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Ann Thorac Surg 1996;62:581-582
© 1996 The Society of Thoracic Surgeons

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Case Report

Complicated Right Subclavian Artery Pseudoaneurysm After Central Venipuncture

Department of Cardiovascular Surgery, Memorial Regional Heart Center, Houston, Texas

Accepted for publication February 27, 1996.

	Abstract

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Life-threatening complications of central venipuncture are rare. We report an unusual case of a patient in whom a large right subclavian pseudoaneurysm developed, causing pressure necrosis of the membranous trachea and esophagus, after right internal jugular vein cannulation. The patient underwent oversewing of the proximal and distal ends of the subclavian artery and primary tracheal repair. An esophageal leak that presented on the sixth postoperative day was treated by primary suture repair with proximal and distal diversion.

	Introduction

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Serious complications of central venous access occur in 0.4% to 9.9% of patients undergoing attempted central venipuncture [1]. These complications include local hematoma, pneumothorax, hemothorax, hydrothorax, central venous thrombosis, air embolism, and cardiac tamponade due to superior vena cava or right heart perforation [2–8]. Pseudoaneurysm formation of the great vessels and the right subclavian artery is rare in patients undergoing central venipuncture [9]. We report a case of a large right subclavian pseudoaneurysm that caused life-threatening pressure necrosis injuries to the patient's trachea and esophagus after central venipuncture.

A 67-year-old man underwent laparotomy and right hemicolectomy for a Duke's class C adenocarcinoma of the colon approximately 1 month before admission. His preoperative chest radiograph was normal at that time. Two weeks later, he underwent Port-A-Cath (Hoizon Medical Products, Atlanta, GA) placement via the right internal jugular vein at an outlying hospital to receive his adjuvant chemotherapy. Attempts at right subclavian and left subclavian venipuncture had been made but were unsuccessful. Two days before the patient's admission, hoarseness, hemoptysis, severe shortness of breath, and dysphagia developed. A computed tomographic scan of his chest without intravenous contrast revealed a large superior mediastinal mass located between the trachea and esophagus, causing significant intrathoracic tracheal compression (Fig 1). Upon transfer to our institution, attempts at arteriography and contrast-enhanced computed tomographic scan were unsuccessful because of the patient's severe dyspnea, stridor, and arterial desaturation in the supine position. Because relieving the patient's stridor became paramount, we took him to the operating room and performed fiberoptic nasotracheal intubation while he was awake and sitting. Approximately 200 mL of bright red hemoptysis was encountered after the tube was passed, but the hemoptysis resolved spontaneously.

View larger version (40K): [in this window] [in a new window]   Fig 1. . A limited computed tomographic scan of the patient's chest showed a large mass posterior to the trachea with impressive tracheal compression. The patient's dyspnea precluded a completely supine position during imaging.

The patient tolerated the procedure well and was extubated 6 hours after the operation. He was neurologically intact and able to breathe without difficulty, and he was able to eat regular food the following day. On the fifth postoperative day, food contents were noted in the patient's chest tube, and a Gastrografin (Squibb Diagnostic, Princeton, NJ) swallow confirmed an esophageal leak at the thoracic outlet. He underwent endotracheal intubation and reentrant thoracotomy through his previous incision. The pleural cavity was drained and irrigated. Primary suture repair of a 1-cm by 1-cm hole in his esophagus was performed with buttressing using a second viable intercostal muscle flap from his third intercostal space. Three well-positioned pleural drainage tubes were inserted. A decompressive gastrostomy and feeding jejunostomy were performed. A lateral cervical esophagostomy was created for partial proximal diversion.

