|Year : 2021 | Volume
| Issue : 1 | Page : 111-113
Accidental carotid artery cannulation during internal jugular vein access for hemodialysis
Thilina Gunawardena, Rezni Cassim, Mandika Wijeyaratne
University Vascular Surgical Unit, National Hospital of Colombo, Colombo, Sri Lanka
|Date of Submission||04-May-2020|
|Date of Acceptance||02-Jun-2020|
|Date of Web Publication||20-Feb-2021|
University Vascular Surgical Unit, National Hospital of Colombo, Colombo
Source of Support: None, Conflict of Interest: None
Temporary central venous catheters are frequently used for vascular access in patients who require renal replacement therapy. The right internal jugular vein is the preferred central vein in such occasions. Accidental cannulation of the carotid artery is a potential complication of catheter placement in the internal jugular vein. This can lead to serious consequences such as stroke, life threatening hemorrhage and airway obstruction. Surgical removal is the management option of choice if a catheter is inadvertently placed in the carotid artery.
Keywords: Accidental carotid puncture, internal jugular vein central line, vascular catheter
|How to cite this article:|
Gunawardena T, Cassim R, Wijeyaratne M. Accidental carotid artery cannulation during internal jugular vein access for hemodialysis. Indian J Vasc Endovasc Surg 2021;8:111-3
|How to cite this URL:|
Gunawardena T, Cassim R, Wijeyaratne M. Accidental carotid artery cannulation during internal jugular vein access for hemodialysis. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Mar 1];8:111-3. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/111/309718
| Introduction|| |
The right internal jugular vein (IJV) is the preferred central vein for temporary vascular access in patients who need urgent haemodialysis because of the ease of cannulation and as the right IJV provides a short direct route to the right atrium. Accidental cannulation of the carotid artery is a rare complication of such central line placement. However, it can be associated with serious consequences due to the associated risk of stroke, hemorrhage, arteriovenous fistula formation and airway obstruction due to haematoma. We report a 72-year-old male patient who had an inadvertent placement of an 11.5 French (F) dialysis catheter into his right carotid artery, which was successfully removed surgically.
| Case Report|| |
A 72-year-old male patient diagnosed with type 2 diabetes, hypertension, and end-stage renal failure, who had defaulted follow-up, presented to the local hospital with fluid overload and uremia. Blood investigations revealed his serum potassium to be >7 mmol/L. An urgent hemodialysis was planned, and a right internal jugular vein (IJV) temporary dialysis catheter was attempted without ultrasound guidance. After complete placement of the catheter, due to forceful pulsatile backflow, it was suspected to be inside the right carotid artery. No attempt was made to remove the misplaced line, and hemodialysis was done via a separately placed left femoral vein catheter. Then, the patient was transferred to the vascular unit at the National Hospital of Colombo for the removal of the misplaced catheter.
When we saw the patient, he was hemodynamically stable without any neurological impairment. Since the catheter was wide bore, we decided to remove it surgically. The procedure was done under cervical plexus block. The patient was placed supine with the neck extended and rotated to the left side. The incision was placed along the anterior border of the right sternomastoid muscle. Common carotid artery was dissected, and circumferential control was achieved. During exploration, it was found that the catheter entered the right IJV through its lateral wall, exited its medial wall, and penetrated the lateral wall of the right common carotid [Figure 1]. A purse string suture was placed around the catheter entry site into the artery. The catheter was pulled out of the vessel, and the suture was tightened. The same steps were taken to repair the defects in the vein wall. The surgical wound was closed with a suction drain.
|Figure 1: Intraoperative photograph of the vascular catheter entering the common carotid artery|
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The patient had an uneventful recovery and was transferred back to local hospital on the postoperative day 1.
| Discussion|| |
Temporary IJV vascular catheters are the preferred option for dialysis access in “crash landers” such as our patient. Use of a small caliber needle for initial vein puncture and railroading the large bore catheter along a guidewire inserted through the small needle is the standard technique of central venous access. Anatomical landmarks were used to locate the central veins until ultrasound-guided punctures were found to be superior due to less risk of complications. There is a 5.9% risk of puncturing the carotid artery when using the landmark technique for IJV puncture. However, some who deal with vascular access procedures lack formal training on the use of ultrasound, so the landmark technique remains in use.
Stroke, hemothorax, pseudoaneurysms, airway compromise due to hematomas and arteriovenous fistula formation are the adverse effects of accidental carotid artery cannulation.
Early detection of catheter placement in the carotid artery is of the utmost importance. The color of the blood and pulsatile nature of the flow through the catheter have been reported as unreliable indicators of arterial puncture. Use of manometer to measure the pressure, imaging with chest X ray, comparison of partial pressure of oxygen (pO2) in a sample of blood drawn from the catheter as well as a separate sample obtained through another arterial puncture are the methods with moderate reliability. Anatomical anomalies in the venous drainage may result in falsely high pO2 values even when the catheter is placed correctly on the IJV. Use of transesophageal echo and direct visualization of the catheter in the carotid artery during surgical exploration are the most reliable indicators.
Manual compression, surgical removal and endovascular techniques are the options for management when a vascular catheter is inadvertently placed in the carotid artery. Pulling a large bore catheter out of an artery and application of direct pressure over the puncture site so as to compress the artery against a bony prominence is an acceptable technique of achieving hemostasis, provided the site of puncture is accessible for compression. This method has been used with success after using 7–8 F catheters in the femoral artery for interventional procedures. However, the use of direct pressure after removing a catheter in the carotid artery is associated with an unacceptable risk of stroke (53%).
Exploration, removal of the device, and arterial repair have been considered as the safest techniques by some authors. According to the review done by Dornbos et al., surgery was associated with complications only when it was used as a second-line option after failed direct compression.
Endovascular closure devices and covered stents have been used successfully to seal the defect in the artery once the catheter is manually pulled out. Failed attempts with closure devices have been managed with subsequent stent deployment. There is a reported case of postprocedure stroke and death following the use of a covered stent for treating a patient with a misplaced dialysis catheter in the carotid artery.
| Conclusions|| |
Inadvertent carotid artery cannulation is a rare, but serious complication of IJV vascular access. During puncture, ultrasound can be used to differentiate the artery from the vein by the demonstration of such features as pulsatility of the artery, compressibility of the vein, and engorgement of the vein with head low position. Once inadvertent carotid placement of a vascular catheter is confirmed, it is best to refer the patient to experienced clinicians for further management. Surgical repair of the artery appears to be the safest management option.
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.
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