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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 181-184

Superior vena cava perforation complicating ultrasound-guided subclavian venous catheterization: A case report


1 Department of Anesthesiology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
2 Department of Thoracic Surgery, School of Medicine, Ondokuz Mayis University, Samsun, Turkey

Date of Submission06-Aug-2020
Date of Acceptance03-Nov-2020
Date of Web Publication25-Sep-2021

Correspondence Address:
Dr. Cengiz Kaya
Department of Anesthesiology, School of Medicine, Ondokuz Mayis University, Kurupelit, Samsun Tr55139
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_139_20

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   Abstract 


We present a case of a severe mechanical complication (superior vena cava [SVC] perforation) that developed after subclavian vein catheterization using an ultrasound-guided static approach in a patient who underwent right lower lobectomy with video-assisted thoracic surgery. The use of ultrasound during catheterization is reported to reduce mechanical complications. Despite the use of ultrasound in our patient, surgical exploration showed that the catheter placed in the right subclavian vein penetrated the superior portion of the SVC. At the end of the surgery, the catheter was removed under direct visualization. The surgeon attempted to stop bleeding in the SVC by compressing with gauze. However, bleeding could only be stopped by administering a hemostatic matrix. It is concluded that to reduce the incidence or size of iatrogenic perforation of the SVC, catheters with the smallest possible diameter should be used, and the dilator should only be inserted deep enough to enter the vein. If the static approach is used, the modifiedSeldinger technique is useful and to provide training to improve the ultrasound experience, especially if the dynamic approach is used.

Keywords: Case report, central venous catheterization, adverse effects, risk management, superior vena cava


How to cite this article:
Kaya C, Beldagli M, Celik B. Superior vena cava perforation complicating ultrasound-guided subclavian venous catheterization: A case report. Int J Crit Illn Inj Sci 2021;11:181-4

How to cite this URL:
Kaya C, Beldagli M, Celik B. Superior vena cava perforation complicating ultrasound-guided subclavian venous catheterization: A case report. Int J Crit Illn Inj Sci [serial online] 2021 [cited 2021 Nov 28];11:181-4. Available from: https://www.ijciis.org/text.asp?2021/11/3/181/326595




   Introduction Top


Complications related to central venous catheterization can be classified as mechanical and nonmechanical.[1],[2] The incidence of mechanical complications (pneumothorax, major vascular injury, hemothorax, cardiac tamponade, and nerve injury) ranges from 1.4% to 18%, and include vascular injuries of varying degree which may at times be life-threatening.[1],[3]

The use of an ultrasound (US)-guided technique reduces the incidence of mechanical complications.[1],[2],[4],[5] US guidance can be based on static or dynamic approaches. In the static approach, the skin entry site is marked following the imaging of the vessel to be entered, and catheterization is performed as in the landmark method. By contrast, in the dynamic approach, US is used throughout the process, from skin entry to the placement of the guidewire.[5],[6]

This case report presents a very rare severe mechanical complication (superior vena cava [SVC] perforation) that developed in a patient who underwent subclavian vein catheterization through the US-guided static approach.

The patient provided consent for publication of the case report and the related images. This manuscript adheres to the EQUATOR Network guideline for case reports.


   Case Report Top


A 73-year-old woman with suspected lung malignancy was planned to undergo right lower lobectomy with video-assisted thoracic surgery. The preoperative evaluation revealed a history of hypertension and goiter, with normal blood tests (blood cell count, routine biochemistry, and coagulation profile). Computed tomography showed two nodules (0.4–0.6 cm) in the lower lobe of the right lung. She was informed about all potential risks, and she provided consent for all procedures.

At our hospital, we routinely perform subclavian vein catheterization on the ipsilateral side of the surgery for patients undergoing lobectomy. After the administration of general anesthesia, the patient was placed in the supine position, with the ipsilateral arm abducted at 45° for right subclavian vein catheterization. Under strict aseptic conditions, the introducer needle of the catheter kit (triple lumen, 7Fr, ARROW®, Teleflex, USA) was slowly forwarded to the sternal notch.[4] After the aspiration of dark-colored venous blood from the target vein, the guidewire was forwarded through the needle without any resistance for a distance of 14–15 cm. When the US short-axis plane indicated that the guidewire had penetrated the anterior wall of the vein, the entire dilator (10 cm) was inserted along the guidewire. Finally, the catheter was inserted into the vein over the guidewire to a depth of 12 cm.

Surgery was performed with the patient in the left lateral decubitus position. One-lung ventilation was instituted, and a subsequent surgical exploration revealed that the central catheter placed in the right subclavian had pierced through the posterior wall of the subclavian vein, moved inside the thoracic cavity, and penetrated the superior portion of the SVC [Figure 1] and [Figure 2]. Although the catheter tip was within the vascular compartment, the fluid infusions through the catheter were stopped. Subsequent fluid management was administered using large-diameter intravascular cannulas in the peripheral vessels. At the end of the surgery, the catheter was removed under direct visualization. The surgeon attempted to stop bleeding from the SVC by compressing with gauze but eventually had to resort to the administration of a hemostatic matrix (FloSeal®, Baxter, Switzerland) [Figure 3]. The patient remained hemodynamically stable during the surgery and did not require transfusion. The patient was extubated after surgery without any complications and was followed up postoperatively in close communication with the surgical team. She made an uneventful recovery and was discharged on the fifth postoperative day.
Figure 1: Schematic illustration of superior vena cava puncture. (a), the right lung was collapsed before the catheter was inserted. (b), the catheter penetrates the subclavian vein and enters the superior vena cava. Image in (c) is magnified image of the regions highlighted in (b)

