Original Article
Inadvertent subclavian artery cannulation and options for management
Vascular 2015, Vol. 23(2) 132–137 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114534841 vas.sagepub.com
Albeir Y Mousa, Shadi Abu-Halimah, Aravinda Nanjundappa and Ali F AbuRahma
Abstract Central line placement is an integral part of our daily routine and although it is necessary in a select group of patients, serious complications may occur in up to 10% of cases. Inadvertent placement in the subclavian artery is considered to be one of the most challenging complications to the vascular specialist, which is mainly due to its deep anatomical location. Several endovascular options are available and should be tailored to fit each scenario. Herein, we present different approaches for the management of three cases of inadvertent subclavian artery cannulation. The first patient was treated with a covered stent, the second with prolonged balloon inflation, and the third with a closure device.
Keywords Subclavian, angiogram, balloon, closure devices, central line
Introduction Central venous accesses (CVA) are always required for certain indications, such as trauma patients, ICU patients, or in surgical patients in whom no other sufficient peripheral lines are available. Although ultrasound-guided needle localization has evolved as a standard of care in most institutions, early procedurerelated complications still occur from inadvertent insertion; in fact, some reports have indicated that serious complications can occur in up to 10%1 of these patients. In this report, multiple presentations, as well as appropriate treatment modalities, are outlined in algorithmic fashion in order to provide adequate guidance and experience to our armamentarium when it comes to such a challenging situation.
Case 1 A 25-year-old woman presented with severe postpartum hemorrhage, secondary to inadequate peripheral veins. A right subclavian central line was inserted while the patient was in the emergency room. Pulsatile arterial bleeding, as well as waveform on arterial line monitoring, confirmed that the central line had been inadvertently placed in the subclavian artery. A femoral CVA was inserted for resuscitation and the patient was taken to a hybrid operating room. An arch angiogram, along with the location of the CVA,
was achieved via a right common femoral artery access, and the patient’s right subclavian artery measured 6 mm in diameter. The lesion was crossed with a 0.035-inch guidewire and a 6-mm balloon was positioned across the line entry to the subclavian vessel. After the CVA was removed, a 6-mm balloon was inflated for a total of 5 min. A completion angiogram demonstrated a complete seal with no extravasation. Her postoperative course was uneventful, and arterial duplex ultrasounds done at two weeks and three months showed a triphasic waveform and underlying gross pathology (Figures 1 and 2).
Case 2 A 70-year-old male patient was brought to the hospital with a traumatic long bone fracture due to a motor vehicle accident. During his initial resuscitation, a central line was inadvertently placed in the right subclavian artery. A vascular surgeon was consulted and the patient was taken to a hybrid operating room where Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA Corresponding author: Albeir Y Mousa, Robert C. Byrd Health Sciences Center, West Virginia University, 3110 MacCorkle Ave., SE, Charleston, WV 25304, USA. Email: [email protected]
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Figure 1. Angiogram of innominate artery showing CVA inadvertently placed in right subclavian.
Figure 3. Perclose device deployment.
Figure 2. Completion angiogram after 5 min of balloon inflation.
he underwent an arch angiogram. A guidewire was passed across the entry, and another guidewire was passed through the central line. The central line was removed and a Perclose devise was deployed. A completion angiogram showed no extravasation and arterial duplex ultrasounds done at three and six months were uneventful (Figures 3 to 5).
Case 3 A 65-year-old male patient was transferred to our institution with inadvertent placement of central line in his right subclavian artery. The patient had acute lower
Figure 4. Completion angiogram showing successful sealing of innominate artery.
