|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 190-191
Iatrogenic subclavian artery cannulation: Implications and management
Joshi Thomas, Deepak Dwivedi, Debarshi Guha, Jagdeep Singh Bhatia
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, India
|Date of Submission||13-May-2020|
|Date of Decision||02-Jun-2020|
|Date of Acceptance||08-Jun-2020|
|Date of Web Publication||13-Apr-2021|
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Thomas J, Dwivedi D, Guha D, Bhatia JS. Iatrogenic subclavian artery cannulation: Implications and management. Indian J Vasc Endovasc Surg 2021;8:190-1
Central venous access through the neck veins is the mainstay of management for patients requiring volume, blood resuscitation, dialysis, drug therapy, parenteral nutrition, and hemodynamic monitoring. The incidence of the mechanical complication is about 1%. Mechanical complications include hematoma formation, airway obstruction, stroke, and pseudoaneurysm. Unintentional arterial injury can occur up to 8% of the central venous access and is being noticed more in obese, short neck, hypovolemic patients where the landmark technique has been used. We present the management of an inadvertent cannulation of the subclavian artery during the surgery while attempting central venous access through the right internal jugular vein (IJV).
A 77-year-old male, weighing 44 kg, a diagnosed case of adenocarcinoma colon, was planned for hemicolectomy. The patient had no comorbidities and was taken up under general anesthesia with standard monitoring. Two 16G intravenous accesses were secured preoperatively, and the hemodynamics were maintained until 45 min into the surgery, the patient developed hypotension (blood pressure - 83/42 mmHg) which was persistent despite the fluid resuscitation. Infusion of noradrenaline was started at 0.05 μg/kg/min through the peripheral line. At this juncture, central venous access was planned, and under strict asepsis, right IJV cannulation was done by Seldinger's technique employing the landmark method. Once the introducer needle aspirated the blood, it was stabilized followed by the insertion of 7 Fr central venous catheter (CVC), which passed effortlessly followed by the dark-colored nonpulsatile blood, which was aspirated from all the ports. Once the line was transduced, it showed the arterial waveform having the high suspicion of inadvertent puncture and cannulation of the artery. Arterial blood gas analysis confirmed the findings with SaO2 of 99% and CVC was capped. Transfusion of the blood and vasopressor infusion restored the hemodynamics, and the surgical hemostasis was achieved. Vascular surgeon's opinion was sought, and postoperatively, after extubation and complete recovery, the patient was taken to the cardiac catheterization laboratory, and under fluoroscopic guidance, CVC was identified to be lying in the subclavian artery [Figure 1]. Under the fluoroscopic guidance, the catheter was removed by the endovascular approach and the puncture site was sealed by the collagen based 6 Fr (2 mm) AngioSeal™ VIP (Terumo Medical Corporation Somerset, NJ, USA) [Figure 2]. Postprocedure fluoroscopy did not reveal any leaks, the patient was detained in the intensive care unit, and his hematocrit was measured at regular intervals along with computed tomography scan after 4 h to rule out any signs of bleeding and hemothorax. The patient was discharged on the 5th postoperative day with no neurological sequelae.
|Figure 1: (a) The fluoroscopic image of the chest with the central venous catheter in the right subclavian artery. (b) The angiogram confirming the catheter in the right subclavian artery|
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|Figure 2: Cardiac fluoroscopic image showing the site of the deposition of sealant (AngioSeal) at the entry point of the central venous catheter into right subclavian artery|
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Various modalities of management have been described in the literature. Mousa et al. tailored the algorithm based on the hemodynamic status, site of cannulation, status of artery, and the size of the catheter. Guilbert et al., in their retrospective analysis, concluded that arterial central venous access was managed by pull and external compression technique in 38% of the patients, which was associated with stroke, death, and false aneurysm with bleeding, but majority (62%) of the patients were managed with either the endovascular approach or surgical open repair. Choi et al. described subclavian artery cannulation while securing a temporary hemodialysis vascular access through the right IJV which was repaired surgically. Paliwal et al. while attempting right IJV inadvertently punctured right subclavian artery similar to our case and attributed it to the course of subclavian artery, with its second portion being the highest and susceptible to puncture. Ultrasonography (USG)-guided central venous access has reduced the complications rate up to 73%, but it is not fool proof in preventing the arterial cannulation when the short-axis view of USG is employed. Literature has suggested the inclusion of the long-axis view for delineating the correct placement of the guidewire before the catheter is cannulated.
Algorithm as suggested by Guilbert et al. was followed where, on identification of inaccessible arterial cannulation site, endovascular approach was selected. The case meted the criteria for the closure device as suggested by Mousa et al. which includes, the use of <8 Fr CVC, minimal evidence of calcifications in the arterial wall, and absence of kinking and availability of the straight path for subcutaneous insertion. A systematic approach with early identification of the arterial cannulation and the choice of intervention depending on the accessibility of the site, patient's hemodynamic status, and condition of the artery when followed judiciously improved the outcome.
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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Guilbert MC, Elkouri S, Bracco D, Corriveau MM, Beaudoin N, Dubois MJ, et al
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[Figure 1], [Figure 2]