Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 158-163

Step-by-step guide to averting and managing a central line insertion misadventure

1 Vascular Surgery Unit, Sultan Qaboos University Hospital, Muscat, Oman
2 Department of Anesthesia, Christian Medical College, Vellore, Tamil Nadu, India
3 Critical Care Unit, Sultan Qaboos University Hospital, Muscat, Oman
4 Department of Radiology, Sultan Qaboos University Hospital, Muscat, Oman

Date of Submission03-Nov-2019
Date of Decision11-Dec-2019
Date of Acceptance18-Dec-2019
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Serina Ruth Salins
Department of Anesthesia, Christian Medical College, Vellore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_90_19

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Background: Central venous cannulation or catheterization (CVC) forms the core of managing critically ill patients. Inadvertent arterial or venous injury, despite the use of duplex ultrasound (DUS), can lead to significant and devastating complications, especially when large-bore cannulas are used. This article explains the way we managed four different scenarios and suggests a step-by-step guide to insertion of a CVC and management of a misadventure. Methods: We maintained the records and followed up four adult patients requiring hemodialysis who had misadventures with CVC insertion between March 2018 and January 2019, with large-bore (>7Fr) cannulas. They were all followed up for 6 months. Results: Four patients, 2 males and 2 females, between 25 and 82 years of age, underwent CVC insertion in an intensive care setting. The youngest had a carotid-jugular arteriovenous fistula that was detected after discharge and managed successfully by open surgery. The eldest, a male patient, had a perforation of the external iliac vein, which was managed successfully with endovascular balloon inflation. The third patient had femoral artery pseudoaneurysms, which were managed successfully with serial DUS compression. The fourth had an inadvertent puncture of the right common carotid artery during the insertion of jugular CVC and was managed by manual and DUS compression. Conclusion: DUS has reduced the incidence of complications from the insertion of CVC. However, in order to further reduce or nullify the possibility of arterial punctures during CVC insertion, whether it be a small (<7Fr) or large (>7Fr) cannula, the operator needs to follow certain basic steps, be aware of potential complications and know how to approach an inadvertent arterial/venous/nerve injury. The literature mostly deals with how complications were managed while we impress on the need for prevention. The authors recommend that clinical guidelines be formulated and followed in hospitals.

Keywords: Arterial, arteriovenous, cannulation, carotid, central, dialysis, femoral, fistula, inadvertent, injury, jugular, management, perma-cath, subclavian, venous catheter

How to cite this article:
Stephen E, Salins SR, Abdelhedy I, AlBusaidi M, AlHashim AH, AlSukaiti R, AlAamri H, AlMawali H, AlWahaibi K. Step-by-step guide to averting and managing a central line insertion misadventure. Indian J Vasc Endovasc Surg 2020;7:158-63

How to cite this URL:
Stephen E, Salins SR, Abdelhedy I, AlBusaidi M, AlHashim AH, AlSukaiti R, AlAamri H, AlMawali H, AlWahaibi K. Step-by-step guide to averting and managing a central line insertion misadventure. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Dec 1];7:158-63. Available from:

  Introduction Top

Central venous lines and catheters are lifelines for critically ill patients requiring administration of medications, total parenteral nutrition, bone marrow transfusion, renal replacement therapy (RRT), cardiac pacing/catheterization, and at times for those with difficult peripheral access.[1]

The right internal jugular vein (IJV) provides direct access to the superior vena cava (SVC), and hence, is the preferred vein, making the left IJV – a second best. The SVC because of its close proximity to the mediastinal pleura if accidentally perforated by the guidewire, dilator, or catheter can lead to catastrophic bleeding into the pleural space, which is a low-pressure zone.[2]

Lim et al. studied computed tomography images and reported that the IJV was lateral to the carotid artery in 85.2% of patients and the distance between the two was <1 mm in 69.5% of cases.[3]

Malposition of a catheter is not as uncommon as we presume and can range between 5% and 15%, with arterial misadventures being in the range of 6.3%–9.4%.[4] Complications include among others, catastrophic-cerebrovascular accidents, hematomas, pseudoaneurysms, arteriovenous fistulas (AVFs), pericardial/pleural effusion nerve injury, and death.[5],[6]

Over the past decade or so, there has been an increase in the use of ultrasound (USG)-guided insertion of CVC's. However, we still encounter the cases and read isolated reports of serious consequences following CVC insertion/attempts. The authors suggest a set of guidelines for the insertion and management protocol in the event of a complication.

  Case Series Top

Case 1

A 25-year-old female, juvenile diabetic, was referred to us from a peripheral hospital where she was undergoing hemodialysis (HD) thrice weekly through a right internal jugular vein (IJV) permcath with a history of headache and hearing a “sound” in her left ear.