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gastrointestinal bleeding and required a blood transfusion. His medical history included end-stage renal disease, insulin-dependent diabetes mellitus, and hypertension. The patient was taken to a hybrid operating room, and an ultrasound of the right common femoral artery and an arch angiogram were performed. The right subclavian artery line was confirmed with the tip at the transverse aortic arch. Approach from right groin was achieved and a supracore guidewire was passed across the insertion site, a 0.035-inch guidewire was passed through one of the central line ports, and the CVA was removed. An attempt to deploy a Perclose device was unsuccessful, secondary to significant wall calcification. At this time, we elected to deploy a covered stent (Viahbhan, 7 mm 50 mm) after removal of the wire access at the CVA insertion site. A completion angiogram demonstrated no extravasation, and his postoperative course was uneventful (Figures 5
Figure 5. Active extravasation at level of central line arterial puncture.
and 6). Patient was discharged home on Clopidogrel for eight weeks and then aspirin indefinitely.
Discussion Central line placement is an integral part of our daily routine, with more than six million lines inserted in the United States every year.2 The incidence of mechanical complications after CVA placement is estimated to be 1%,3–4 and the subsequent trend for underlying vascular injuries is increasing. The anatomy of the subclavian vein, as well as its deep location and the absence of a direct bony structure to hold pressure in case of inadvertent placement, makes this site very challenging and more likely to have serious complications, including pseudoaneurysm or hemothorax, if the pull and hold pressure technique is utilized. In addition, other significant complications have been reported after inadvertent central line placement,5–12 such as cardiac tamponade,13–15 wire/catheter embolization,16 carotid artery injury, pneumothorax, hemothorax,17 air embolism,18 and cardiac arrhythmia. These complications carry significant morbidity, mortality,19 and a potential for liability claims against clinicians. Although the preferred central line placement should be the jugular vein, some clinicians still perform subclavian access. The proponents for subclavian vein access base their choice on the fact that there is a 50% less chance of infection, in comparison to the internal jugular vein;20 and that it is the only access for patients with neck collars and an unstable pelvis. The subclavian artery is the chief arterial supply for the upper limb. The right subclavian artery is a branch of the innominate (brachiocephalic) artery, whereas the
Figure 6. A covered stent deployment with complete sealing of extravasation.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
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Inadvertent Central Line Placement Subclavian Artery Pulsatile arterial bleeding A-line monitoring Confirm Diagnosis
Arterial duplex CTA
Patient is stable
Patient is unstable
Resuscitation Rapidly hemodynamically unstable. Consider endovascular approach to establish diagnosis and initial treatment if possible (Balloon Occlusion). Indications for open surgical approach: Groin or brachial approach
1. Critical arterial branches or bifurcations 2. Failure of endovascular approach
Ultrasound guided
3. Difficult or inaccessible anatomy; e.g., Bovine arch
Intervention
Cross lesion with wire & attempt balloon inflation (4 mins.)
Unsuccessful
Successful
Closure device
Covered stent
Successful
Unsuccessful
Completion angiogram before removal of wire
Consider open repair
Complete hemostasis Arterial duplex study @ 4 weeks, 3 months, 6 months Possible complications of treatment options: Pseudoaneurysm
Covered Stent
Dissection
Self-Expanding Stent
Figure 7. Inadvertent central line placement of subclavian artery.
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left subclavian artery is a branch of the arch of the aorta. Each subclavian artery enters the neck behind the corresponding sternoclavicular joint, curves upwards for one inch above the clavicle (half an inch below the apex of the lung) to end at the outer border of the first rib behind the mid clavicular point, where it becomes the axillary artery. This anatomical configuration of the subclavian artery may hinder direct digital pressure in most patients. On the other hand, the subclavian vein, which is a continuation of the axillary vein, starts at the outer border of the first rib and ends behind the corresponding sternoclavicular joint by joining the internal jugular vein to form the innominate vein (branchiocephalic). Prolonged arterial cannulation can result in thrombus formation, propagation, and possible stroke;21 therefore, expeditious intervention is necessary in order to avoid these dreaded complications. Treatment options should be tailored to each patient’s hemodynamic condition: site of arterial cannulation, underlying arterial disease, and the size of the inserted catheter. Our algorithm for treating inadvertent subclavian artery cannulation is illustrated in Figure 7. Balloon inflation is an efficient option that should be attempted in selected cases. Factors that may be considered are as follows: 1. 2. 3. 4.
