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Ministernotomy repair of inadvertent proximal right subclavian artery injury following right internal jugular central venous catheter insertion
  1. Myat Soe Thet1,
  2. Jimmy Kyaw Tun2,
  3. Aung Ye Oo1 and
  4. Ana Lopez-Marco1
  1. 1Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
  2. 2Department of Interventional Radiology, The Royal London Hospital, London, UK
  1. Correspondence to Myat Soe Thet; myatsoe.thet{at}nhs.net

Abstract

A man in his 60s was referred for urgent coronary artery bypass grafting (CABG) procedure following acute coronary syndrome. After induction of general anaesthesia, right jugular venous catheterisation under two-dimensional ultrasound guidance was planned as part of perioperative management. While obtaining vascular access, the pulsatile flow was noted once the dilator was inserted, having to abandon the procedure and immediately apply manual pressure. CT angiogram showed proximal right subclavian artery injury with active contrast extravasation and resultant large haematoma in the neck. The patient underwent urgent exploration of the injured vessel through a J-shaped ministernotomy, and primary repair of the artery was performed. The patient recovered from the procedure without any complications. He continued to stay in the hospital for a few days, afterwards, he underwent the initially planned CABG surgery. He was discharged home on day 5 after surgery without further concerns.

  • Anaesthesia
  • Cardiothoracic surgery
  • Vascular surgery

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Background

Central venous catheters are necessary for monitoring as well as administration of medical therapy. For cardiac surgery, they are routinely placed in a central vein, usually the right jugular vein, after induction of anaesthesia. Placement of central venous catheters, however, is not without risks such as mechanical, infectious and thrombotic complications.1

The risk of arterial injury following central venous catheter placements is less than 1%.2 Commonly injured arteries include carotid, subclavian, brachiocephalic, vertebral arteries and the aorta. Management of the arterial injury differs from patient to patient depending on the extent of injury, the artery involved and the demographics and comorbidities of the patients.

Case presentation

A man in his 60s, previously fit and well, was referred to our cardiac surgery unit for myocardial revascularisation after the diagnosis of three-vessel coronary artery disease presenting with an acute coronary syndrome about a week earlier. His medical history included hepatitis B, for which he has been on antiviral treatment with undetectable viral load, non-insulin dependent type II diabetes mellitus and hypertension. He was scheduled for an urgent coronary artery bypass grafting (CABG) procedure. As part of the routine perioperative monitoring, catheterisation of the right internal jugular vein was performed in the Trendelenburg position after the induction of general anaesthesia.

A 5-lumen 9.5 Fr 12.5 cm catheter (multicath5expert, Vygon) was planned to be inserted in the right internal jugular vein, using two-dimensional (2D) ultrasound guidance (out-of-plane view) and Seldinger technique with an 18 gauge × 70 mm needle. The procedure was performed by a senior anaesthetist, and venous back bleeding was achieved with the first attempt. A nitinol 0.88 mm × 600 mm guide wire was easily passed through the needle and a 10 Fr × 100 mm dilator was also introduced easily over the guidewire. However, after removal of the guidewire, the pulsatile flow was noted through the dilator, and arterial pressure trace was confirmed by manometry. The dilator was then removed, and the site was compressed with manual external pressure since it was thought to be a puncture of the right carotid artery. Due to the concerns of increased risk of bleeding after the mandatory systemic heparinisation required for cardiopulmonary bypass, the cardiac procedure was postponed.

A CT angiogram was performed to evaluate the arterial injury. This demonstrated a through and through injury to the right subclavian artery just proximal to the vertebral artery, internal mammary artery and thyrocervical trunk. There was evidence of a small amount of active bleeding at the entry site and a small pseudoaneurysm at the exit site, with associated extensive surrounding haematoma. In addition, there was a non-occlusive focal dissection flap in the subclavian artery proximal to the entry site (figure 1A,B).

