Ann Thorac Surg 1996;62:895-896
© 1996 The Society of Thoracic Surgeons
Case Report
Percutaneous Tamponade of Inadvertent Transthoracic Catheterization of the Aorta
Eric M. Walser, MD,
Wayne N. Crow, MD,
Joseph B. Zwischenberger, MD,
Vincent R. Conti, MD
Division of Cardiothoracic Surgery, Departments of Radiology and Surgery, The University of Texas Medical Branch, Galveston, Texas
Accepted for publication March 28, 1996.
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Abstract
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During routine placement of a subclavian central venous catheter for cancer chemotherapy, a sheath was inadvertently placed into the aortic arch, through the left lung. We describe a technique for transthoracic compression of the aortic injury using the sheath in conjunction with an occlusion balloon catheter.
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Introduction
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A 59-year-old woman with metastatic ovarian and breast carcinoma was admitted for placement of a central venous catheter for chemotherapy.
In the operating room, the attending physician decided to insert a left subclavian central venous catheter and the left subclavian fossa was palpated and punctured with an 18-gauge needle. Upon blood return, the tract was dilated with a 10F sheath/introducer combination. Immediately upon removal of the dilator and guidewire, pulsatile blood return was observed and a pressure recording from the sheath indicated a left ventricular waveform. A portable chest roentgenogram clearly showed that the sheath had transgressed the left lung and entered the aortic arch directly (Fig 1
).
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Fig 1.. Portable chest roentgenogram obtained in the operating room. A sheath enters anteriorly in the left second intercostal space and passes through the lung, into the arch. The tip of the sheath is in the left ventricle.
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The cardiothoracic surgeons (J.B.Z., V.R.C.) were immediately consulted and concluded that the patient was a poor candidate for a major thoracic operation due to her debilitated state. Therefore, we elected to attempt percutaneous tamponade of the aortic puncture. After making precautionary preparations for a left thoracotomy, we placed a guidewire through the sheath into the left ventricle. The dilator was removed and a 7F balloon occlusion catheter (Meditech, Watertown, MA) was inserted, through the sheath, into the aorta. Under fluoroscopic guidance, the balloon catheter was pulled back until it was flush with the sheath tip. Both catheter and sheath were then withdrawn until blood no longer returned from the sheath. The sheath was further withdrawn over the catheter, exposing the balloon, which was then inflated with contrast solution. The sheath/balloon combination was then pushed against the external aortic wall for 20 minutes. This duration was chosen on the basis of our standard 15-minute groin compression for hemostasis after femoral arterial catheterization. The sheath was left in place to act as a stiff "pusher" to oppose the balloon firmly against the aorta. During this maneuver, the patient remained hemodynamically stable and periodic fluoroscopy confirmed the balloon's direct contact with the aortic wall (Fig 2). As a final step, the balloon was deflated and the patient was observed for another 20 minutes before the catheter was removed.
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Fig 2. . (A) Fluoroscopic image from the operating room. A balloon occlusion catheter is flush to the aortic wall. The guidewire remains in the aorta. (B) Method of balloon tamponade of the aortic puncture site. The rigid sheath around the catheter permits the operator to push the balloon firmly against the aortic wall.
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Surprisingly, no postprocedure pneumothorax was observed fluoroscopically or on a chest roentgenogram obtained after arrival to the intensive care unit. Pleural adhesions likely prevented any significant lung collapse. Minimal mediastinal and apical subpleural hemorrhage was evident, however. To minimize mediastinal bleeding, vasodilators were given to maintain mild hypotension (100 mm Hg systolic) during the procedure and for 6 hours afterward. The patient remained asymptomatic during 12 hours of observation in the intensive care unit, and, 2 days later, a tunneled jugular vein catheter was placed uneventfully.
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Comment
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Radiotherapy and previous operations can distort the anatomy in an area where venous cannulation is attempted [1]. In our patient, the thorax was so scarred by bilateral mastectomies and radiation therapy that the anterior portion of the second rib was mistaken for the head of the clavicle, and the needle entered the chest far inferior to the subclavian vein location. Radiotherapy-induced pericardial and mediastinal adhesions increase the complexity and bleeding complications of thoracotomy or sternotomy [2] and made this patient a poor surgical candidate. On the contrary, these adhesions probably contributed to the success of our percutaneous procedure as periaortic fibrotic tissue prevented hemorrhagic dissection around the occlusion balloon and through various mediastinal tissue planes. As such, this procedure may fail in patients who have not undergone thoracic radiation or previous operation in the chest and they are better candidates for operative management.
The most common complications of elective subclavian central line placement include pneumothorax (2% to 6%) [3–5] and inadvertent subclavian artery puncture (1.0% to 1.5%) [4, 5]. Significant hemorrhage from accidental subclavian artery puncture is rare as needle or catheter removal and manual compression control bleeding in almost all patients. A 10F hole in the aortic arch, on the other hand, requires surgical or percutaneous closure. Because no direct pressure can be applied to the ascending aorta, we chose "indirect" compression using the sheath/balloon combination described. Transfemoral, catheter-directed embolization was not considered an option due to the risk of "losing" embolic materials in the thoracic aorta, leading to peripheral or cerebral embolization. In addition, it is unlikely that these embolic materials would tamponade the aortic bleeding without a mature catheter tract (2 or more weeks old) to hold them in place. Achieving successful hemostasis with this method of temporary balloon occlusion requires either a mature tract to inflate the balloon within or some sort of rigid "pusher" to maintain direct occlusion of the vessel injury. Other important determinants of success include the absence of a bleeding diathesis and the use of vasodilators that facilitate hemostasis. This procedure should not be undertaken without surgical backup, for obvious reasons.
In conclusion, we have described a method of controlling hemorrhage after inadvertent sheath placement in the ascending aorta, where no direct compression is possible. Using the sheath as a firm "pusher," an occlusion balloon was pressed against the aortic puncture to effect hemostasis. This method may be useful in other cases where an incompressible artery has been mistakenly catheterized.
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Footnotes
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Address reprint requests to Dr Walser, UTMB-Department of Radiology, 301 University Blvd, Galveston, TX 77555-0709.
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References
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- Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian vein catheterization. N Engl J Med1994;331:1735–8.[Abstract/Free Full Text]
- Nkere UU, Whawell SA, Sarraf CE, Schofield JB, Thompson JN, Taylor KM. Perioperative histologic and ultrastructural changes in the pericardium and adhesions. Ann Thorac Surg1994;58:437–44.[Abstract]
- Bo-Lin GW, Anderson DJ, Anderson KC, McGoon MD. Percutaneous central venous catheterization performed by medical house officers: a prospective study. Cathet Cardiovasc Diagn1982;8:23–9.[Medline]
- Christensen KH, Nerstrom B, Baden H. Complications of percutaneous catheterization of the subclavian vein in 129 cases. Acta Chir Scand1967;133:615–20.[Medline]
- Herbst CA. Indications, management, and complications of percutaneous subclavian catheters. Arch Surg1978;113:1421–5.[Abstract/Free Full Text]
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