Vertebral Artery Pseudoaneurysm: A Rare Complication of Internal Jugular Vein Catheterization Hiroshi Aoki, MD, Toshiki Mizobe, and Yoshifumi Tanaka, PhD, MD

PhD, MD,

Shinnji Nozuchi,

MD,

Tetsuo Hatanaka, MD,

Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan

P

ercutaneous catheterization of the internal jugular vein is widely practiced for central venous access and flow-directed pulmonary artery catheter placement. This approach has many wellknown advantages over the subclavian route (1).It also has the potential for several critical complications, especially accidental arterial puncture. We report a case of vertebral artery pseudoaneurysm caused by internal jugular vein puncture.

Case Report A 72-yr-old man entered the hospital because of acute exacerbation of chronic obstructive pulmonary disease of 30-yr duration. On admission, analysis of arterial blood gases revealed pHa 7.42, Pao, 35.8 mm Hg, Paco, 63.9 mm Hg, and a base excess of -12.4 mEq/L while the patient was breathing room air, indicating the terminal stages of pulmonary insufficiency. On the following day, the patient developed circulatory shock with respiratory arrest and required cardiopulmonary resuscitation. To obtain central venous access, catheterization was attempted through the right internal jugular vein into the superior vena cava. Because arterial blood was aspirated on the first attempt with a 22-gauge needle, manual compression was begun, and the catheter was placed through the right femoral vein. That night, a hematoma was observed in the right neck region, along with a decrease in arterial blood pressure and hematocrit, requiring blood transfusion. The hematoma gradually enlarged over several days to the right scapular region, but conservative therapy was continued. On the 70th day, the patient complained of pain and numbness in the right shoulder extending to the forearm, suggesting compression of the brachial plexus Accepted for publication March 31, 1992. Address correspondence to Dr. Aoki, Department of Anesthesiology, Kyoto Prefectural University of Medicine, KawaramachiHirokoji, Kamikyo-Ku, Kyoto 602, Japan.

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by the hematoma. A computed tomography scan of the neck demonstrated a giant hematoma and compression of the internal jugular vein and trachea (Figure 1). Surgical removal of the hematoma was believed to be high risk in view of the severity of the pulmonary insufficiency (Pao, 40-80 mm Hg; Paco, 50-90 mm Hg; inspired 0, concentration [Fro,] 0.35-0.5, assisted by a respirator and synchronized intermittent mandatory ventilation mode) and the need for resuscitation several times. Digital subtraction angiography performed on the 104th day revealed a pseudoaneurysm, probably fed from the vertebral artery (Figure 2). Because the possibility of rupture was thought to be high, we believed that a surgical procedure was necessary despite the patient's poor general condition. The cardiovascular surgery staff was consulted, but the patient developed circulatory shock with a decrease in hematoait. Rupture of the pseudoaneurysm was suspected, and an emergency operation was therefore performed. When the pseudoaneurysm was opened and the hematoma removed, a jet of arterial blood was observed from a hole with a diameter of approximately 1 mm in the right vertebral artery. After clamping of the right subclavian artery, the site of hemorrhage was sutured and the operation completed (Figure 3). The procedure was relatively uncomplicated. The patient's general condition remained relatively stable in the intensive care unit using a respirator and catecholamines (Pao, 70-125 mm Hg; Paco, 40-80 mm Hg; FIO, 0.3-0.4), but his pulmonary insufficiency was exacerbated suddenly on the 11th postoperative day, and the patient died despite attempts at cardiopulmonary resuscitation.

Discussion Although the method of internal jugular vein catheterization introduced by English et al. (2) and Jernigan et al. (3) was thought to have few complications, various complications have been reported, including pneumo-, hydro-, and hemothorax caused by puncture of the pleura (4,5); chylothorax as the result of 01992 by the International Anesthesia Research Society

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Figure 1. Computed tomography scan of the neck showing giant hematoma (arrows) and compression of the internal jugular vein (enhanced) and trachea.

Figure 3. Photograph taken during the operation. The point of hemorrhage has been sutured (arrow) after removal of blood clot in the pseudoaneurysm.

Figure 2. Digital subtraction angiography showing pseudoaneurysm (arrows) fed from the vertebral artery.

thoracic duct injury (6); Horner’s syndrome, probably caused by compression by hematoma or direct needle injury (7); and hematoma at the puncture site (8). A case of fistula formation between the inferior thyroid artery and internal jugular vein (9) and a case of puncture of the ascending cervical artery (10) have also been reported. Because there are many arteries and veins in the neck region, undetected injuries of these vessels may occasionally occur. Moreover, because the vertebral artery is surrounded by a very rich network of veins, there are several reports of verte-

bral arteriovenous fistula (11-13). Most of these cases occurred after heart surgery with extracorporeal circulation; that is, systemic heparinization was performed after accidental injuries of arteries and probably caused and aggravated such complications. Amaral et al. (14) reported a case of vertebral artery pseudoaneurysm as a complication of subclavian vein catheterization. That case was described in a female patient who received total knee replacement because of an infected knee prosthesis. She seemed to have no hemorrhagic tendency. There was no evidence of disseminated intravascular coagulation, and systemic heparinization was never performed. Nevertheless, this hematoma occurred. Our patient also had no lack of capacity for hemostasis. These two cases suggest the possibility of complications with injury of the arteries, even in those with normal hemostasis and those who undergo common operations without systemic heparinization. The reason for this seems to be the anatomic construction of the vertebral artery. The vertebral artery arises as the first branch of the subclavian artery and courses cephalad between the

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of the vertebral artery. To avoid this complication, care should be taken not to insert the needle too deeply or penetrate the internal jugular vein. Moreover, it is important to exert sufficient manual compression on the puncture site to prevent serious complications at an early stage; however, the fact must be kept in mind that hemostasis by manual compression is anatomically difficult to achieve, as mentioned previously. In addition, because pseudoaneurysm differs from true aneurysm in that it lacks a specific three-layer structure (15),it enlarges progressively when left untreated and finally leads to rupture, as in our case. Thus, when a puncture of one of the arteries is strongly suspected and a large hematoma is created, intensive follow-up care, such as radiographic examination, computed tomography scanning, and angiography, should ensue.