Aggressive enteral feedings of 4,400 calories/day and intravenous antibiotics were administered. His esophageal leak recurred on the sixth postoperative day and was managed conservatively. It resealed on the 21st postoperative day, and administration of his antibiotics was discontinued after 30 days of total therapy. His chest tubes, gastric tube, and jejunal tube were slowly removed on an outpatient basis after he was discharged. His right arm systolic blood pressure is 40 mm Hg less than his left arm systolic blood pressure, but this has not caused him any symptoms. Three months after his injury, his cervical esophagostomy closed spontaneously and he is now eating regular food without difficulty. A new liver mass was noted on a subsequent restaging computed tomographic scan, and he is presently undergoing systemic chemotherapy for metastatic colon cancer.

	Comment

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Accidental arterial puncture has been estimated to occur in as many as 20% of central venous access attempts [6]. Most of these transpire without any inadvertent complications or harmful sequelae. Local hematoma can result from bleeding into subcutaneous tissue that stops spontaneously. Subclavian arterial bleeding through transected pleura may cause hemothorax that stops spontaneously or requires emergency arterial repair. An arterial laceration that is contained by mediastinal structures and parietal pleura may develop into a slowly enlarging pseudoaneurysm.

Preoperative evaluation of a patient with pseudoaneurysm formation of any great vessel would include arteriograms and probably a contrast-enhanced computed tomographic scan of the chest. Our patient's stridor precluded any additional diagnostic evaluation and led us to an inaccurate preoperative diagnosis of mediastinal hematoma because of the posterior location of the mass. Our choice of a right thoracotomy was serendipitous because we probably would have used a median sternectomy had we known that the mass was a pseudoaneurysm to facilitate proximal control. This would have left us unable to manage the sizable injury in his membranous trachea. We believe that the stridorous patient who requires management of a central venipuncture-related pseudoaneurysm with tracheal proximity should be approached through the appropriately sided thoracotomy to facilitate inspection of the trachea.

	Footnotes

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Address reprint requests to Dr Baldwin, Department of Cardiovascular Surgery, Memorial Regional Heart Center, 7737 Southwest Freeway, Suite 625, Houston, TX 77074-1880.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Borja AR, Masri Z, Shruck L, Pefo S. Unusual and lethal complications of infraclavicular subclavian vein catheterization. Int Surg 1972;57:42–5.[Medline]
2. McGoon MD, Benedetto PW, Greene BM. Complications of percutaneous central venous catheterization: a report of two cases and review of the literature. Johns Hopkins Med J 1979;145:1–6.[Medline]
3. Lefrak EA, Noon GP. Management of arterial injury secondary to attempted subclavian vein catheterization. Ann Thorac Surg 1972;14:294–8.[Medline]
4. Morgan RNW, Morrell DF. Internal jugular catheterization: a review of a potentially lethal hazard. Anaesthesia 1981;36:512–7.[Medline]
5. Feliciano DV, Mattox KL, Graham JM, Beall AC, Jordan GL. Major complications of percutaneous subclavian vein catheters. Am J Surg 1979;138:869–74.[Medline]
6. Meloni T, Carbonatto P, Rossi G, Aillon C, Marti G, Devoti G. Percutaneous embolization of subclavian pseudoaneurysmatic arteriovenous iatrogenic fistula by steel coils. J Cardiovasc Surg 1993;34:87–9.[Medline]
7. Barton BR, Hermann G, Weil R. Cardiothoracic emergencies associated with subclavian hemodialysis catheters. JAMA 1983;250:2660–2.[Abstract/Free Full Text]
8. Halldorsson A, Hunter GC, McIntyre KE, Bernhard VM. Internal mammary artery subclavian vein fistula following internal jugular vein catheterization: a case report and review of the literature. J Cardiovasc Surg 1991;32:376–9.[Medline]
9. Shield CF, Richardson JD, Buckley CJ, Hagood CO. Pseudoaneurysm of the brachiocephalic arteries: a complication of percutaneous internal jugular vein catheterization. Surgery 1975;78:190–4.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert T. Baldwin Michael W. Gallagher Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baldwin, R. T. Articles by Gallagher, M. W. Search for Related Content PubMed PubMed Citation Articles by Baldwin, R. T. Articles by Gallagher, M. W.