On examination, she had a thrill in the left carotid triangle with dilated neck veins. She had a left IJV, 11Fr perm-cath inserted, under USG guidance, in the intensive care unit (ICU) of our hospital when she had presented with sepsis 6 months earlier. Postinsertion pressures had been high, and hence, HD was carried out through a Quinton line in the right femoral vein. Once her condition stabilized, a right IJV perm-cath inserted and the left perm-cath removed 1 month later.

A computed tomography angiography (CTA) was done to assess the AVF, which clearly showed a left common carotid artery (CCA) to IJV AVF [Figure 1].
Figure 1: Computed tomography angiography showing a carotid–jugular fistula

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An elective open repair of the AVF was done [Figure 2] and [Figure 3]. The fistula was disconnected and the defect in the CCA and IJV closed separately with 6-0 prolene sutures. The repair led to the resolution of her headache and the disappearance of the dilated veins.
Figure 2: Intraoperative images of carotidjugular fistula

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Figure 3: Intraoperative images of carotidjugular fistula, after repair

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Case 2

An 82-year-old male, diabetic, hypertensive patient was admitted to the ICU with sepsis secondary to pyelonephritis. A left femoral 11Fr Quinton line was inserted for RRT under USG guidance. The line on aspiration drew venous blood; however, on connecting the HD machine, it gave an alarm due to high returning pressure and the patient complained of pain. A couple of hours later, the patient became hypotensive, and there was a drop in hemoglobin of 6 g from the baseline.

After stabilizing his blood pressure with inotropes, a CTA was done which revealed that the tip of the catheter had perforated the external iliac vein (EIV) with a large retroperitoneal hematoma around it.

The patient was taken to the endovascular suite. Water-soluble contrast was injected through the dialysis catheter which showed the tip of the catheter bulging out of the lumen of the EIV with a small focal venous perforation [Figure 4]. After placing a 0.035 Terumo guidewire, the dialysis catheter was removed [Figure 5] and a 10-mm diameter balloon was kept inflated in EIV at the site of venous perforation to tamponade any bleeding for 5 min [Figure 6]. Postprocedure angiogram showed the normal flow of contrast into the common iliac vein without any extravasation [Figure 7]. The tip of the catheter and the distal hole lay outside the EIV, but the proximal hole [Figure 8] was in the lumen permitting backflow at aspiration and not free forward flow.
Figure 4: Venogram showing tip of the catheter piercing the vein wall

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Figure 5: Catheter withdrawn over a 0.035 Terrumo wire into the external iliac vein

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Figure 6: 10 × 40 Balloon inflated in the external iliac vein

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Figure 7: Free flow of contrast into the inferior vena cava

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Figure 8: Close-up view of the Quinton catheter

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Case 3

A 72-year-old female on HD was referred to our hospital with aneurysmal dilatation of her left brachiocephalic AVF, upper limb edema, and high pressures at HD [Figure 9].
Figure 9: Depicting venous hypertension and aneurysmal dilation in the arterio-venous fistula

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As the AVF could not be used at admission, and the patient needed HD, a right femoral Quinton catheter insertion was planned. A right femoral arterial puncture (despite being a USG attempt) resulted in a pseudoaneurysm [Figure 10]. Her hemoglobin dropped by 4 g with a thigh hematoma. Duplex USG compression was carried out for 20 min each day for 3 consecutive days; the pseudoaneurysm size reduced significantly and closed over a period of 1 month. She required to be transfused and was dialyzed through a left femoral vein Quinton line, the same night as the misadventure.
Figure 10: Computed tomography angiography showing the right femoral artery pseudoaneurysms and hematoma

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Case 4

A 33-year-old male diagnosed to have sickle cell disease with difficult intravenous access was referred to the intensive care team for the insertion of a CVC for bone marrow transfusion. Under USG, the first pass was unsuccessful. At the second attempt, there was an aspirate of “venous blood,” but within seconds, he developed a rapidly expanding neck hematoma [Figure 11]. The team on-site applied external pressure and the vascular surgery team on call used USG-guided compression. After 10 min of sustained pressure, no breach in the wall of the carotid artery was seen. A femoral CVC line was inserted.
Figure 11: Note the neck hematoma and puncture site

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Dos and don'ts for safe insertion of a central venous catheter