Young patients Small healthy vessels Entry is far away from important branches Patient is hemodynamically stable
Factors that may contradict balloon inflation are as follows: 1. 2. 3. 4.
Calcified arterial wall Larger-sized arterial cannulas Patient is hemodynamically unstable Entry is near important branches
In a select group of patients, balloon inflation will control extravasation: prolonged inflation for 4 min is recommended and a repeat angiogram must be done to rule out any bleeding. A postoperative arterial duplex ultrasound is recommended at one and three months. Closure devices (Angio-seal, Perclose, and Starclose) are available and can be used judiciously, according to the catheter size and the clinician’s comfort zone. The Angio-seal VIP 6-Fr system (St. Jude Medical, Minnetonka, MN) is a device that creates a mechanical seal by sandwiching the site of the arteriotomy between a bio-absorbable anchor and a collagen sponge, which usually dissolves within two to three months.
The Perclose A-T 6-Fr SMC System (Abbott, Abbott Park, IL) closure device is designed to deliver a polyester suture to the arterial puncture site with one suture and two needles. Although other closure devices exist and, theoretically, can be used, our authors’ experience was exclusively with Perclose. Factors that may aid in intervention are: 1. Small arterial puncture (defined as less than 8 Fr.) 2. Minimal arterial wall calcifications 3. Straight path for the subcutaneous insertion without much kinking Factors that may contradict the use of a closure device are: 1. Large arterial puncture 2. Severe wall calcifications 3. Tortuous subcutaneous path An open surgical approach remains a valid option for repair of a subclavian arterial injury. The location of the arterial puncture dictates the surgical approach. If the injury occurs in the first part of artery, it will require either a left posterolateral thoracotomy or median thoracotomy. A supra-clavicular incision is appropriate for injuries that occur in the second and third parts of the subclavian artery. Counter-infraclavicular incisions may be required in selected cases. It is imperative to keep the tip of the closure device away from the aortic valve to prevent inadvertent injury.
Tips and tricks 1. Avoid using the subclavian vein, if possible 2. Avoid a low jugular vein stick, as this can contribute to more central arteries, such as innominate or subclavian arteries 3. Although arterial injury may still occur, ultrasound guidance21 is the safest approach to minimize inadvertent CVA insertion In conclusion, inadvertent central line placement is a significant complication with dreadful outcomes. Early diagnosis and prompt intervention are imperative. This case series offers a glimpse of possible therapies in some challenging scenarios.
Patient consent Appropriate consent was obtained from each patient.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
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Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Koklu E, Poyrazoglu H, Yikilmaz A, et al. Subclavian artery pseudoaneurysm: a rare and serious complication of central venous catheterization in an infant. Pediatr Radiol 2008; 38: 220–223. 2. Fletcher SJ and Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000; 85: 188–191. 3. Akmal AH, Hasan M and Mariam A. The incidence of complications of central venous catheters at an intensive care unit. Ann Thorac Med 2007; 2: 61–63. 4. Shah PM, Babu SC, Goyal A, et al. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: case for surgical management. J Am Coll Surg 2004; 198: 939–944. 5. Elihu A and Gollin G. Complications of implanted central venous catheters in neutropenic children. Am Surg 2007; 73: 1079–1082. 6. Shirotani N, Iino T, Numata K, et al. Complications of central venous catheters in patients on home parenteral nutrition: an analysis of 68 patients over 16 years. Surg Today 2006; 36: 420–424. 7. Savage AP, Picard M, Hopkins CC, et al. Complications and survival of multilumen central venous catheters used for total parenteral nutrition. Br J Surg 1993; 80: 1287–1290. 8. Kappers-Klunne MC and Degener JE. Complications from long-term indwelling central venous catheters, with special reference to infections. Neth J Med 1985; 28: 192–196.