Figure 1

(A,B) Maximum intensity projection in the oblique coronal plane and 3D reconstruction of the CT angiogram demonstrate through and through injury of the first part of the right subclavian artery (arrow) just proximal to the thyrocervical trunk and vertebral artery. 3D, three dimensions.

Given the sizeable haematoma and location of the injury, further control with manual compression was not possible. Due to the close proximity of the vertebral and internal mammary artery, endovascular stent grafting was also not possible, especially given that the patient required a CABG. Therefore, following a multidisciplinary discussion involving cardiothoracic surgeons, vascular surgeons, neuroradiologists and anaesthetists, the decision was made to perform surgical exploration and repair of the right subclavian artery.

The procedure was performed through a right J-shaped ministernotomy. Tissues were dissected proximally to expose the innominate vein, brachiocephalic artery (innominate artery), right carotid artery and right subclavian artery. Slings were placed around the individual vessels. A bleeding point with surrounding haematoma was identified posteriorly on the proximal part of the right subclavian artery. A primary repair with two 5–0 pledgeted polypropylene sutures was performed with care to avoid luminal narrowing (figure 2). Once satisfied with haemostasis, a 16F Redivac drain was left in place before the closure of the mini-sternotomy with stainless steel sternal wires. Subcutaneous tissue was closed in layers using 2–0 vicryl sutures and skin was closed with a 5–0 monocryl suture in a subcuticular manner. The patient was transferred back to the intensive care unit in a stable condition, where he was extubated in the next following hours. The schematic diagram of the procedure is demonstrated in figure 3A,B (Both figures are illustrated by the first author, MST).

Figure 2

Intraoperative image showing repair of the right subclavian artery.

Figure 3

(A,B) Schematic diagram of J-shaped ministernotomy and repair of the injured right subclavian artery with pledgeted sutures. (The figure is illustrated by the first author, MST).

Once the patient was fully awake, we informed him of the complication he suffered and the need for additional surgery, following the duty of candour. He understood and was grateful for the care received. No complaints were made.

The patient recovered without any clinical signs of complications, and the redivac drain was removed after 2 days following minimal drainage. He had a repeat CT angiogram to reassess the repair of the right subclavian artery, which was satisfactory. He underwent the initially planned CABG surgery with completion of median sternotomy after 5 days of the right subclavian artery repair and recovered without any further complications, being discharged from the hospital on day 5 after the CABG surgery. The timeline of events is described in figure 4 (The timeline is illustrated by the first author, MST).

Figure 4

The timeline of events. (The timeline is illustrated by the first author, MST).

Outcome and follow-up

The patient attended a routine follow-up clinic 6 weeks after discharge. He was found to have a small left pleural effusion, which was managed with oral diuretics. He was physically well without any symptoms. At the 3-month follow-up clinic appointment, a repeated chest X-ray showed no pleural effusion. He also had a follow-up CT angiogram, which showed no significant changes since the initial right subclavian artery repair, and he was discharged from the surgical clinic.

Discussion

Traditionally, anatomical landmarks are used for guiding central venous catheter insertion. However, the use of ultrasound reduces the rate of arterial injury by more than 70% and since has become the standard of care in central venous catheter insertions.3 National Institute for Health and Care Excellence (NICE) guidelines in 2002 recommended the use of 2D ultrasound as the preferred method for central venous catheter insertion, and all involved in those procedures should undertake appropriate training.4 Multiple puncture attempts increase arterial injury with a 54% failure rate after two attempts.5 Nevertheless, our presented case demonstrates that despite the use of ultrasound by an experienced physician and a clean puncture in the vein, insertion of a central venous catheter could still lead to inadvertent arterial injury. We believe the needle initially placed in the right internal jugular vein, might have been inadvertently advanced to the close right subclavian artery, where the guidewire and dilator were ultimately placed.

