Successful bleeding control by a combined conventional surgical approach and video-assisted surgery: a case report.

The use of central venous catheters (CVCs) nowadays is a routine practice in the treatment of severely acute-diseased children. However, the procedure still carries a risk of morbidity, and severe complications are reported. When respiratory and/or hemodynamic instability develop after the procedure, prompt patient evaluation to exclude iatrogenic damage is mandatory, regardless of the primary patient condition. If a vascular injury related to CVC placement procedure is detected, the availability of an interventional radiologist and/or any surgical facilities plays an important role in the management of this life-threatening complication. We report the case of a 12-year-old boy hospitalized in the Pediatric Intensive Care Unit of our hospital for a severe motorveicle accident, who, about 30 minutes from the percutaneous CVC placement, developed tachycardia, hypoxemia, and hypotension. A chest X-ray confirmed the right positioning of the catheter, the presence also of a large left hemothorax. Interventional radiology took place, but it failed to stop the bleeding. Urgent anterolateral thoracotomy was performed while the patient was kept in a supine position because of a cervical spine luxation. During surgery, bleeding was found coming from the thoracic dome and because of a tear next to the left subclavian artery. Access to that area was technically difficult; after blood and clots were removed, multiple attempts to obtain the hemostasis failed, and definitive control of the hemorrhage was achieved only by video-assisted thoracic surgery (VATS). The postoperative period was uneventful. In this study, the authors discuss the management of this kind of complication and the value of a combined surgical approach (conventional, with a minimal access surgery procedure such as VATS) in the treatment of thoracic vascular injuries related to the insertion of a percutaneous CVC. To the best of our experience, this is the first time in which this combination of procedures has been reported in the literature.