Journal of Clinical Neuroscience xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Inadvertent subclavian artery cannulation treated by percutaneous closure José E. Cohen a,b,⇑, J. Moshe Gomori b, Haim Anner c, Eyal Itshayek a a
Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel Department of Endovascular Neurosurgery and Interventional Neuroradiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel c Department of Vascular Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel b
a r t i c l e
i n f o
Article history: Received 13 April 2014 Accepted 21 April 2014 Available online xxxx Keywords: Hemorrhage Iatrogenic cannulation Stent graft Subclavian artery Vascular closure device
a b s t r a c t Accidental arterial puncture occurs in around 1% and 2.7% of jugular and subclavian approaches, respectively. When a line has been inadvertently inserted into an artery at a noncompressible site, there is an increased risk for serious complications. This complication can be treated by either surgical or endovascular intervention or a combination; however, in critically ill patients or in those with impaired coagulation, therapeutic options are more limited. We describe successful endovascular management of inadvertent subclavian artery cannulation during insertion of a triple lumen central line catheter in a 35-year-old man suffering from leukemia, with sepsis and multi-organ failure. He was hypotensive and hemodynamically unstable, with severe coagulopathy. The catheter had entered the artery at the level of the origin of the internal mammary artery, just above the origin of the vertebral artery. The tip was lying in the aortic arch. The artery was successfully closed by endovascular deployment of an 8 French Angio-Seal device (St. Jude Medical, St. Paul, MN, USA). The device is licensed for use in femoral arterial puncture sites but provided safe and effective closure of the subclavian artery puncture in our patient. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Internal jugular vein and subclavian vein catheterizations are commonly performed procedures [1], with inadvertent puncture of the subclavian artery representing an uncommon but potentially fatal complication [1–3]. This complication can be treated by either surgical, endovascular or combined methods. However, in critically ill patients or in those with impaired coagulation, therapeutic options are more limited. We report a case of accidental subclavian artery cannulation successfully managed by percutaneous closure.
2. Case presentation A 35-year-old man suffering from leukemia was admitted to the intensive care unit with sepsis and multi-organ failure. The patient was hypotensive and hemodynamically unstable, and developed a severe thrombocytopenia in addition to a previously diagnosed chronic coagulopathy. A triple lumen central line catheter was introduced via a right subclavian approach. Inadvertent subclavian ⇑ Corresponding author. Tel.: +972 2 677 7092; fax: +972 2 641 6281. E-mail address: [email protected] (J.E. Cohen).
artery cannulation was not immediately recognized and only suspected after a routine chest radiograph was obtained. This showed that the catheter was projected to the left of the intended position, consistent with an inadvertent arterial insertion (Fig. 1A). The patient was brought to the neuroendovascular suite for catheter removal. Under ultrasound guidance, a 4 French (Fr) introducer sheath was placed in the right femoral artery and a vertebral catheter was placed proximal to the origin of the right subclavian artery. Diagnostic angiogram demonstrated that the catheter entered the artery at the level of the origin of the internal mammary artery, just above the origin of the vertebral artery, with the tip lying in the aortic arch (Fig. 1B, C). Measurement of the subclavian artery, the precise entrance of the catheter into the subclavian artery, and the relationship to the origin of the vertebral artery and internal mammary artery were evaluated. The vertebral catheter was left at the origin of the right vertebral artery. The catheter in this location preserved access across the subclavian artery, which would allow a subclavian stent to be deployed in the event of failure of the closure device (Angio-Seal device; St. Jude Medical, St. Paul, MN, USA). An already selected balloon-mounted stent was available for bailout use. A 50 cm (0.035 inch) Amplatz guidewire (Boston Scientific, Boston, MA, USA) was inserted into the catheter (Fig. 1D). The inadvertently
http://dx.doi.org/10.1016/j.jocn.2014.04.009 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Cohen JE et al. Inadvertent subclavian artery cannulation treated by percutaneous closure. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2014.04.009
2
J.E. Cohen et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
A
B
D
C
E
Fig. 1. (A) Anterior-posterior (AP) chest radiograph showing abnormal position of the right subclavian line. (B) Radioscopic image of the right subclavian line entering the aortic arch. A vertebral catheter was placed at the origin of the subclavian artery. (C) Selective angiogram of the right subclavian artery shows the relationship between the catheter site and the vertebral and mammary arteries. (D) Radioscopic image after Amplatz guidewire (Boston Scientific, Boston, MA, USA) insertion into the catheter line before its exchange for the Angio-Seal device (St. Jude Medical, St. Paul, MN, USA). (E) Angiogram obtained immediately after deployment of the closure device shows no signs of active hemorrhage or pseudoaneurysm, and preservation of the major arteries.
