monitoring and administration of intravenous antihypertensives without success. A computed tomographic angiogram (CTA) of the chest and abdomen led to the diagnosis of a type B aortic dissection. A tubular soft tissue density encased the proximal right subclavian artery that extended along the course of the right vertebral artery with an attenuation of 30 to 60 Hounsfield unit (HU), consistent with a hematoma (Figure 1). From the Department of Surgery (Momiy) and the Department of Vascular Surgery (Vasquez), Baylor University Medical Center at Dallas. Corresponding author: Janneth Momiy, MD, Resident, Department of Surgery, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, Texas ( jmomiy@yahoo.com). 96 Proc (Bayl Univ Med Cent) 2011;24(2):96 100

2 a b Figure 2. CT angiogram of the chest and abdomen demonstrating (a) the vertebral artery pseudoaneurysm (arrow) and (b) the pseudoaneurysm of the subclavian artery distal to the vertebral artery takeoff (arrow). She was admitted to the intensive care unit and placed on a cardizem drip and intravenous beta-blockers for blood pressure and heart rate control. A cardiothoracic surgeon was consulted, and medical management was deemed appropriate. She remained stable in the intensive care unit and achieved good blood pressure control. Magnetic resonance angiography of the chest and abdomen on hospital day 3 showed a stable dissection without progression. The patient was asymptomatic, medical management was successful, and she was discharged on hospital day 5. The patient remained asymptomatic on follow-up evaluations, and in January 2008 a follow-up CTA was performed, which showed near complete resolution of the aortic dissection. The CTA also showed a new cm pseudoaneurysm of the right vertebral artery near its origin and a second 0.7-cm pseudoaneurysm of the subclavian artery distal to the takeoff of the vertebral artery (Figure 2). An angiogram confirmed the diagnosis and the location of the pseudoaneurysms (Figure 3). Figure 3. Angiogram showing the vertebral artery and subclavian artery pseudoaneurysms. Figure 4. Intraoperative picture of the pseudoaneurysm. Given her history of a right internal jugular central line placement attempt and the subsequent hematoma in the location of the right subclavian and vertebral arteries, these pseudoaneurysms were thought to be a complication of the central venous catheterization attempt. Her acute and chronic hypertension also likely contributed to the formation and growth of the pseudoaneurysms. At the time of angiography, minimally invasive techniques for treating the pseudoaneurysms were considered. It was noted, however, that the neck of the vertebral artery pseudoaneurysm was not adequate for coiling and would have placed the vertebral artery at risk for thrombosis. Stenting of the pseudoaneurysms was also considered, but the location of the vertebral artery pseudoaneurysm at the subclavian vertebral artery junction (SVJ) and the close proximity of the subclavian artery pseudoaneurysm to the SVJ also placed the vertebral artery at risk for occlusion. Thus, an open repair was pursued. Intraoperatively, the vertebral artery pseudoaneurysm was found to be approximately 3 cm (three times larger than imaging had indicated), with an extensive inflammatory reaction (Figure 4). The vertebral artery pseudoaneurysm was closely abutting the SVJ, with the subclavian artery pseudoaneurysm just distal to the SVJ. More extensive involvement of the subclavian artery was found than illustrated on preoperative imaging. In addition, the pseudoaneurysm was also noted to have April 2011 Iatrogenic vertebral artery pseudoaneurysm due to central venous catheterization 97

3 Figure 5. Postoperative follow-up CT angiogram showing the polytetrafluoroethylene bypass graft and patent vertebral and subclavian artery. transmural involvement and was not amenable to simple suture repair. Thus, we resected the vertebral artery and subclavian artery pseudoaneurysms. Due to the extensive involvement of the pseudoaneurysms, there was insufficient length for primary reconstruction of the subclavian artery after excision. The decision was made to repair the subclavian artery with an interposition 6-mm polytetrafluoroethylene graft with plans of reimplanting the vertebral artery to the ipsilateral carotid artery. Despite extensive mobilization, the vertebral artery did not reach the carotid artery. An attempt to reimplant the vertebral artery to the polytetrafluoroethylene graft was also unsuccessful, as the artery was very inflamed and friable. With a strong pulse and good cross-fi lling from the contralateral vertebral artery, the vertebral artery was deemed amenable to ligation. Our preoperative angiographic imaging also supported this decision, demonstrating a large left vertebral artery and good basilar flow. Hence, excision of the pseudoaneurysms with ligation of the vertebral artery and repair of the subclavian artery with an interposition polytetrafluoroethylene graft was performed. The patient s postoperative course was uneventful, with good palpable bilateral upper extremity pulses and no claudication or neurological deficits, and she was discharged on postoperative day 2. Four months after repair, the patient remained asymptomatic, and a follow-up CTA showed a patent subclavian artery bypass graft (Figure 5). arterial punctures occur during the internal jugular approach (5). The carotid artery is most susceptible to arterial injury (7, 8) due to its location and relationship to the internal jugular vein. However, injuries of the vertebral artery, subclavian artery, brachiocephalic artery, and thyrocervical trunk have been described (11 18). Vertebral artery injury due to central venous catheterization is rare. Catheter-related vertebral