References Figure 4. The anatomy of the neck region. IJ-V, internal jugular vein; EJ-V, external jugular vein; C-A, common carotid artery; V-A, vertebral artery; SC-A, subclavian artery; IT-A, inferior thyroid artery; AC-A, ascending cervical artery; M1, sternocleidomastoid muscle; M2, anterior scalene muscle; M3, medial scalene muscle; M4, posterior scalene muscle; Thy, thyroid gland. (Reprinted with permission from von Kahle W, Leonhardt H, Platzer W. Taschenatlas der Anatomie. Stuttgart: Georg Thierne Verlag, 1979, page 181, with some modifications.)

longus colli medially and the anterior scalene muscle laterally, following its ascent through the foramina of the transverse processes of C-6 to C-1. This extraspinous portion of the artery, approximately 4 cm, lies deeper than other vessels, and hemostasis is difficult to achieve by manual compression. The anatomy in this region of the neck is shown in Figure 4. The vertebral artery (V-A) lies slightly more medially and deeper than the internal jugular vein (IJ-V). Moreover, the internal jugular vein is also located adjacent to the common carotid artery (C-A) and crosses under the inferior thyroid artery (IT-A). The ascending cervical artery (AC-A) is often a branch of the inferior thyroid artery, with the junction situated on the anterior scalene muscle (M2) and beneath the internal jugular vein. Therefore, accidental injuries of these vessels may occur during attempts at internal jugular vein cannulation in the wrong direction and at the wrong depth. In our case, although puncture was of course performed by a well-trained operator, conditions were not favorable because it was performed during external chest compression. Therefore, the needle is thought to have been shifted slightly inward and deeper, resulting in the puncture

1. Defalque RJ. Percutaneous catheterization of the internal jugular vein. Anesth Analg 1974;53:116-21. 2. English ICW, Frew RM, Pigott JF, Zaki M. Percutaneous catheterisation of internal jugular vein. Anaesthesia 1969;24: 521-31. 3. Jemigan WR, Gardner WC, Mahr MM, Milburn JL. Use of the

internal jugular vein for placement of central venous catheter. Surg Gynecol Obstet 1970;1305204. 4. McGoon MD, Benedetto PW, Greene BM. Complication of percutaneous central venous catheterization: a report of two iases and review of the literature. Johns Hopkns Med J 1979;145:1-6. 5. Hopkins RB, Parkin CE. Hydrohemothorax following percutaneous internal jugular vein cannulation recognized by intravenous pyelography. Anesth Analg 1978;57507-11. 6 . Khalil KG, Parker FB, Mukherjee N, Webb WR. Thoracic duct injury. A complication of jugular vein catheterization. JAMA 1972;221:908-9. 7. Parikh RK. Homer's syndrome. A complication of percutaneous catheterisation of internal jugular vein. Anaesthesia 1972; 27:327-9. 8. Brown CS, Wallace CT. Chronic hematoma-a complication of percutaneous catheterization of the internal jugular vein. Anesthesiology 1976;45:368-9. 9. Ortiz J, Dean WF, Zumbro GL, Treasure RL. Arteriovenous fistula as a complication of percutaneous internal jugular vein catheterization: case report. Milit Med 1976;141:171. 10. Wisheart JD, Hassan MA, Jackson JW. A complication of percutaneous cannulation of the internal jugular vein. Thorax 1972;27496-9. 11. Piechowiak H, Buchels H, Ingrisch H, Hess H. AV-Fistel der arteria vertebralis: eine seltene Komplikation nach zentralvenoser Katheterisierung. Anaesthesist 1984;33:327-9. 12. Dodson T, Quindlen E, Crowell R, McEnany MT. Vertebral arteriovenous fistulas following insertion of central monitoring catheters. Surgery 1980;87343-6. 13. Baleriaux-Waha D, Jeanmart L, Brihaye J, Henneaux J. Traumatic arteriovenous fistulas of the vertebral artery. Neuroradiology 1976;11:83-5. 14. Amaral JF, Grigoriev VE, Dorfman GS, Carney WI. Vertebral artery pseudoaneurysm. A rare complication of subclavian artery catheterization. Arch Surg 1990;125:546-7. 15. Titus JL, Kim H. Blood vessels and lymphatics. In: Kissane JM, ed. Anderson's pathology. 8th ed. St. Louis: Mosby, 1985:707.

Vertebral artery pseudoaneurysm: a rare complication of internal jugular vein catheterization.

Vertebral Artery Pseudoaneurysm: A Rare Complication of Internal Jugular Vein Catheterization Hiroshi Aoki, MD, Toshiki Mizobe, and Yoshifumi Tanaka,...
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