placed subclavian artery catheter was then removed and an 8 Fr Angio-Seal device was deployed over the guide wire. Subclavian artery angiographic images obtained from the catheter placed via the femoral artery showed no extravasation of contrast from the subclavian artery at the site of the Angio-Seal deployment, confirming procedural success (Fig. 1E). 3. Discussion Accidental arterial puncture occurs in around 1% and 2.7% of jugular and subclavian approaches, respectively [4,5]. This complication is usually recognized immediately; however, in hypotensive and hemodynamically unstable patients this can be more difficult to detect due to the lack of characteristic pulsatile flow. When a line has been inadvertently inserted into an artery at a compressible site, this can be safely managed by removal and manual compression. However, if line removal is attempted at a noncompressible site, there is an increased risk for serious complications, including active hemorrhage, pseudoaneurysm formation, arterial dissection or occlusion, and distal embolism. Inadvertent subclavian artery line insertion can be treated by surgical or endovascular techniques, or a combination of these approaches. Critically ill patients and patients with coagulopathy are poor surgical candidates, and they also present more limited endovascular options. Use of a stent-graft is a good alternative in selected patients, although the implant requires specific anatomic conditions and
the administration of antiplatelet agents. The lateral aspects of the subclavian artery are prone to compression between the clavicle and the first rib and stent fractures have been described at these locations [6]. In the medial section of the subclavian artery, the risk of occluding the vertebral artery with potential impact on the vertebrobasilar supply, the risk of occluding the inferior mammary artery, and the proximity of more proximal major trunks must be considered. In our patient, the line pierced the subclavian artery in close relation to the origin of the right vertebral artery; thus, a stent-graft would irremediably cover the arterial origin. We were concerned about the adequacy of the vertebrobasilar supply after occlusion of the large caliber vertebral artery in a patient with limited primary collateral supply. Furthermore, the patient presented severe coagulopathy that precluded the safe use of antiplatelet agents required after stent graft implant. Percutaneous closure devices have been used to close arterial punctures in both emergency and elective scenarios. The AngioSeal device used in this case is licensed for use in femoral arterial puncture sites, where it has been demonstrated to be both safe and effective [7,8]. However, this device has been already used ‘‘off label’’ in transbrachial artery access with similar good results [9] and recently, for inadvertent subclavian arterial punctures in a wide range of line diameters [10–12]. In our case, the closure device proved to be a simple, rapid, effective, and safe option in a debilitated patient with severe coagulopathy and thus limited surgical or endovascular options. The advantages of this approach in
Please cite this article in press as: Cohen JE et al. Inadvertent subclavian artery cannulation treated by percutaneous closure. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2014.04.009
J.E. Cohen et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
comparison to stent-graft implant prompted us, as well as others [11], to reconsider this as the method of choice. Further experience with this and other specifically designed percutaneous closure devices will determine the definite role of these devices in the management of inadvertent subclavian artery punctures. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Mansfield PF, Hohn DC, Fornage BD, et al. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735–8. [2] Conces DJ Jr, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293–5. [3] Kilbourne MJ, Bochicchio GV, Scalea T, et al. Avoiding common technical errors in subclavian central venous catheter placement. J Am Coll Surg 2009;208:104–9.
