To the Editor:—
We present a case of a patient with a mature forearm arteriovenous hemodialysis fistula ipsilateral to the site of insertion of the venous central line before a coronary artery bypass operation.
To differentiate the inadvertent insertion of a venous central line into the carotid artery in a patient with an ipsilateral arteriovenous fistula, we have utilized a novel maneuver that has not been described before.
Since the early description of the percutaneous cannulation of the internal jugular vein in the late 1960s by English et al. ,1the internal jugular vein has become the central vein of choice among anesthesiologists because of its constant anatomy, accessibility intraoperatively, and lower incidence of associated pneumothorax. However, this venous access has been associated with many acute and long-term complications, the most frequent of which is inadvertent puncture of the carotid artery.
Our case is a 66-yr-old woman with a history of severe peripheral vascular and cerebrovascular occlusive disease and end-stage renal disease on hemodialysis via a mature left forearm arteriovenous fistula who presented with symptoms of congestive heart failure and respiratory distress. Ejection fraction was 35% with moderate systolic dysfunction. Coronary angiography showed severe multivessel coronary artery disease with diffuse heavy calcification of coronary arteries and aorta. The left anterior descending coronary artery was occluded, the circumflex was small, and the right coronary system was diffusely diseased.
The coronary lesions were not amenable to percutaneous intervention, and the patient was referred for coronary artery bypass grafting. An off-pump coronary artery bypass graft approach was preplanned.
A venous central line insertion was planned for introduction of a pulmonary artery catheter for hemodynamic monitoring. Right internal jugular and right subclavian vein cannulation was not feasible because of significant hematoma provoked during previous attempts of venous central line insertions while in the intensive care unit.
A 9-French introducer (Arrow International, Reading, PA) was placed without difficulty into the left internal jugular vein. Bright blood at high pressure was encountered with that cannulation. To exclude the possibility of arterial puncture, a pressure transducer was connected to the catheter and wave form was displayed on a monitor. The mean pressure was approximately 30 mmHg. A sample of blood, which appeared arterial by gross color inspection, was drawn from that line and submitted for blood gas analysis. The Pao2measured 106 mmHg. The Pao2in a blood sample obtained from the femoral artery for comparison was 297 mmHg. The possibility of left internal jugular vein puncture with subsequent inadvertent carotid artery cannulation could not be excluded. Another possible source of well oxygenated blood and modestly high pressures obtained from the newly placed line was a high output arteriovenous fistula ipsilateral to the side of the central line, which resulted in significant admixture near the line entry site.
To verify venous cannulation and reject possibility of inadvertent arterial puncture, digital pressure was applied on the venous limb of the arteriovenous fistula. The observation of immediate disappearance of the high pressure wave form from the monitor confirmed a venous-only cannulation.
A 7.5-French pulmonary catheter (Swan-Ganz; Edwards Lifesciences Corp., Irvine, CA) was then placed through the venous introducer without difficulty. The patient underwent a two-vessel off-pump coronary artery bypass graft operation without complications. She was discharged from hospital on the fourth postoperative day. The internal thoracic artery was not used as one of the bypass grafts because of the risk of a flow steal phenomenon (dialysis access-associated steal syndrome) and potential for venous hypertension in the internal thoracic artery pedicle.2–4
This resultant phenomenon and consequences of arterialized blood within close proximity to a potential central venous cannulation site should also be considered when selecting the site for the insertion of a central line in patients with a high output upper extremity arteriovenous fistula. Percutaneous cannulation of the internal jugular vein is common practice in surgical patients undergoing open heart procedures. Although is regarded as a safe procedure, a complication rate of 2–13% has been reported.1,5–7The most common complication is inadvertent puncture of the carotid artery with a resultant hematoma.8Simple compression has been reported to provide hemostasis; however, systemic heparinization before cardiopulmonary bypass can result in serious complications.9
In the case presented, it is clear that the existence of a high output arteriovenous fistula was the confounding factor in determination of appropriate venous cannulation. The maneuvers employed to rule out an arterial puncture: transduction of the pressure and wave form onto a monitor, comparison of arterial and venous blood sample colors, and blood gas analysis, have been described by different authors.10,11
To our knowledge the description of simple application of digital pressure on the fistula observing simultaneously the disappearance of the pressure wave form from the monitor has not been previously described.
* University of Cincinnati Hospital, Cincinnati, Ohio. firstname.lastname@example.org.