DURING routine placement of a subclavian venous catheter for parenteral nutrition, aortic puncture occurred, resulting in cardiac tamponade. The authors describe a rare but dramatic complication of subclavian venous catheterization. Guidelines to prevent and manage this unusual adverse event are proposed.

A 46-yr-old woman was admitted to our surgical intensive care unit for a peritonitis-induced septic shock after multiple knife injuries to the bowel. On day 10 of the patient's hospitalization, a central venous catheter was to be placed for additional parenteral nutrition. An experienced physician (more than 50 subclavian venous catheterizations) performed the procedure. After two attempts using the right infraclavicular approach, arterial puncture with an 18-gauge needle, attested by pulsatile red blood return, occurred. After needle removal and manual compression, the right subclavian vein was successfully cannulated. Several minutes later, a sinus tachycardia followed by hemodynamic instability appeared, requiring fluid resuscitation with 1000 ml of hydroxylethylstarch, which resulted in a marked increase in central venous pressure (from 4 to 22 mmHg). A hemopneumothorax was ruled out by bedside chest radiography. Despite fluid infusion, hemodynamic instability increased, leading to paradoxical bradycardia and circulatory arrest. After tracheal intubation, cardiac massage, and intravenous injection of 5 mg of epinephrine, an adequate circulatory state was restored in less than 5 min. Transthoracic echocardiography demonstrated a large amount of intrapericardial fluid compressing right cardiac chambers, allowing the diagnosis of cardiac tamponade. The patient was immediately transported to the operating room with an epinephrine infusion for urgent sternotomy. Three hundred milliliters of fresh blood were removed from the pericardium through the pericardiotomy. A punctiform perforation of the right anterolateral side of the intrapericardial ascending aorta was identified with active bleeding, and sutured by a single stitch of polypropylene. Neither pericardium nor cardiac cavity injuries were found. No related complications occurred in the first 2 weeks after sternotomy. Nevertheless, 3 weeks after thoracic surgery, the patient died of multiple organ failure, after ventilator-associated pneumonia developed.

Complications after subclavian vein catheterization are not rare, especially immediate complications during the procedure. In a prospective study, 821 patients were randomly assigned to subclavian vein catheterization with or without ultrasound-guided location of the vein. Acute complications occurred in eighty patients (9.7%), including misplacement (6%), subclavian arterial puncture (3.7%), pneumothorax (1.5%), and mediastinal hematoma (0.6%). 1These complications occurred in over one-quarter of the patients in whom catheterization was unsuccessful. Cardiac tamponade after the placement of central venous catheter by direct perforation of the right ventricle, 2,3superior vena cava, or right atrium has also been described. 4 

We report a case of injury to the intrapericardial-ascending aorta complicated by cardiac tamponade during attempted subclavian vein catheterization. Five cases have been reported in the literature. 5–8Reviewing these case reports, together with ours, some common characteristics can be identified. The accidental puncture of the right lateral side of the ascending aorta is always reported in the context of multiple and unsuccessful puncture attempts of the right subclavian vein. Bleeding from the perforation of the intrapericardial ascending aorta results in rapid filling of the pericardium, which induces cardiac tamponade and cardiac arrest. In three cases, the diagnosis of hemopericardium and aortic injury was only autopsy-proven. In the other two, a pericardiocentesis was done, followed rapidly by a sternotomy and an anterolateral thoracotomy that allowed identification of the aortic injury. 6,7 

Injury of the ascending intrapericardial aorta by needle puncture during a right subclavian vein catheterization attempt is a rare but potentially lethal acute complication that must be acknowledged and recognized by all physicians involved in the placement of central venous catheterization. In all of the cases reported, including ours, aortic injury occurred exclusively after an infraclavicular approach of the right subclavian vein. Nevertheless, injury of the aortic arch through the left lung has also been reported once, during routine placement of a left subclavian venous catheter. 9This could be explained by the relatively close anatomic links between the right brachiocephalic venous trunk, and down and backward, the right lateral side of the ascending aorta. Incorrect technique, evidenced by improper direction of the needle toward the down and backward direction, predisposes the patient to aortic injury (fig. 1).

Fig. 1. Suspected needle direction that led to aortic perforation. (1 ) Ascending aorta; (2 ) right subclavian vein; (3 ) right subclavian artery; (4 ) clavicle; (5 ) right internal jugular vein; (6 ) aortic arch; (7 ) innominate brachiocephalic vein; (8 ) pulmonary artery; (9 ) left ventricle; (10 ) inferior vena cava; (11 ) first rib; (12 ) trachea; (13 ) esophagus.

Fig. 1. Suspected needle direction that led to aortic perforation. (1 ) Ascending aorta; (2 ) right subclavian vein; (3 ) right subclavian artery; (4 ) clavicle; (5 ) right internal jugular vein; (6 ) aortic arch; (7 ) innominate brachiocephalic vein; (8 ) pulmonary artery; (9 ) left ventricle; (10 ) inferior vena cava; (11 ) first rib; (12 ) trachea; (13 ) esophagus.

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Several practical recommendations can be proposed to avoid and manage this particular complication. It is important to weigh the potential benefit of a subclavian vein catheterization against the risk of immediate complications. Because of possible arterial puncture, bleeding disorders should lead us to prefer a different venous access. The procedure should be discontinued after attempts are repeatedly unsuccessful, and if another site is considered, the contralateral subclavian one should be ruled out. In a prospective trial evaluating the complications and failures of subclavian vein catheterization, 1the strongest predictor of complication using an univariate analysis was failed catheterization attempt. The complication rate was 4.3% for one needle pass, 10.9% for two needle passes, and 24% for three or more passes. Complications and failures were also found to occur twice as frequently in patients who were especially thin or obese or who had previously undergone major surgery, radiotherapy, or catheterization in the region; this was not the case of our patient. Moreover, an initial failed attempt of subclavian vein catheterization by an operator does not seem predictive of a failed procedure at the same site by another operator, and the risk of complications does not increase. 1Ultrasound guidance for subclavian venous access can be used with success to locate vascular structures, decreasing the number of failed catheter placements and complications. 10Nevertheless, in the study by Mansfield et al. , this approach had no effect on the incidence of complications and failures. 1Moreover, these guided techniques are not cost-effective, and require training. Their use in treating patients with predicting factors of immediate complications must be studied. When arterial puncture is observed during attempted venous cannulation, especially if it was difficult, the patient should be carefully examined and monitored to detect early symptoms of cardiac tamponade. Continuous measurement of central venous pressure can be helpful. If hemodynamic instability occurs, a chest radiograph should first exclude tension pneumothorax or hemothorax. Urgent transthoracic echocardiography should then be performed. Once cardiac tamponade is diagnosed, single pericardiocentesis is not an adequate treatment and thoracotomy should be undertaken without delay. Pericardiocentesis alone is always unsuccessful because of uncontrolled bleeding from the aortic perforation, which has to be repaired surgically. In case of inadvertent placement of the catheter in the aorta, suspected on chest radiograph, the catheter should not be removed, but its location precisely established by angiography or chest computed tomography. Surgical removal is mandatory to prevent uncontrolled bleeding or cardiac tamponade. 7 

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