3
[4] Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med 2006;21:40–6. [5] Iovino F, Pittiruti M, Buononato M, et al. Central venous catheterization: complications of different placements. Ann Chir 2001;126:1001–6. [6] Phipp LH, Scott DJ, Kessel D, et al. Subclavian stents and stent-grafts: cause for concern? J Endovasc Surg 1999;6:223–6. [7] Antonsen L, Jensen LO, Thayssen P. Outcome and safety of same-day-discharge percutaneous coronary interventions with femoral access: a single-center experience. Am Heart J 2013;165:393–9. [8] Looby S, Keeling AN, McErlean A, et al. Efficacy and safety of the angioseal vascular closure device post antegrade puncture. Cardiovasc Intervent Radiol 2008;31:558–62. [9] Lupattelli T, Clerissi J, Clerici G, et al. The efficacy and safety of closure of brachial access using the AngioSeal closure device: experience with 161 interventions in diabetic patients with critical limb ischemia. J Vasc Surg 2008;47:782–8. [10] Ananthakrishnan G, White RD, Bhat R, et al. Inadvertent subclavian artery cannulation: endovascular repair using a collagen closure device-report of two cases and review of the literature. Case Rep Vasc Med 2012;2012:150343. [11] Bangard C, Chang DH, Libicher M, et al. Misplacement of central venous catheters in the subclavian artery: safe retrieval with a percutaneous closure device (AngioSeal). Rofo 2013;185:546–9. [12] Sobrinho G, Ribeiro K, Albino JP. Delayed percutaneous closure of the subclavian artery after inadvertent placement of a hemodialysis catheter. J Vasc Access 2012;13:266.
Please cite this article in press as: Cohen JE et al. Inadvertent subclavian artery cannulation treated by percutaneous closure. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2014.04.009
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Inadvertent subclavian artery cannulation treated by percutaneous closure José E. Cohen a,b,⇑, J. Moshe Gomori b, Haim Anner c, Eyal Itshayek a a
Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel Department of Endovascular Neurosurgery and Interventional Neuroradiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel c Department of Vascular Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel b
a r t i c l e
i n f o
Article history: Received 13 April 2014 Accepted 21 April 2014 Available online xxxx Keywords: Hemorrhage Iatrogenic cannulation Stent graft Subclavian artery Vascular closure device
a b s t r a c t Accidental arterial puncture occurs in around 1% and 2.7% of jugular and subclavian approaches, respectively. When a line has been inadvertently inserted into an artery at a noncompressible site, there is an increased risk for serious complications. This complication can be treated by either surgical or endovascular intervention or a combination; however, in critically ill patients or in those with impaired coagulation, therapeutic options are more limited. We describe successful endovascular management of inadvertent subclavian artery cannulation during insertion of a triple lumen central line catheter in a 35-year-old man suffering from leukemia, with sepsis and multi-organ failure. He was hypotensive and hemodynamically unstable, with severe coagulopathy. The catheter had entered the artery at the level of the origin of the internal mammary artery, just above the origin of the vertebral artery. The tip was lying in the aortic arch. The artery was successfully closed by endovascular deployment of an 8 French Angio-Seal device (St. Jude Medical, St. Paul, MN, USA). The device is licensed for use in femoral arterial puncture sites but provided safe and effective closure of the subclavian artery puncture in our patient. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Internal jugular vein and subclavian vein catheterizations are commonly performed procedures [1], with inadvertent puncture of the subclavian artery representing an uncommon but potentially fatal complication [1–3]. This complication can be treated by either surgical, endovascular or combined methods. However, in critically ill patients or in those with impaired coagulation, therapeutic options are more limited. We report a case of accidental subclavian artery cannulation successfully managed by percutaneous closure.