artery injuries can often be attributed to internal jugular catheterization attempts. In fact, only four vertebral artery injuries secondary to subclavian vein catheterization have been reported (9, 12, 19, 20). Injury of the vertebral artery can occur when the trajectory of the needle is too lateral and too deep to the skin. Such as in this case, most injuries occur at the V1 portion of the vertebral artery (21). This encompasses the vertebral artery at the point of its origin to the C6 vertebrae. Most injuries of the vertebral artery result in arteriovenous fistula formation, specifically a vertebrojugular or vertebrovertebral fi stula (10). Other complications include dissection, thrombosis, and pseudoaneurysm formation. Although pseudoaneurysm formation after central line placement has been well documented in the literature, with an incidence rate of 0.05% to 2%, most iatrogenic pseudoaneurysms arise as a complication of femoral central line attempts (22). Vertebral artery pseudoaneurysm as a consequence of central line placement is extremely rare, with only five reported cases (11 14, 17, 19) (Table). There are no prior reports of multiple pseudoaneurysm formation after inadvertent arterial puncture during central line placement. It is likely that this was a difficult line placement with multiple arterial punctures performed in the emergency room 4 months prior to diagnosis and at the time of admission for a thoracic aortic dissection. Most vertebral artery pseudoaneurysms go undiagnosed until patients present with delayed symptoms (11 14, 17, 19). Symptoms may include a supraclavicular/neck mass, pain, stridor, and/or dysphagia. In the few cases reported, time elapse from injury to development of symptoms and diagnosis ranged from 1 to 70 days (Table). Most presented with a pulsatile mass at the time of diagnosis. Unlike the cases described in the literature, this patient did not have symptoms or physical examination findings attributed to the vertebral artery pseudoaneurysm. DISCUSSION Central venous catheterization is a vital element in the resuscitation and hemodynamic monitoring of the acutely ill patient. Millions of central venous catheters are placed every year. Arterial injuries secondary to central venous catheters have been well documented in the literature. When comparing the subclavian and internal jugular vein approaches for central venous catheterization, most inadvertent 98 First author, year (ref) Table. Reported cases of vertebral pseudoaneurysm due to central venous catheterization Target vein Time to presentation (days) Presentation Treatment Outcome Amaral, 1990 (19) SCV 5 Airway obstruction Excision No follow up Aoki, 1992 (11) IJV 70 Pulsatile mass/pain Excision No follow up Elias, 1999 (14) IJV Several (not specified) Pulsatile mass/bruit Excision No follow up Bernik, 2002 (12) IJV 1 Pulsatile mass Excision No follow up Cihangiroglu, 2002 (13) IJV 32 Pulsatile mass Excision 2 month, US negative SCV indicates subclavian vein; IJV, internal jugular vein; US, ultrasound. Baylor University Medical Center Proceedings Volume 24, Number 2

4 This raises the question regarding the number of vertebral artery injuries that may go undiagnosed due to lack of symptoms. We had the unique opportunity to be able to diagnose this asymptomatic pseudoaneurysm through follow-up imaging for an unrelated diagnosis. In this case, the pseudoaneurysms were diagnosed using a CTA secondary to follow-up imaging for a type B aortic dissection. However, most pseudoaneurysms can be diagnosed with a duplex ultrasound to assess size and artery of origin. The location of a pseudoaneurysm of the vertebral or subclavian artery makes it difficult to assess the neck of the pseudoaneurysm; therefore, for a better understanding of the anatomy of the pseudoaneurysm, angiography should be performed. Angiography can also better demonstrate the artery s luminal blood flow and assess the contralateral vertebral artery, essential information for surgical planning. Pseudoaneurysm excision and bypass is the mainstay of treatment for pseudoaneurysms of the vertebral artery (8). In fact, all reported pseudoaneurysms secondary to central venous catheterization have been treated by open surgical repair (Table) (10). Endovascular exclusion with covered stents may be an option for treatment of distal subclavian artery pseudoaneurysms if coverage of the vertebral origin can be avoided. Endovascular repair has also been described in the treatment of traumatic vertebral artery pseudoaneurysms with good results (23, 24). However, this option was not feasible in our case due to the location of the vertebral and subclavian artery pseudoaneurysms. The neck of the vertebral artery pseudoaneurysm was inadequate for coiling and placed the vertebral artery at a significant risk for thrombosis. In addition, both pseudoaneurysms were located near the SVJ, making stenting difficult without compromise of vertebral artery flow. We were able to excise both pseudoaneurysms, ligate the vertebral artery, and reconstruct the subclavian artery with an interposition graft repair via a supraclavicular approach. Our initial goal was to preserve the vertebral artery, but we were unable to do so and were able to ligate the vertebral artery without complications. Given the rarity of vertebral artery pseudoaneurysms, we know little about their natural course and risk of rupture. The potential devastating consequences of vertebral artery rupture or embolization make observation a less favorable option unless a patient s risk is too high to undergo either endovascular or open intervention. This patient was young and relatively healthy, with a history of uncontrolled hypertension complicated by a type B aortic dissection. We felt her risk of rupture of