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Figure 2: Following video-assisted thoracoscopic exploration, we noticed that the catheter penetrated the right subclavian vein, moved through the thoracic cavity, and entered the superior vena cava. Right subclavian vein; catheter; superior vena cava; phrenic nerve

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Figure 3: Under direct visualization, the catheter was removed, and bleeding from the residual puncture site could not be stopped by compressing with gauze and could only be stopped with the administration of a hemostatic matrix (FloSeal®, Baxter, Switzerland; dotted line area

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   Discussion Top


This case report demonstrates that even with the use of US during central vein catheterization, major vascular injuries can still occur. SVC perforation is a rare but significant complication of central vein catheterization occurring in 0.2%–0.5% of cases.[1],[7] Perforation can be caused by many instruments, including the introducer needle, guidewire, dilator, or even the catheter itself.[6] Guidewires can be responsible for perforation and can also lead to laceration of the vein by dilators or the catheter when they are placed in close proximity to the posterior wall of the vessel.[4]

The diameter of dilators and catheters is a particularly important risk factor for vascular perforation. The catheter becomes more rigid as the diameter increases, thereby increasing the probability of perforation.[7] One study reported that the use of ≥6 Fr catheters increases the risk of SVC perforation. Therefore, the use of catheters with the smallest possible diameter is recommended.[8]

Dilators carry perhaps the highest risk of vascular damage because they are very rigid and cannot always be guided by the guidewire inside the vein. When dilators are forced in too deeply, they can easily perforate major vascular structures or right-sided cardiac chambers. Therefore, the dilator should not be advanced too far, and the advance should be stopped if any resistance is encountered.[6] In retrospect we realized that the treating the entire dilator (8.5 Fr, 10 cm) into the vein, and this had most likely been the cause of the perforation.

A static or dynamic approach can be used with US guidance. Of the two, the dynamic approach has a higher overall success rate and a lower mechanical complication rate.[5] However, this approach requires considerable training to gain sufficient experience. If the static approach is chosen, the use of the modified Seldinger technique (a “guide sheath-over-the-needle” technique), in place of the Seldinger technique, may reduce the incidence of complications. In the Seldinger technique, the guidewire is advanced through the needle. By contrast, the modified Seldinger technique (which is not used in our clinic) uses a guidewire needle covered by a guiding sheath; the needle is first pulled back and then advanced through the guiding sheath.[6],[9]

Regardless of the technique used, after the guidewire has been placed in a static approach, the dilator should be placed when US confirms that the guidewire has moved through the vessel and has not penetrated the posterior wall. We have no fluoroscope in our clinic; therefore, we routinely use ultrasonography to trace the intravascular course of the guidewire. For this purpose, the US probe should be gently moved from the guidewire entry site to the heart along the clavicle, and the guidewire should be displayed in the short-axis plane.[6] In our case, the view in the short-axis plane showed that the guidewire had penetrated the anterior wall and entered the vein during the procedure, but the guidewire could not be traced to the heart along the clavicle. We believe that our inadequate experience with the use of US in subclavian vein catheterization may have played a significant role in the development of this complication because subclavian vein puncture under US guidance has been reported to have high success rates and low incidence of complications only with experienced practitioners.[10]

In conclusion, the incidence or size of iatrogenic perforation of the SVC could be reduced by choosing catheters with the smallest possible diameter and by advancing the dilator only deep enough to enter the vein. If a static approach is chosen, the modified Seldinger technique is useful and to provide adequate training and repeated performance of the procedure to improve the US experience, especially if the dynamic approach is used.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to not require Institutional Review Board/Ethics Committee review.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Björkander M, Bentzer P, Schött U, Broman ME, Kander T. Mechanical complications of central venous catheter insertions: A retrospective multicenter study of incidence and risks. Acta Anaesthesiol Scand 2019;63:61-8.  Back to cited text no. 1
    
2.
Lamperti M, Bodenham AR, Pittiruti M, Blaivas M, Augoustides JG, Elbarbary M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med 2012;38:1105-17.  Back to cited text no. 2
    
3.
Kornbau C, Lee K, Hughes G, Firstenberg M. Central line complications. Symposium -ICU & trauma procedure complication. Int J Crit Illn Inj Sci 2015;5:170-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Central line catheters and associated complications: A review. Cureus 2019;11:e4717.  Back to cited text no. 4
    
5.
Sazdov D, Srceva MJ, Todorova ZN. Comparative analysis of ultrasound guided central venous catheterization compared to blind catheterization. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2017;38:107-14.  Back to cited text no. 5
    
6.
Safety Committee of Japanese Society of Anesthesiologists. Practical guide for safe central venous catheterization and management 2017. J Anesth 2020;34:167-86.  Back to cited text no. 6
    
7.
Abdelkefi A, Ben Gaied O, Ladeb S, Labbène I, Torjman L, Lakhal A, et al. Perforation of the superior vena cava after subclavian catheterization: A rare complication after autologous PBSCT. Bone Marrow Transplant 2009;43:891-2.  Back to cited text no. 7
    
8.
Mukau L, Talamini MA, Sitzmann JV. Risk factors for central venous catheter-related vascular erosions. J Parenter Enteral Nutr 1991;15:513-6.  Back to cited text no. 8
    
9.
Ivar Seldinger S. Catheter replacement of the needle in percutaneous arteriography: A new technique. Acta Radiol 2008;49:47-52.  Back to cited text no. 9
    
10.
Jiang L, Zhang M, Ma Y. Ultrasound-guided subclavian vein catheterization: A systematic review and meta-analysis: Several facts need to be noticed. Crit Care Med 2015;43:e474-5.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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