Successful management of pseudoaneurysm and hemothorax following central venous cannulation.

Sir,

Central venous cannulation is being used in clinical practice successfully since 1945 for various therapeutic and diagnostic purposes. Rarely, it can be associated with fatal complications. The incidence of central venous catheter (CVC) complication as reported in the literature varies from 5% to 19% respectively[12] and unintended arterial puncture occurs in about 2-4.5% of CVC resulting in 0.1-0.5% of the arterial injury.[2]

Though rare, but fatal complications such as massive hemothorax, pneumothorax, common carotid artery puncture can occur. There are few case reports in literature, which have reported the formation of pseudoaneurysm, arteriovenous fistulas and dissection after arterial puncture.[3] We share a case of a patient with posterior communicating artery (PCOM) aneurysm who presented with delayed hemothorax, pseudoaneurysm of thyrocervical trunk and brachial plexus paresis post operatively on 3rd day.

A 45-year-old female patient with PCOM aneurysm was admitted for craniotomy and clipping. She was a known case of controlled hypertension. Her pre-operative investigations were within the normal limits. After induction and intubation Rt. Internal jugular vein (IJV) cannulation was attempted through supraclavicular approach. Under all aseptic precautions, pilot puncture with 24 G needle was performed. After confirmation of venous blood in pilot puncture, cannulation was attempted with 18 G needle of B. Braun. On aspiration, arterial blood was noted hence needle was removed immediately and site was manually compressed for 5 min.

Subsequently, Rt. subclavian vein was successfully cannulated without any difficulty and surgery was performed. Her intraoperative period was uneventful. At the end of surgery, patient was put on T-piece and extubated on 2nd day postoperatively. On the 3rd day, patient was complaining of pain in neck with difficulty in movement of right arm and respiratory distress. On examination, there was swelling in neck extending to the base of chest, breast and axilla. An urgent X-ray chest was done on bedside, which showed fluid level on right side. Significant fall of hemoglobin from 9% (pre-operatively) to 5% was also observed with normal coagulation profile. Urgent chest tube was inserted and about 700 ml blood was drained. After few hours, patient became comfortable and repeat X-ray chest showed gross improvement in lung field. Swelling of the chest, axilla and neck was also decreased. Chest tube was removed after 72 hrs. On the 6th post-operative day, she complained of pain in neck and axilla and difficulty in lifting of arm. Neck swelling was found to be increased. Pain management with fentanyl patch was done. Further work-up with color Doppler and computed tomography angiogram of neck vessels showed pseudoaneurysm of thyrocervical trunk [Figure 1]. After discussion with radiologist and neurosurgeon the patient was planned for an endovascular intervention and coiling of the pseudoaneurysm was successfully by interventional radiologist [Figure 2]. Later patient showed decrease in swelling and improvement in arm movement.

Figure 1

Image showing pseudoaneurysm of thyrocervical trunk

Figure 2

Image of pseudoaneurysm after endovascular coiling

The various predisposing factors for development of pseudoaneurysm as reported in the literature are atherosclerosis, hypertension, obesity, diabetes, hyperparathyroidism, coagulapathy associated with uremia, heparin use,[4] as in our case, patient was a known case of hypertension with intracranial aneurysm. Many case reports of arterial injury during IJV cannulation resulting in hemothorax and pseudoaneurysm have been reported.[45]

The treatment of iatrogenic pseudoaneurysm is controversial. It depends on several factors such as size, location, presence of expansion, presence of coagulopathy.[3] Treatment may be thrombin injection, ultrasound guided compression, endovascular embolization and surgical ligation of aneurysm. The rapidly evolving endovascular techniques have shown successful results in treatment of pseudoaneurysms and arteriovenous fistulas. In our case, patient had already underwent one major surgery so less invasive endovascular coiling was planned for safe and effective treatment. Her post coiling angiogram showed obliteration of psudoaneurysm. Later on, patient showed decrease in swelling with improvement in right arm movement.

The agency for healthcare research and quality did a review and designed the practical guide lines to improve the quality, safety, efficiency and effectiveness of CVC suggested. Use of ultrasound and pressure measurement during the placement of central line procedures can prevent arterial cannulation and injury.