9. Efsing HO, Lindblad B, Mark J, et al. Thromboembolic complications from central venous catheters: a comparison of three catheter materials. World J Surg 1983; 7: 419–423. 10. Thromboembolic complications and central venous catheters. Lancet 1982; 2: 936–937. 11. Adar R. Letter: potentially fatal complications of central venous catheters. Surgery 1976; 79: 726. 12. Walters MB, Stanger HA and Rotem CE. Complications with percutaneous central venous catheters. JAMA 1972; 220: 1455–1457. 13. Collier PE, Blocker SH, Graff DM, et al. Cardiac tamponade from central venous catheters. Am J Surg 1998; 176: 212–214. 14. Collier PE, Ryan JJ and Diamond DL. Cardiac tamponade from central venous catheters. Report of a case and review of the English literature. Angiology 1984; 35: 595–600. 15. Dane TE and King EG. Fatal cardiac tamponade and other mechanical complications of central venous catheters. Br J Surg 1975; 62: 6–10. 16. Freytes CO. Thromboembolic complications related to central venous access catheters in cancer patients. Semin Thromb Hemost 2007; 33: 389–396. 17. Lumb PD. Complications of central venous catheters. Crit Care Med 1993; 21: 1105–1106. 18. Grace DM. Air embolism with neurologic complications: a potential hazard of central venous catheters. Can J Surg 1977; 20: 51–53. 19. Adar R and Mozes M. Fatal complications of central venous catheters. Br Med J 1971; 3: 746. 20. Graham AS, Ozment C, Tegtmeyer K, et al. Videos in clinical medicine. Central venous catheterization. N Engl J Med 2007; 356: e21. 21. Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: case series, review and proposed algorithm. J Vasc Surg 2008; 48: 918–925.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
Inadvertent subclavian artery cannulation and options for management
Vascular 2015, Vol. 23(2) 132–137 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114534841 vas.sagepub.com
Albeir Y Mousa, Shadi Abu-Halimah, Aravinda Nanjundappa and Ali F AbuRahma
Abstract Central line placement is an integral part of our daily routine and although it is necessary in a select group of patients, serious complications may occur in up to 10% of cases. Inadvertent placement in the subclavian artery is considered to be one of the most challenging complications to the vascular specialist, which is mainly due to its deep anatomical location. Several endovascular options are available and should be tailored to fit each scenario. Herein, we present different approaches for the management of three cases of inadvertent subclavian artery cannulation. The first patient was treated with a covered stent, the second with prolonged balloon inflation, and the third with a closure device.
Keywords Subclavian, angiogram, balloon, closure devices, central line
Introduction Central venous accesses (CVA) are always required for certain indications, such as trauma patients, ICU patients, or in surgical patients in whom no other sufficient peripheral lines are available. Although ultrasound-guided needle localization has evolved as a standard of care in most institutions, early procedurerelated complications still occur from inadvertent insertion; in fact, some reports have indicated that serious complications can occur in up to 10%1 of these patients. In this report, multiple presentations, as well as appropriate treatment modalities, are outlined in algorithmic fashion in order to provide adequate guidance and experience to our armamentarium when it comes to such a challenging situation.
Case 1 A 25-year-old woman presented with severe postpartum hemorrhage, secondary to inadequate peripheral veins. A right subclavian central line was inserted while the patient was in the emergency room. Pulsatile arterial bleeding, as well as waveform on arterial line monitoring, confirmed that the central line had been inadvertently placed in the subclavian artery. A femoral CVA was inserted for resuscitation and the patient was taken to a hybrid operating room. An arch angiogram, along with the location of the CVA,
was achieved via a right common femoral artery access, and the patient’s right subclavian artery measured 6 mm in diameter. The lesion was crossed with a 0.035-inch guidewire and a 6-mm balloon was positioned across the line entry to the subclavian vessel. After the CVA was removed, a 6-mm balloon was inflated for a total of 5 min. A completion angiogram demonstrated a complete seal with no extravasation. Her postoperative course was uneventful, and arterial duplex ultrasounds done at two weeks and three months showed a triphasic waveform and underlying gross pathology (Figures 1 and 2).
