Flexible Subclavian Artery Closure for an Inadvertent Injury to the Internal Mammary Artery During Internal Jugular Vein Catheterization.

Central vein catheter (CVC) placement, which is widely utilized in clinical departments, is also highly important in preoperative preparations for radiofrequency catheter ablation (RFCA). The internal jugular vein or subclavian vein is the routine target. Arterial injury is not uncommon during the procedure but is potentially devastating in spite of the safety and advantages of the Seldinger technique. Compressing of the airway by a hematoma, as well as hemothorax, pseudoaneurysm, arteriovenous fistula, stroke, and even death, has been well-described.[1] Percutaneous interventional management of inadvertent arterial catheterization during central venous access has been recognized as the first-line treatment. Balloon tamponade, embolization, stent-graft placement, and dedicated percutaneous closure devices can be implemented depending on the type of lesion.[2] Here, we reported an instance of iatrogenic subclavian artery injury associated with the internal mammary artery (IMA) during internal jugular vein catheterization that was repaired using a general vascular closure device. An underweight 13-year-old boy was suffering from frequent premature ventricular contraction (PVC), and RFCA was suggested. All results of examinations and tests including X-rays and coagulation tests were negative. The internal jugular vein was targeted for the placement of ten-pole (mapping of the coronary sinus) due to underweight of the patient. No anomalies of the neck were detected in physical examination, and all vital landmarks were normal. The patient was lying still with his neck sufficiently tilted to the left, and the triangle consisting of the sternocleidomastoid and clavicle was completely exposed. After local infiltration anesthesia, a syringe was used as finder needle to obliquely penetrate the skin toward the right nipple until blood was aspirated. An alternative 18-gauge introducer needle (Radifocus®, Introducer II, Terumo, Tokyo, Japan) was positioned at the same site with a similar angle and direction. Dark red, nonpulsatile blood was aspirated, and a loach guide wire was smoothly inserted through the introducer, the tip of which was observed at the shadow of inferior vena cava (IVC) in the anteroposterior view. The introducer was advanced routinely along with the wire to its full length to verify the right vessel, and no bright or pulsatile blood was observed. A 6-F Terumo catheter (Radifocus®, Introducer II, Terumo, Tokyo, Japan) was completely inserted. Coronary sinus electrode placement failed, and the re-placed wire had obviously deviated from heart shadow in the left anterior oblique view and the right lateral view [Figure ​[Figure1a1a and ​and1b].1b]. At this time, we realized that an artery or the lung might have been catheterized. Given the stable hemodynamics, another internal jugular vein puncture was completed via the advancement of the guide wire through the right femoral vein [Figure 1c], and a similar catheter was inserted. RFCA of the PVC was completed with the mistakenly placed catheter in position. Fortunately, the patient did not complain of discomfort during the procedure. The contrast medium was injected through the former catheter, and an arteriole was observed instead of contrast dispersion [Figure 1d]. Another contrast injection showed that the IMA had been catheterized after slightly withdrawing the catheter [Figure 1e]. The catheter was carefully removed, and local compression was applied for hemostasis while the wire remained in place. After approximately 15 min of manual compression, no diffuse swelling was noted at the base of the right side of the neck. To prevent undetectable hemostasis, flexible subclavian artery closure was performed with a vascular closure device (Angio-Seal™ VIP, St. Jude Medical, MN, USA) after the wire moved into the subclavian artery [Figure 1f]. No obvious swelling was noted on the right side of the neck during the 1st day after the operation. The patient remained stable and was discharged on the 3rd day after the operation without any sequelae. No further abnormalities were observed after 3-month follow-up. Figure 1 The re-advanced loach wire after the coronary sinus electrode placement failure was out of the shadow of SVC in LAO (a) and in front of the heart in RL (b). A guide J-type wire through right femoral vein was advanced to internal jugular vein for puncture ... Although complications associated with CVC are relatively rare, they tend to be fatal and devastating with significant morbidity and mortality.[3] The majority of devastating complications of arterial injuries described in the literature were reported in the carotid or vertebral arteries and resulted from the use of large-bore catheters.[1] These complications rarely occur in small caliber arteries such as the IMA. However, IMA pseudoaneurysms have been reported after subclavian line placements or internal jugular catheterization.[4] This unique location coupled with the dynamic motion of the chest wall and the relative lack of surrounding supporting tissue creates an ideal environment for the growth and possible rupture of a pseudoaneurysm arising from the IMA. Both surgical repair and endovascular coiling are optimal treatment options for pseudoaneurysms. However, this may be the first presentation of IMA-mediated subclavian artery injury during internal jugular vein catheterization. Whether the IMA was helpful or harmful to the subclavian artery injury in this case was difficult to determine. Although dark and nonpulsatile blood was detected, the 18-gauge introducer needle (Radifocus®, Introducer II, Terumo, Tokyo, Japan), which is the finest introducer needle available, might have penetrated the superior wall of subclavian artery and reached the ostium of the IMA [Figure 1g], which allowed the smooth loach guide wire to possibly reach the IMA; the tip of the wire appeared in the shadow of the IVC in the anteroposterior oblique view. The introducer was advanced into the IMA and thus failed to avoid the artery due to the low pressure inside, ultimately leading to a mistaken catheterization. The IMA may have caused this complication, but severe consequences to the subclavian artery, such as lacerations, and pseudoaneurysms, were avoided. Given its simplicity and convenience, a vascular closure device is designed for superficial and straight arteries. Luckily, the right subclavian artery was successfully closed after the wire was pulled into the venous cavity to prevent an undetected hemorrhage. Although various methods were applied to ensure the correct catheterization procedure, including multiple fluoroscopic visualizations of the position and blood color verification, accidental catheterization regretfully occurred because the IMA was located opposite to the penetration point. Randomized controlled trials[5] have indicated that real-time ultrasound guided venipuncture of the internal jugular vein has a higher first insertion attempt success rate, reduced access time, higher overall successful cannulation rate, and decreased the rate of arterial puncture compared to the landmark-guided technique. Although, real-time ultrasound guidance is highly recommended, the high cost of this technique prohibits its use. Financial support and sponsorship This study was supported by grants from Science and Technology Planning Project of Guangdong Province, China (No. 2013B021800323) and the Popular Science Project of Haizhu District, Guangzhou, Guangdong, China (No. 2014HZKP-TJ-13). Conflicts of interest There are no conflicts of interest.