  1. It is imperative that the physician knows the anatomy of the central veins.[7] Anatomical variations of the SVC such as a persistent left SVC can occur in 2.1% of the population.[1],[2] The azygos vein can be cannulated through the IJV, accidentally in up to 1.2% of cases. In such a scenario, aspiration does not yield blood despite a smooth placement of the guidewire and catheter.[8] About 9% of cases have anatomical variations of the IJV making cannulation a challenge.[9] In approximately 50% of patients, the IJV overlies the carotid artery, which predisposes to arterial puncture if the needle traverses the posterior wall of the IJV[10]
  2. Remember that patients requiring a CVC are often critically ill. Ensure you have checked their full blood count, coagulation parameters (in certain emergency situations, this may not be possible) and have blood and or blood products available at the hand
  3. Do not forget to take prior informed consent for the procedure, exception being an emergency situation
  4. Make sure you have observed a physician/surgeon trained in the insertion of CVC a few times, in a setup where procedural competency in central line insertion is taught and assessed, hence, covering knowledge, practical applications, and awareness of complications
  5. Get comfortable with the use of a USG machine (thereby reducing the risk of inadvertent arterial puncture) and have the first CVC done under supervision. The United States and United Kingdom clinical guidelines for the insertion of a CVC have recommended the use of real-time USG for CVC placement[11],[12]
  6. Ensure that all the materials that are needed for the procedure are in the room, and there is a nurse and or paramedic available
  7. The operator should know the type, gauge (<7Fr; >7Fr) of the CVC being used, and what the catheter kit contains have it preflushed and ensure the stopcock's are closed
  8. Proper lighting and positioning of the patient are vital. Have a tracheostomy roll under the shoulder blades, table tilted in antiTrendelenberg position for neck, upper chest access and Trendelenberg position for femoral vein access with the table height adjusted to the comfort of the primary operator. Excessive rotation of the head can lead to the vertebral vein or carotid artery cannulation, as it increases the degree of overlap of IJV over the artery[7],[10]
  9. Once all the above are in place, perform a USG of the (neck, upper chest, and groin) for an assessment of the anatomy, vessel wall/lumen and ensure there is no thrombus within.[9] An IJV <7 mm in diameter has a higher failure rate of catheterization[12]
  10. Administer local anesthesia (if needed) before needle insertion and use the long, short, or oblique axis views to access the vessel. The short axis gives a good idea for appropriate needle angle; the long axis gives better depth perception as the needle enters the vessel. Only an oblique view can provide both these[13]
  11. Prior to insertion of the guidewire, steady the needle in a pincer grip; aspirate to see if the return is venous blood; then advance the wire gently, while looking to see if any ectopics develop
  12. Before inserting the dilator, time permitting, take a short and/or long axis X-ray view, from the point of insertion, distally to see the lie of the guidewire, as the needle could have moved leading the guidewire out of the vessel lumen
  13. The guidewire needs to be anchored at all times while passing the dilator. Do not push the dilator more than half its length. Withdrawal of the guidewire during “dilator passes” is one of the common causes of CVC malposition
  14. Do not use force while introducing or withdrawing the guidewire or catheter
  15. Do not hesitate to call for help, especially after a single inadvertent arterial puncture or two-venous punctures
  16. Once the CVC is in place look at the color and pulsatility of the backflow, connect the CVC to the transducer (should be routine practice) to confirm final placement, alternatively, a blood gas analysis or USG to check catheter is in the vein.[14] If none of the above is possible, a simple yet practical tip is to run a bottle of normal saline through the cannula and ensure free forward flow[6]
  17. Do use at least two of the techniques mentioned in step 16 to confirm proper placement like a “timeout”[14]
  18. The final check X-ray (for neck and upper chest CVC) should show that the catheter is positioned between the mid-lower SVC and the cavoatrial junction[7]
  19. The authors recommend that hospitals should have a competency test before independent CVC insertions.

Do's and don'ts in the event of an inadvertent arterial injury or malposition of central venous catheter

Needle injury

If the size of the needle is 22G and above and only a single pass has been made, then external pressure alone for 3–15 min should suffice. If the needle size is 21G and below, with more than one attempt and/or the carotid artery is atherosclerotic, there is a risk of embolic stroke in the next 48 h, and for this reason, elective surgery should be postponed and the patient kept on neurological observation for at least 24 h. An USG should be done to confirm that there is no further bleeding. Often, these incidents are not reported in patient's records or in literature.[14],[15]

Regardless of size of the catheter or catheter <7Fr

  • If it is in an artery and being left in situ while help is being sought, heparinization should be considered to prevent thrombus formation around the site of injury. In the case of cannulas larger than 7 Fr within the carotid artery, a stroke risk of 5.6% has been reported. Please note a carotid duplex can be normal in a sedated patient[15]
  • When there is a clinical suspicion that the point of injury is below the sternoclavicular joint, then prompt imaging is needed to assess the site of injury as the vessel involved could be the subclavian, innominate, or aorta and the patient may require a sternotomy to access the vessel/bleed[6],[15]
  • If the patient complains of severe back or chest pain, then it is likely that the catheter is in the extradural space or the mediastinum, respectively, and the catheter should be withdrawn gently[7]
  • Fluid in the pericardium or pleural cavity needs for the infusion to be stopped and the cardiothoracic surgical team contacted immediately[7]
  • If the carotid artery was injured, imaging of the carotid and brain should be done once the catheter is out to look for any evidence of neurological insult.