Case 2 A 70-year-old male patient was brought to the hospital with a traumatic long bone fracture due to a motor vehicle accident. During his initial resuscitation, a central line was inadvertently placed in the right subclavian artery. A vascular surgeon was consulted and the patient was taken to a hybrid operating room where Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA Corresponding author: Albeir Y Mousa, Robert C. Byrd Health Sciences Center, West Virginia University, 3110 MacCorkle Ave., SE, Charleston, WV 25304, USA. Email: [email protected]
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
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Figure 1. Angiogram of innominate artery showing CVA inadvertently placed in right subclavian.
Figure 3. Perclose device deployment.
Figure 2. Completion angiogram after 5 min of balloon inflation.
he underwent an arch angiogram. A guidewire was passed across the entry, and another guidewire was passed through the central line. The central line was removed and a Perclose devise was deployed. A completion angiogram showed no extravasation and arterial duplex ultrasounds done at three and six months were uneventful (Figures 3 to 5).
Case 3 A 65-year-old male patient was transferred to our institution with inadvertent placement of central line in his right subclavian artery. The patient had acute lower
Figure 4. Completion angiogram showing successful sealing of innominate artery.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
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Vascular 23(2)
gastrointestinal bleeding and required a blood transfusion. His medical history included end-stage renal disease, insulin-dependent diabetes mellitus, and hypertension. The patient was taken to a hybrid operating room, and an ultrasound of the right common femoral artery and an arch angiogram were performed. The right subclavian artery line was confirmed with the tip at the transverse aortic arch. Approach from right groin was achieved and a supracore guidewire was passed across the insertion site, a 0.035-inch guidewire was passed through one of the central line ports, and the CVA was removed. An attempt to deploy a Perclose device was unsuccessful, secondary to significant wall calcification. At this time, we elected to deploy a covered stent (Viahbhan, 7 mm 50 mm) after removal of the wire access at the CVA insertion site. A completion angiogram demonstrated no extravasation, and his postoperative course was uneventful (Figures 5
Figure 5. Active extravasation at level of central line arterial puncture.
and 6). Patient was discharged home on Clopidogrel for eight weeks and then aspirin indefinitely.
Discussion Central line placement is an integral part of our daily routine, with more than six million lines inserted in the United States every year.2 The incidence of mechanical complications after CVA placement is estimated to be 1%,3–4 and the subsequent trend for underlying vascular injuries is increasing. The anatomy of the subclavian vein, as well as its deep location and the absence of a direct bony structure to hold pressure in case of inadvertent placement, makes this site very challenging and more likely to have serious complications, including pseudoaneurysm or hemothorax, if the pull and hold pressure technique is utilized. In addition, other significant complications have been reported after inadvertent central line placement,5–12 such as cardiac tamponade,13–15 wire/catheter embolization,16 carotid artery injury, pneumothorax, hemothorax,17 air embolism,18 and cardiac arrhythmia. These complications carry significant morbidity, mortality,19 and a potential for liability claims against clinicians. Although the preferred central line placement should be the jugular vein, some clinicians still perform subclavian access. The proponents for subclavian vein access base their choice on the fact that there is a 50% less chance of infection, in comparison to the internal jugular vein;20 and that it is the only access for patients with neck collars and an unstable pelvis. The subclavian artery is the chief arterial supply for the upper limb. The right subclavian artery is a branch of the innominate (brachiocephalic) artery, whereas the
Figure 6. A covered stent deployment with complete sealing of extravasation.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
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Inadvertent Central Line Placement Subclavian Artery Pulsatile arterial bleeding A-line monitoring Confirm Diagnosis
Arterial duplex CTA
Patient is stable
Patient is unstable
Resuscitation Rapidly hemodynamically unstable. Consider endovascular approach to establish diagnosis and initial treatment if possible (Balloon Occlusion). Indications for open surgical approach: Groin or brachial approach
1. Critical arterial branches or bifurcations 2. Failure of endovascular approach
Ultrasound guided
3. Difficult or inaccessible anatomy; e.g., Bovine arch
Intervention
Cross lesion with wire & attempt balloon inflation (4 mins.)
