© 2014 Wiley Periodicals, Inc.
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SURGICAL TECHNIQUE ___________________________________________________________
Type A Aortic Dissection: A Rare Complication of Central Venous Catheter Placement Masaki Tsukashita, M.D., Ph.D., Abe DeAnda, M.D., and Leora Balsam, M.D. Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York ABSTRACT Aortic injury during central venous catheter (CVC) insertion is an extremely rare complication. We report successful repair of an iatrogenic type A aortic dissection caused during mediport catheter insertion and discuss the prevention and management of aortic injury during CVC placement. doi: 10.1111/jocs.12300
(J Card Surg 2014;29:368–370) Approximately six million central venous catheters (CVCs) are inserted every year in the United States. Complications associated with CVC insertion include pneumothorax, arterial injury, venous perforation, air embolism, infection, nerve injury, hemothorax, and cardiac tamponade.1 We report successful surgical repair of an iatrogenic type A aortic dissection associated with CVC insertion and review previously reported cases of aortic complications. Because iatrogenic aortic injury can be lethal, thorough knowledge of prevention and management of aortic injury is crucial. SURGICAL TECHNIQUE A 73-year-old female with anal squamous cell cancer underwent attempted mediport catheter placement for chemotherapy at an outside hospital. The left external jugular vein was accessed by surgical cut-down, but a guidewire could not be advanced. Several attempts to access the left subclavian vein via an infraclavicular approach of the left subclavian vein were unsuccessful, so a supraclavicular puncture was performed. After several needle punctures, blood was drawn. The backflow was not pulsatile. A guidewire was inserted through the needle and a 10 Fr Peel-Apart sheath introducer (Bard Access Systems, Inc., Salt Lake City, Utah, USA) with a dilator was inserted. At this point, arterial placement of the catheter was suspected because of pulsatile backflow. Angiography demon-
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Abe DeAnda, M.D., Department of Cardiothoracic Surgery, New York University School of Medicine, New York, NY. Fax: þ1-212-263-3842; e-mail: [email protected]
strated a Stanford type A aortic dissection (Fig. 1). The catheter was left in place and the patient was transferred to our hospital for emergent surgery. On arrival, the patient was hemodynamically stable and neurologically intact. Upon median sternotomy and pericardiotomy, aneurysmal dilatation, and bluish discoloration of the ascending aorta were noted, as depicted in Figure 2. There was only scant blood in pericardial cavity. The catheter entered the transverse arch between the origins of the left carotid artery and the left subclavian artery and exited the posterior wall of the ascending aorta. Under deep hypothermic circulatory arrest, the ascending aorta was opened. The catheter was removed and the catheter entry site was repaired with a pledgetted suture from outside the aorta. The intimal tear of the dissection, which occurred at the catheter exit site, was resected. BioGlue1 (CryoLife, Inc., Georgia, Atlanta, USA) was used to reconstruct the aortic wall and a hemiarch replacement was performed with a 22 mm GelweaveTM tube graft (Vascutek Ltd, Terumo, Somerset, New Jersey, USA). The patient’s postoperative course was complicated by transient left-sided weakness and heparin-induced thrombocytopenia. She was discharged to a rehabilitation facility on postoperative day 16. A postoperative computer tomographic scan demonstrated that the left internal jugular vein was hypoplastic or atretic. Her longterm outcome was excellent, and the patient was discharged home after rehabilitation. Institutional review board permission was not needed. COMMENT Arterial injury is a rare complication of CVC insertion. Inadvertent arterial puncture with a small needle during CVC placement ranges from 4.2% to 9.3% in reported
J CARD SURG 2014;29:368–370
Figure 1. Angiography demonstrating a Stanford type A aortic dissection. Contrast was infused through the mediport catheter.