Although no definite guideline exists for the management of arterial injury following central venous catheter insertion, proposed algorithms of management have been previously published in the literature.6 7 Manual external compression, endovascular intervention and open surgical exploration are the three main choices for treatment, either alone or combined. If the central venous catheter is already inserted, it is generally recommended to leave the central venous catheter in situ until the intervention.

The choice of intervention is usually open surgical exploration if the site of injury is surgically accessible and the patient is a surgical candidate. Balloon tamponade, percutaneous closure devices and covered stents are used for endovascular intervention in surgically inaccessible erratic sites of injury. Manual external compression is usually combined with surveillance angiographic imaging and has the highest overall failure and complication rates including stroke, pseudoaneurysms and arterial dissections.6 7

Injuries of the subclavian artery can be accessed via different approaches (ie, sternotomy, thoracotomy, subclavicular or supraclavicular incisions, as well as endovascular approach) depending on the location of the injury, relationship to neighbouring structures and any further planned incisions. Many of the patients with subclavian artery injury had an endovascular repair. Percutaneous closure devices are the most commonly reported form of endovascular intervention, balloon tamponade and covered stents being the other modalities. The complication rate for percutaneous closure devices is 4%, balloon tamponade carries 4.8% and covered stents have a complication rate of 12.1%.7 The main complications include stroke, arterial dissection, pseudoaneurysm, occlusion of the artery.

Open surgical repair of the subclavian artery has been reported previously, although in limited numbers, without any complications.6 8–11 The repair is usually performed through standard median sternotomy or thoracotomy. Additionally, open surgical repair may be considered as a bailout option when endovascular intervention fails. There have been successful reports of open surgical repair after failed balloon tamponade, embolisation and covered stents.7 12 13 In our case, due to the location of the injury, an endovascular approach was not a suitable option as it would have covered the origin of the vertebral artery.

We report a case of subclavian artery repair through a J-shaped ministernotomy. Ministernotomy approach, compared with traditional median sternotomy, tends to have a shorter hospital stay, less 24-hour chest tube drainage, less coagulopathy and better cosmetic results.14 In the past, a malpositioned haemodialysis catheter in the brachiocephalic artery has been successfully removed and the artery was repaired using a limited upper sternotomy approach, as well.15 Therefore, the ministernotomy approach to subclavian and brachiocephalic arteries is both feasible and safe with appropriate expertise.

However, the benefit of the ministernotomy was limited in this case, as a full sternotomy was required for his CABG operation. We abandoned the initially planned CABG procedure at the time of initial arterial injury due to concerns of bleeding-related complications considering the need for systemic heparinisation to maintain cardiopulmonary bypass. Proceeding with cardiac surgery in these patients could lead to major catastrophic bleeding resulting in death.16

In cases of proximal subclavian artery injury following central venous catheters, urgent surgical and endovascular consultation should be sought. Through a multidisciplinary approach, the choice of treatment may differ depending on the extent of injury, anatomy of the vessels, and expertise of the specialists involved.

A rare and challenging case of the right subclavian artery injury repair following central venous catheter insertion is presented. The case highlights the feasibility of proximal subclavian artery injury repair through a ministernotomy approach without any complications.

Learning points

  • Despite the use of two-dimensional (2D) ultrasound guidance, inadvertent arterial injury during central venous catheter insertion can still occur.

  • Routine use of 2D ultrasound by appropriately trained operators and avoiding more than two attempts can potentially reduce the risk of arterial injury during central venous catheter insertion.

  • Once the arterial injury is suspected, prompt imaging and discussion with the surgical team are very important to achieve the best outcome.

  • Right subclavian artery injury can safely be repaired using the ministernotomy approach in centres with appropriate expertise.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors MST: data acquisition, writing—original draft, review and editing, final approval. JKT: data acquisition, writing—review and editing, final approval. AYO: supervision, writing—review and editing, fInal approval. AL-M: data acquisition, writing—review and editing, supervision, final approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.