Unsuccessful
Successful
Closure device
Covered stent
Successful
Unsuccessful
Completion angiogram before removal of wire
Consider open repair
Complete hemostasis Arterial duplex study @ 4 weeks, 3 months, 6 months Possible complications of treatment options: Pseudoaneurysm
Covered Stent
Dissection
Self-Expanding Stent
Figure 7. Inadvertent central line placement of subclavian artery.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
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left subclavian artery is a branch of the arch of the aorta. Each subclavian artery enters the neck behind the corresponding sternoclavicular joint, curves upwards for one inch above the clavicle (half an inch below the apex of the lung) to end at the outer border of the first rib behind the mid clavicular point, where it becomes the axillary artery. This anatomical configuration of the subclavian artery may hinder direct digital pressure in most patients. On the other hand, the subclavian vein, which is a continuation of the axillary vein, starts at the outer border of the first rib and ends behind the corresponding sternoclavicular joint by joining the internal jugular vein to form the innominate vein (branchiocephalic). Prolonged arterial cannulation can result in thrombus formation, propagation, and possible stroke;21 therefore, expeditious intervention is necessary in order to avoid these dreaded complications. Treatment options should be tailored to each patient’s hemodynamic condition: site of arterial cannulation, underlying arterial disease, and the size of the inserted catheter. Our algorithm for treating inadvertent subclavian artery cannulation is illustrated in Figure 7. Balloon inflation is an efficient option that should be attempted in selected cases. Factors that may be considered are as follows: 1. 2. 3. 4.
Young patients Small healthy vessels Entry is far away from important branches Patient is hemodynamically stable
Factors that may contradict balloon inflation are as follows: 1. 2. 3. 4.
Calcified arterial wall Larger-sized arterial cannulas Patient is hemodynamically unstable Entry is near important branches
In a select group of patients, balloon inflation will control extravasation: prolonged inflation for 4 min is recommended and a repeat angiogram must be done to rule out any bleeding. A postoperative arterial duplex ultrasound is recommended at one and three months. Closure devices (Angio-seal, Perclose, and Starclose) are available and can be used judiciously, according to the catheter size and the clinician’s comfort zone. The Angio-seal VIP 6-Fr system (St. Jude Medical, Minnetonka, MN) is a device that creates a mechanical seal by sandwiching the site of the arteriotomy between a bio-absorbable anchor and a collagen sponge, which usually dissolves within two to three months.
The Perclose A-T 6-Fr SMC System (Abbott, Abbott Park, IL) closure device is designed to deliver a polyester suture to the arterial puncture site with one suture and two needles. Although other closure devices exist and, theoretically, can be used, our authors’ experience was exclusively with Perclose. Factors that may aid in intervention are: 1. Small arterial puncture (defined as less than 8 Fr.) 2. Minimal arterial wall calcifications 3. Straight path for the subcutaneous insertion without much kinking Factors that may contradict the use of a closure device are: 1. Large arterial puncture 2. Severe wall calcifications 3. Tortuous subcutaneous path An open surgical approach remains a valid option for repair of a subclavian arterial injury. The location of the arterial puncture dictates the surgical approach. If the injury occurs in the first part of artery, it will require either a left posterolateral thoracotomy or median thoracotomy. A supra-clavicular incision is appropriate for injuries that occur in the second and third parts of the subclavian artery. Counter-infraclavicular incisions may be required in selected cases. It is imperative to keep the tip of the closure device away from the aortic valve to prevent inadvertent injury.