Catheter larger than 7Fr or if dilator has been used

  • The pull and pressure technique is associated with higher morbidity (stroke, sudden expansion of hematoma, airway compromise, and pseudoaneurysm) and death[15]
  • It is best to shift the patient to the operating room if hemodynamically and neurologically stable and call the vascular/cardiothoracic surgical/interventional radiology teams
  • If the surgery is an emergency, the surgeons can proceed, provided heparinization is possible, and there is no major bleeding into a cavity
  • Groin hematoma and major bleeds occur in about 1%–2.4% of patients in whom a femoral puncture has been attempted and this is higher when the caliber is large[15]
  • Endovascular first approach will depend on the availability of experienced personnel and hardware. It is the modality of choice for injuries below and behind the clavicle, patients with previous neck surgery or radiation, and hemodynamically unstable patients. It gives the option to use balloons, stents, perform tract embolization, and downsizing of the catheter[14]
  • Open surgery facilitates the removal of the needle/catheter under direct vision, embolectomy, and repair of the vessel.

  Conclusion Top

The incidence of misadventure during CVC placement is under-reported and often limited to cases with rare complications. Any hospital that caters to critically ill patients would have their share of “near-miss” situations and these should be audited along with the ones that have had complications for the purpose of learning and thereby reduction in adverse events.

Adequate training of residents, junior faculty by experienced personnel along with the formulation of guidelines like those followed in the United States of America and the United Kingdom with a “time-out” policy at the end of each CVC insertion will bring in an atmosphere of prevention – this is the way forward.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bader M, Bromley P, Jester I, Bennett J, Arul GS. Central venous catheters in the left-sided superior vena cava: Clinical implications. J Pediatr Surg 2013;48:400-3.  Back to cited text no. 1
Gibson F, Bodenham A. Misplaced central venous catheters: Applied anatomy and practical management. Br J Anaesth 2013;110:333-46.  Back to cited text no. 2
Lim CL, Keshava SN, Lea M. Anatomical variations of the internal jugular veins and their relationship to the carotid arteries: A CT evaluation. Australas Radiol 2006;50:314-8.  Back to cited text no. 3
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 4
Bechara CF, Barshes NR, Pisimisis G, Kougias P, Lin PH. Management of inadvertent carotid artery sheath insertion during central venous catheter placement. JAMA Surg 2013;148:1063-6.  Back to cited text no. 5
Rajinikanth J, Stephen E, Agarwal S. Complication of central venous cannulation. Can J Surg 2008;51:E113-4.  Back to cited text no. 6
Wang L, Liu ZS, Wang CA. Malposition of central venous catheter: Presentation and management. Chin Med J (Engl) 2016;129:227-34.  Back to cited text no. 7
Bankier AA, Mallek R, Wiesmayr MN, Fleischmann D, Kranz A, Kontrus M, et al. Azygos arch cannulation by central venous catheters: Radiographic detection of malposition and subsequent complications. J Thorac Imaging 1997;12:64-9.  Back to cited text no. 8
Denys BG, Uretsky BF. Anatomical variations of internal jugular vein location: Impact on central venous access. Crit Care Med 1991;19:1516-9.  Back to cited text no. 9
Lorchirachoonkul T, Ti LK, Manohara S, Lye ST, Tan SA, Shen L, et al. Anatomical variations of the internal jugular vein: Implications for successful cannulation and risk of carotid artery puncture. Singapore Med J 2012;53:325-8.  Back to cited text no. 10
Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, et al. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2011;24:1291-318.  Back to cited text no. 11
NICE guidelines;2019;Pg 1-32. Guidance on the use of ultrasound locating devices for placing central venous catheters. [Last accessed on 2019 Aug 01].  Back to cited text no. 12
Phelan M, Hagerty D. The oblique view: An alternative approach for ultrasound-guided central line placement. J Emerg Med 2009;37:403-8.  Back to cited text no. 13
Ho L, Spanger M, Hayward P, McNicol L, Weinberg L. Missed carotid artery cannulation: A line crossed and lessons learnt. Anaesth Intensive Care 2014;42:793-800.  Back to cited text no. 14
Guilbert MC, Elkouri S, Bracco D, Corriveau MM, Beaudoin N, Dubois MJ, et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg 2008;48:918-25.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]


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