Perforation into the pericardial sac of an infant: a rare complication of central venous catheter insertion.

Editor,

Cardiac tamponade following insertion of a central venous (CV) catheter is a rare but recognised complication associated with a high mortality rate, that was addressed recently in a circular from the Department of Health, Social Services and Public Safety in Northern Ireland (1). We report a case of CV line perforation into the pericardium that was diagnosed early by a simple contrast study.

A male neonate was born by elective Caesarean section following an antenatal diagnosis of exomphalos major. During a stormy in-patient course, a left-sided subclavian line (SCL) was inserted on day 33 of life. In the hours that followed, the patient’s left arm and face were noted to be “puffy”. The SCL was documented to be flushing easily but not bleeding back; its use was discontinued and a “linogram” contrast study requested [Fig. 1]. Contrast was seen outlining the central great vessels and the superior aspect of the pericardial sac. A follow-up chest radiograph showed layering of contrast within the pericardial sac, outlining the heart [Fig. 2]. An echocardiogram demonstrated a small pericardial effusion.

Fig 1.

“Linogram” study. Water-soluble contrast has been injected into the left subclavian line. The contrast extravasates from the line tip outlining the central great vessels and the superior aspect of the pericardial sac.

Fig 2.

Follow up chest radiograph after removal of the left subclavian line and insertion of a new right-sided internal jugular vein catheter. Contrast is seen filling the pericardial sac, outlining the heart.

The infant gradually recovered from his surgeries over the next weeks and was discharged at 3 months.

DISCUSSION

Complication rates for CV catheter insertion vary between studies depending upon the puncture site. Earlier studies reported rates of up to 6% for infra-clavicular subclavian line insertion (2), with the rate of complication being less for those operators with greater experience (3,4).

In the described case, no problems at the time of line insertion were recorded in the patient’s operative notes, and an immediate chest radiograph showed a catheter that appeared to be well placed. A subsequent contrast study showed the line tip to have perforated into the pericardial sac; a complication that is associated with a significant mortality rate due to the risks of cardiac tamponade if the problem is not recognised and fluid infusions via the line continue (5). In 2009, a circular from the Department of Health in Northern Ireland highlighted the risks of CV line insertion. It followed a review after a patient died from cardiac tamponade due to a perforated right atrium, as a complication of CV line insertion. Whilst late perforation may be caused by the catheter tip eroding through the vein or chamber wall (2), early tamponade was thought more likely due to the dilator used to assist line placement. The Department counselled that dilators should not be inserted to the hilt over the guide wire, but should only be inserted far enough to open the vein puncture site. Moreover, cardiac tamponade should be considered if a patient clinically deteriorates soon after CV catheter placement. In the infant described, the line had been in situ for only a few hours before problems became apparent, and its use was immediately halted. This case highlights a rare and serious complication of CV line insertion that both radiologists and intensivists should be aware of.