2. Case presentation A 35-year-old man suffering from leukemia was admitted to the intensive care unit with sepsis and multi-organ failure. The patient was hypotensive and hemodynamically unstable, and developed a severe thrombocytopenia in addition to a previously diagnosed chronic coagulopathy. A triple lumen central line catheter was introduced via a right subclavian approach. Inadvertent subclavian ⇑ Corresponding author. Tel.: +972 2 677 7092; fax: +972 2 641 6281. E-mail address: [email protected] (J.E. Cohen).
artery cannulation was not immediately recognized and only suspected after a routine chest radiograph was obtained. This showed that the catheter was projected to the left of the intended position, consistent with an inadvertent arterial insertion (Fig. 1A). The patient was brought to the neuroendovascular suite for catheter removal. Under ultrasound guidance, a 4 French (Fr) introducer sheath was placed in the right femoral artery and a vertebral catheter was placed proximal to the origin of the right subclavian artery. Diagnostic angiogram demonstrated that the catheter entered the artery at the level of the origin of the internal mammary artery, just above the origin of the vertebral artery, with the tip lying in the aortic arch (Fig. 1B, C). Measurement of the subclavian artery, the precise entrance of the catheter into the subclavian artery, and the relationship to the origin of the vertebral artery and internal mammary artery were evaluated. The vertebral catheter was left at the origin of the right vertebral artery. The catheter in this location preserved access across the subclavian artery, which would allow a subclavian stent to be deployed in the event of failure of the closure device (Angio-Seal device; St. Jude Medical, St. Paul, MN, USA). An already selected balloon-mounted stent was available for bailout use. A 50 cm (0.035 inch) Amplatz guidewire (Boston Scientific, Boston, MA, USA) was inserted into the catheter (Fig. 1D). The inadvertently
http://dx.doi.org/10.1016/j.jocn.2014.04.009 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Cohen JE et al. Inadvertent subclavian artery cannulation treated by percutaneous closure. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2014.04.009
2
J.E. Cohen et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
A
B
D
C
E
Fig. 1. (A) Anterior-posterior (AP) chest radiograph showing abnormal position of the right subclavian line. (B) Radioscopic image of the right subclavian line entering the aortic arch. A vertebral catheter was placed at the origin of the subclavian artery. (C) Selective angiogram of the right subclavian artery shows the relationship between the catheter site and the vertebral and mammary arteries. (D) Radioscopic image after Amplatz guidewire (Boston Scientific, Boston, MA, USA) insertion into the catheter line before its exchange for the Angio-Seal device (St. Jude Medical, St. Paul, MN, USA). (E) Angiogram obtained immediately after deployment of the closure device shows no signs of active hemorrhage or pseudoaneurysm, and preservation of the major arteries.
placed subclavian artery catheter was then removed and an 8 Fr Angio-Seal device was deployed over the guide wire. Subclavian artery angiographic images obtained from the catheter placed via the femoral artery showed no extravasation of contrast from the subclavian artery at the site of the Angio-Seal deployment, confirming procedural success (Fig. 1E). 3. Discussion Accidental arterial puncture occurs in around 1% and 2.7% of jugular and subclavian approaches, respectively [4,5]. This complication is usually recognized immediately; however, in hypotensive and hemodynamically unstable patients this can be more difficult to detect due to the lack of characteristic pulsatile flow. When a line has been inadvertently inserted into an artery at a compressible site, this can be safely managed by removal and manual compression. However, if line removal is attempted at a noncompressible site, there is an increased risk for serious complications, including active hemorrhage, pseudoaneurysm formation, arterial dissection or occlusion, and distal embolism. Inadvertent subclavian artery line insertion can be treated by surgical or endovascular techniques, or a combination of these approaches. Critically ill patients and patients with coagulopathy are poor surgical candidates, and they also present more limited endovascular options. Use of a stent-graft is a good alternative in selected patients, although the implant requires specific anatomic conditions and