the pseudoaneurysms outweighed her surgical risk, and open surgical repair was deemed appropriate. Given the rarity of this complication and the sparsity of literature on the subject, treatment should be individualized. When formulating a treatment plan, the anatomy of the lesions, patient comorbidities, technical feasibility, and risk of intervention need to be taken into consideration. Correct placement of a central venous catheter Placement of a central venous catheter is an essential part of surgical training. Literature indicates that the higher the level of training, the lower the complication rate (25). It is imperative that physicians be taught proper central line placement techniques to avoid serious complications that may lead to major vascular interventions or even death. Several techniques have been documented to minimize mechanical complications from central venous catheterizations via the internal jugular and subclavian vein approach. Internal jugular vein cannulation can be broadly classified as high or low. A high approach is defined as a puncture at or above the apex of the triangle formed by the two heads of the sternocleidomastoid muscle. Any puncture below this level is a low approach. The high approach is recommended given the higher incidence of arterial injury and pneumothorax with the low approach. Ultrasound-guided internal jugular vein cannulation should be performed whenever available. The decrease in complication rate and increase in success rate of internal jugular vein cannulation with ultrasound guidance versus the landmark technique has been well documented (26). To facilitate exposure of the internal jugular vein, the neck should be rotated at a 20 to 30 angle and placed in Trendelenburg position. Extreme rotation of the neck should be avoided, as it tends to collapse the internal jugular vein and increase the incidence of inadvertent carotid artery puncture (27, 28). The carotid pulse should be palpated with the left hand when attempting cannulation of the right internal jugular vein. The finder needle is inserted at or above the apex of the two heads of the sternocleidomastoid muscle and directed to the ipsilateral nipple. The mean distance of the internal jugular vein from the skin is approximately 15 to 21 mm, depending on the size of the finder needle used (29). The larger the size of the finder needle (ranging from 16 to 23 gauge), the longer the distance to the internal jugular vein (29). Inadvertent arterial punctures of the vertebral and subclavian artery occur when the needle is inserted too deeply, at a more acute angle, and/or too laterally. When attempting an infraclavicular approach to subclavian vein cannulation, identification of landmarks is essential. Unlike the internal jugular vein approach, ultrasound use has not been shown to decrease complication rates or increase accuracy in placement of a subclavian central venous catheter (26). The two bony landmarks include the sternal notch and the middle to medial third of the clavicle. The right subclavian vein approach has significantly more cannulation failure rates than the left subclavian vein approach (25); therefore, left subclavian vein central line placement should be performed unless contraindicated. In a recent study (25), six common technical errors in subclavian central line placement were identified: improper/ inadequate landmark identification, improper needle insertion relative to the clavicle, too shallow a trajectory, aiming the needle too cephalad, and failure to keep the needle in place during wire insertion. The most common technical error encountered was the location of the needle insertion relative to the clavicle. The needle was often inserted too close to the clavicle, creating a steep angle into the vein, making wire insertion difficult or missing the vein altogether in the caudal direction. April 2011 Iatrogenic vertebral artery pseudoaneurysm due to central venous catheterization 99

5 After identification of the bony landmarks, an 18-gauge introducer needle should be used to puncture the skin and enter 1 cm below the lateral edge of the first third portion of the clavicle (25). The needle should be directed towards the sternal notch, and if there is failure of blood return, the needle should be withdrawn just below the skin and redirected in a more cephalad direction (30). Inadvertent arterial puncture with the introducer needle can be visually assessed by the return of brisk pulsatile bright red blood flow. However, in a hypotensive, hypoxic patient, it may be difficult to visually assess inadvertent entry into the artery. In such a situation, an 18-gauge needle can be passed over the wire (no need to dilate) and connected to a pressure transducer (31, 32). If a pressure transducer is not available, simultaneous samples of blood gases can be drawn, one from an artery and one from the catheter. In the artery, the needle is removed and constant pressure is applied to prevent hematoma formation. If arterial cannulation occurs with a large catheter (>7Fr), it is best to keep the central venous catheter in place and perform surgical repair and catheter removal under direct visualization (33). The pull and pressure technique after inadvertent arterial catheterization can lead to hematoma, airway obstruction, false aneurysm, and even stroke (33). In conclusion, we used open surgical repair and bypass to treat this case of two pseudoaneurysms of the vertebral and subclavian artery resulting from central line placement. Ultimately, however, the focus should be on preventing these iatrogenic injuries using well-documented techniques to minimize complications. 1. Aubaniac R. Subclavian intravenous injection; advantages and technic. 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