Tips and tricks 1. Avoid using the subclavian vein, if possible 2. Avoid a low jugular vein stick, as this can contribute to more central arteries, such as innominate or subclavian arteries 3. Although arterial injury may still occur, ultrasound guidance21 is the safest approach to minimize inadvertent CVA insertion In conclusion, inadvertent central line placement is a significant complication with dreadful outcomes. Early diagnosis and prompt intervention are imperative. This case series offers a glimpse of possible therapies in some challenging scenarios.
Patient consent Appropriate consent was obtained from each patient.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
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Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Koklu E, Poyrazoglu H, Yikilmaz A, et al. Subclavian artery pseudoaneurysm: a rare and serious complication of central venous catheterization in an infant. Pediatr Radiol 2008; 38: 220–223. 2. Fletcher SJ and Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000; 85: 188–191. 3. Akmal AH, Hasan M and Mariam A. The incidence of complications of central venous catheters at an intensive care unit. Ann Thorac Med 2007; 2: 61–63. 4. Shah PM, Babu SC, Goyal A, et al. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: case for surgical management. J Am Coll Surg 2004; 198: 939–944. 5. Elihu A and Gollin G. Complications of implanted central venous catheters in neutropenic children. Am Surg 2007; 73: 1079–1082. 6. Shirotani N, Iino T, Numata K, et al. Complications of central venous catheters in patients on home parenteral nutrition: an analysis of 68 patients over 16 years. Surg Today 2006; 36: 420–424. 7. Savage AP, Picard M, Hopkins CC, et al. Complications and survival of multilumen central venous catheters used for total parenteral nutrition. Br J Surg 1993; 80: 1287–1290. 8. Kappers-Klunne MC and Degener JE. Complications from long-term indwelling central venous catheters, with special reference to infections. Neth J Med 1985; 28: 192–196.
9. Efsing HO, Lindblad B, Mark J, et al. Thromboembolic complications from central venous catheters: a comparison of three catheter materials. World J Surg 1983; 7: 419–423. 10. Thromboembolic complications and central venous catheters. Lancet 1982; 2: 936–937. 11. Adar R. Letter: potentially fatal complications of central venous catheters. Surgery 1976; 79: 726. 12. Walters MB, Stanger HA and Rotem CE. Complications with percutaneous central venous catheters. JAMA 1972; 220: 1455–1457. 13. Collier PE, Blocker SH, Graff DM, et al. Cardiac tamponade from central venous catheters. Am J Surg 1998; 176: 212–214. 14. Collier PE, Ryan JJ and Diamond DL. Cardiac tamponade from central venous catheters. Report of a case and review of the English literature. Angiology 1984; 35: 595–600. 15. Dane TE and King EG. Fatal cardiac tamponade and other mechanical complications of central venous catheters. Br J Surg 1975; 62: 6–10. 16. Freytes CO. Thromboembolic complications related to central venous access catheters in cancer patients. Semin Thromb Hemost 2007; 33: 389–396. 17. Lumb PD. Complications of central venous catheters. Crit Care Med 1993; 21: 1105–1106. 18. Grace DM. Air embolism with neurologic complications: a potential hazard of central venous catheters. Can J Surg 1977; 20: 51–53. 19. Adar R and Mozes M. Fatal complications of central venous catheters. Br Med J 1971; 3: 746. 20. Graham AS, Ozment C, Tegtmeyer K, et al. Videos in clinical medicine. Central venous catheterization. N Engl J Med 2007; 356: e21. 21. Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: case series, review and proposed algorithm. J Vasc Surg 2008; 48: 918–925.
Downloaded from vas.sagepub.com at University of Otago Library on October 17, 2015