the administration of antiplatelet agents. The lateral aspects of the subclavian artery are prone to compression between the clavicle and the first rib and stent fractures have been described at these locations [6]. In the medial section of the subclavian artery, the risk of occluding the vertebral artery with potential impact on the vertebrobasilar supply, the risk of occluding the inferior mammary artery, and the proximity of more proximal major trunks must be considered. In our patient, the line pierced the subclavian artery in close relation to the origin of the right vertebral artery; thus, a stent-graft would irremediably cover the arterial origin. We were concerned about the adequacy of the vertebrobasilar supply after occlusion of the large caliber vertebral artery in a patient with limited primary collateral supply. Furthermore, the patient presented severe coagulopathy that precluded the safe use of antiplatelet agents required after stent graft implant. Percutaneous closure devices have been used to close arterial punctures in both emergency and elective scenarios. The AngioSeal device used in this case is licensed for use in femoral arterial puncture sites, where it has been demonstrated to be both safe and effective [7,8]. However, this device has been already used ‘‘off label’’ in transbrachial artery access with similar good results [9] and recently, for inadvertent subclavian arterial punctures in a wide range of line diameters [10–12]. In our case, the closure device proved to be a simple, rapid, effective, and safe option in a debilitated patient with severe coagulopathy and thus limited surgical or endovascular options. The advantages of this approach in
Please cite this article in press as: Cohen JE et al. Inadvertent subclavian artery cannulation treated by percutaneous closure. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2014.04.009
J.E. Cohen et al. / Journal of Clinical Neuroscience xxx (2014) xxx–xxx
comparison to stent-graft implant prompted us, as well as others [11], to reconsider this as the method of choice. Further experience with this and other specifically designed percutaneous closure devices will determine the definite role of these devices in the management of inadvertent subclavian artery punctures. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Mansfield PF, Hohn DC, Fornage BD, et al. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735–8. [2] Conces DJ Jr, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293–5. [3] Kilbourne MJ, Bochicchio GV, Scalea T, et al. Avoiding common technical errors in subclavian central venous catheter placement. J Am Coll Surg 2009;208:104–9.
3
[4] Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med 2006;21:40–6. [5] Iovino F, Pittiruti M, Buononato M, et al. Central venous catheterization: complications of different placements. Ann Chir 2001;126:1001–6. [6] Phipp LH, Scott DJ, Kessel D, et al. Subclavian stents and stent-grafts: cause for concern? J Endovasc Surg 1999;6:223–6. [7] Antonsen L, Jensen LO, Thayssen P. Outcome and safety of same-day-discharge percutaneous coronary interventions with femoral access: a single-center experience. Am Heart J 2013;165:393–9. [8] Looby S, Keeling AN, McErlean A, et al. Efficacy and safety of the angioseal vascular closure device post antegrade puncture. Cardiovasc Intervent Radiol 2008;31:558–62. [9] Lupattelli T, Clerissi J, Clerici G, et al. The efficacy and safety of closure of brachial access using the AngioSeal closure device: experience with 161 interventions in diabetic patients with critical limb ischemia. J Vasc Surg 2008;47:782–8. [10] Ananthakrishnan G, White RD, Bhat R, et al. Inadvertent subclavian artery cannulation: endovascular repair using a collagen closure device-report of two cases and review of the literature. Case Rep Vasc Med 2012;2012:150343. [11] Bangard C, Chang DH, Libicher M, et al. Misplacement of central venous catheters in the subclavian artery: safe retrieval with a percutaneous closure device (AngioSeal). Rofo 2013;185:546–9. [12] Sobrinho G, Ribeiro K, Albino JP. Delayed percutaneous closure of the subclavian artery after inadvertent placement of a hemodialysis catheter. J Vasc Access 2012;13:266.
Please cite this article in press as: Cohen JE et al. Inadvertent subclavian artery cannulation treated by percutaneous closure. J Clin Neurosci (2014), http:// dx.doi.org/10.1016/j.jocn.2014.04.009