series.2 Large-bore arterial perforation or cannulation of the carotid or subclavian artery during CVC insertion occurs in 0.1% to 1% of cases.3 Aortic injury is an even rarer complication. Eleven cases have been reported in the literature; aortic dissection was present in one and resulted in death.4 PREVENTION OF AORTIC INJURY DURING CVC INSERTION The traditional method for avoiding large bore arterial puncture is to observe the color and pulsatility of blood
TSUKASHITA, ET AL. IATROGENIC TYPE A AORTIC DISSECTION
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coming from the needle hub before placement of the guidewire and catheter. However, the American Society of Anesthesiologist’s guideline for CVC placement states that color and pulsatility are not reliable for distinguishing vein from artery.5 Ultrasound guidance and pressure monitoring have been suggested as practical and more reliable alternatives. A retrospective analysis of 9348 CVC placements over a 15-year period in a single institution demonstrated that 0.8% of CVC attempts resulted in arterial punctures that were not recognized by color and pulsatility, but that all arterial punctures were recognized by measuring pressure.6 In the present case, neither ultrasound guidance nor pressure monitoring was utilized during CVC placement, and absence of pulsatile backflow was misinterpreted as an evidence of proper venous puncture. Kusminsky3 summarized risk factors of CVC complications: number of needle passes, physician inexperience, body mass index (BMI) >30 or
368
SURGICAL TECHNIQUE ___________________________________________________________
Type A Aortic Dissection: A Rare Complication of Central Venous Catheter Placement Masaki Tsukashita, M.D., Ph.D., Abe DeAnda, M.D., and Leora Balsam, M.D. Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York ABSTRACT Aortic injury during central venous catheter (CVC) insertion is an extremely rare complication. We report successful repair of an iatrogenic type A aortic dissection caused during mediport catheter insertion and discuss the prevention and management of aortic injury during CVC placement. doi: 10.1111/jocs.12300
(J Card Surg 2014;29:368–370) Approximately six million central venous catheters (CVCs) are inserted every year in the United States. Complications associated with CVC insertion include pneumothorax, arterial injury, venous perforation, air embolism, infection, nerve injury, hemothorax, and cardiac tamponade.1 We report successful surgical repair of an iatrogenic type A aortic dissection associated with CVC insertion and review previously reported cases of aortic complications. Because iatrogenic aortic injury can be lethal, thorough knowledge of prevention and management of aortic injury is crucial. SURGICAL TECHNIQUE A 73-year-old female with anal squamous cell cancer underwent attempted mediport catheter placement for chemotherapy at an outside hospital. The left external jugular vein was accessed by surgical cut-down, but a guidewire could not be advanced. Several attempts to access the left subclavian vein via an infraclavicular approach of the left subclavian vein were unsuccessful, so a supraclavicular puncture was performed. After several needle punctures, blood was drawn. The backflow was not pulsatile. A guidewire was inserted through the needle and a 10 Fr Peel-Apart sheath introducer (Bard Access Systems, Inc., Salt Lake City, Utah, USA) with a dilator was inserted. At this point, arterial placement of the catheter was suspected because of pulsatile backflow. Angiography demon-
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Abe DeAnda, M.D., Department of Cardiothoracic Surgery, New York University School of Medicine, New York, NY. Fax: þ1-212-263-3842; e-mail: [email protected]
strated a Stanford type A aortic dissection (Fig. 1). The catheter was left in place and the patient was transferred to our hospital for emergent surgery. On arrival, the patient was hemodynamically stable and neurologically intact. Upon median sternotomy and pericardiotomy, aneurysmal dilatation, and bluish discoloration of the ascending aorta were noted, as depicted in Figure 2. There was only scant blood in pericardial cavity. The catheter entered the transverse arch between the origins of the left carotid artery and the left subclavian artery and exited the posterior wall of the ascending aorta. Under deep hypothermic circulatory arrest, the ascending aorta was opened. The catheter was removed and the catheter entry site was repaired with a pledgetted suture from outside the aorta. The intimal tear of the dissection, which occurred at the catheter exit site, was resected. BioGlue1 (CryoLife, Inc., Georgia, Atlanta, USA) was used to reconstruct the aortic wall and a hemiarch replacement was performed with a 22 mm GelweaveTM tube graft (Vascutek Ltd, Terumo, Somerset, New Jersey, USA). The patient’s postoperative course was complicated by transient left-sided weakness and heparin-induced thrombocytopenia. She was discharged to a rehabilitation facility on postoperative day 16. A postoperative computer tomographic scan demonstrated that the left internal jugular vein was hypoplastic or atretic. Her longterm outcome was excellent, and the patient was discharged home after rehabilitation. Institutional review board permission was not needed. COMMENT Arterial injury is a rare complication of CVC insertion. Inadvertent arterial puncture with a small needle during CVC placement ranges from 4.2% to 9.3% in reported
J CARD SURG 2014;29:368–370
Figure 1. Angiography demonstrating a Stanford type A aortic dissection. Contrast was infused through the mediport catheter.
series.2 Large-bore arterial perforation or cannulation of the carotid or subclavian artery during CVC insertion occurs in 0.1% to 1% of cases.3 Aortic injury is an even rarer complication. Eleven cases have been reported in the literature; aortic dissection was present in one and resulted in death.4 PREVENTION OF AORTIC INJURY DURING CVC INSERTION The traditional method for avoiding large bore arterial puncture is to observe the color and pulsatility of blood
TSUKASHITA, ET AL. IATROGENIC TYPE A AORTIC DISSECTION
369
coming from the needle hub before placement of the guidewire and catheter. However, the American Society of Anesthesiologist’s guideline for CVC placement states that color and pulsatility are not reliable for distinguishing vein from artery.5 Ultrasound guidance and pressure monitoring have been suggested as practical and more reliable alternatives. A retrospective analysis of 9348 CVC placements over a 15-year period in a single institution demonstrated that 0.8% of CVC attempts resulted in arterial punctures that were not recognized by color and pulsatility, but that all arterial punctures were recognized by measuring pressure.6 In the present case, neither ultrasound guidance nor pressure monitoring was utilized during CVC placement, and absence of pulsatile backflow was misinterpreted as an evidence of proper venous puncture. Kusminsky3 summarized risk factors of CVC complications: number of needle passes, physician inexperience, body mass index (BMI) >30 or
