Techniques for Repairing Subclavian Artery Puncture in Central Venous Cathether Placement

Techniques such as stent graft placement, thrombin injection, downsizing, and Gelfoam embolization have been used to repair the subclavian artery after inadvertent puncture.

Background/Objective Placement of a central venous cathether (CVC) in critical care or emergency settings is common, as is puncture of the subclavian artery while trying to obtain venous access. Surgical repair of these inadvertent punctures was the treatment of choice, but now minimally invasive techniques are available. These authors have compiled a case series of five patients showcasing the methods used in their institution to treat these inadvertent arterial punctures.

Case 1: A 53-year-old woman developed a subclavian pseudoaneurysm after removal of a right subclavian arterial catheter. The patient was successfully treated with a homemade 5-mm stent-graft.

Case 2: A 41-year-old man with inadvertent puncture of the left subclavian artery was successfully treated by deployment of a 10-mm self-expanding stent graft (Fluency). Attempts were made at using a closure device (Perclose) twice without success.

Case 3: A 54-year-old woman with inadvertent puncture of the right subclavian artery and a small dissection with a non-occluding flap was successfully treated with a self-expanding covered stent (Viabahn). An attempt was made to use a closure device without success.

Case 4: A 66-year-old man with inadvertent puncture of the right subclavian artery was successfully treated by embolization of the tract with Gelfoam pledgets.

Case 5: A 55-year-old man with left subclavian artery puncture was treated successfully with serial downsizing of the 7-F sheath to a 3-F catheter over 36 hours.

Reviewer’s Comments
Inadvertent arterial placement of a CVC is reported to occur in 2% to 9% of cases, despite the use of ultrasound as a guide. Bleeding does not usually become significant unless the arterial nature of the needle stick goes unrecognized. Risk factors also include operator inexperience, radiation or surgery in the area, and obesity.

There can also be problems such as distal embolization, pseudoaneurysm, vessel rupture, or immediate hemorrhage that follow. The first step in evaluating the punctured artery is imaging via CT angiography or catheter-based angiography. The options available include covered stents, balloon tamponade, closure devices, tract embolization, and serial downsizing.

Closure devices may be used when the tissue tract is <8 cm and when there is no underlying dissection or pseudoaneurysm, but not near branch vessels. Covered stents are useful when there is a pseudoaneurysm or dissection, or when there is persistent bleeding. They should not be used at the thoracic inlet, in the setting of sepsis, or in small children.

Thrombin injection may be attempted if there is a small neck to a pseudoaneurysm. Gelfoam embolization of the tract and sequential downsizing of the catheter can be used in the setting of sepsis or branch vessels, or in the thoracic inlet. The treatment should be tailored to suit each patient.

Author: Sharon Gonzales, MD

Reference:
Abi-Jaoudeh N, Turba UC, et al. Management of Subclavian Arterial Injuries Following Inadvertent Arterial Puncture During Central Venous Catheter Placement. J Vasc Interv Radiol; 2009;20 (March): 396-402