Case Report. A 16-year old male with a history of Duchenne muscular dystrophy, cardiomyopathy, severe kyphoscoliosis and congestive heart failure presented to the emergency department at an outside hospital with acute respiratory distress due to decompensated heart failure. An arterial blood gas revealed severe respiratory acidosis and the patient was emergently intubated. An attempt at placement of a 7 Fr central venous catheter in the subclavian vein resulted in inadvertent cannulation and placement of the central venous catheter in the subclavian artery. The patient was then transferred to our facility for further management. Despite aggressive heart failure therapy, the patient remained intubated and hemodynamically tenuous with a mean blood pressure of 44 mmHg. After initial stabilization in the pediatric intensive care unit , attention was then focused on options available to remove the subclavian catheter. A pediatric cardiovascular surgery consult was obtained. Given the underlying comorbidities of Duchenne muscular dystrophy, acute decompensated heart failure and severe kyphoscoliosis, the patient was deemed to be a poor candidate for open surgical repair. The patient’s weight (27 kilograms), severe kyphoscoliosis and Duchenne muscular dystrophy resulted in particularly challenging anatomy (Figure 1). Activated partial thromboplastin time, international normalized ratio and platelet count were all normal. The decision was made to attempt percutaneous closure of the arteriotomy in the cardiac catheterization laboratory under angiographic guidance.
A 6 Fr long sheath was placed in the right brachiocephalic artery via the left femoral artery. Right brachiocephalic and subclavian angiography was performed with contrast injections through the sheath. The subclavian arteriotomy site was assessed in relation to the origin of the right common carotid, vertebral and the right internal mammary arteries. The point of entry of the central venous catheter was noted to be distal to the origin of these vessels (Figure 2A). The subclavian artery measured 4.5 mm in diameter by quantitative coronary angiography (QCA). A 0.014 inch wire and a Slalom 5 x 20 mm balloon dilatation catheter (Cordis Endovascular, Miami Lakes, Florida) were then advanced into the sheath and positioned at the sheath tip to facilitate immediate balloon tamponade of the subclavian artery in the event of closure device failure.
A 0.035 inch J-wire was introduced through the 7 Fr catheter and advanced under fluoroscopic guidance into the right subclavian artery. The catheter was then removed and a 6 Fr Perclose Proglide device (Abbott Laboratories, Abbott Park, Illinois) was advanced over the wire into the subclavian artery under fluoroscopic guidance. However, no “back-bleeding” was noted from the side port of the Perclose device. The Perclose device was then removed, leaving the wire in position in the right subclavian artery. An 8 Fr Angio-Seal was then inserted and deployed. Angiography performed via the sheath in the brachiocephalic artery immediately after Angio-Seal deployment demonstrated abrupt vessel closure with no contrast flow beyond the site of Angio-Seal deployment (Figure 2B). No contrast extravasation was noted. The patient immediately developed an ischemic right arm which was pale, cold and pulseless. The 0.014 inch guidewire and the angioplasty balloon were advanced across the site of occlusion and contrast injection through the balloon lumen showed a patent subclavian artery distal to the occlusion. Serial inflations were performed at low pressure (0.5–1 atm). Further balloon inflations resulted in resolution of the occlusion with restoration of flow; however, several large thrombi were then noted at the site of closure device deployment (Figure 2C). The patient was immediately given a bolus dose of heparin to achieve an activated clotting time > 250 seconds. A Pronto suction/extraction thrombectomy catheter (Vascular Solutions, Inc., Minneapolis, Minnesota) was then passed 4 times through this region, resulting in aspiration of thrombus (Figure 3) and normal flow was restored in the right subclavian artery (Figure 2D). The patient was then placed on a heparin infusion and transferred to the pediatric ICU. He underwent tailored medical therapy for heart failure without clinical evidence of any hematocrit drop or any arterial compromise of the right upper extremity.
Discussion. A multitude of vascular complications can occur from inadvertent cannulation and subsequent placement of central venous catheters in an artery. Failure to recognize arterial cannulation may lead to further arterial injury due to sheath or catheter placement, resulting in enlargement of the arteriotomy. The risks may include arterial occlusion, embolism, hematoma, pseudoaneurysm, dissection, arterio-venous fistula formation and even fatal exsanguinations on sheath removal.3–11 These risks are likely exponentially increased in patients who are critically ill, hemodynamically unstable or who are on systemic anticoagulation. Although some of these sites of inadvertent arterial puncture and/or sheath placement may allow successful external compression to facilitate hemostasis, the subclavian artery is noncompressible because of its anatomical location. Therefore, inadvertent subclavian artery puncture can result in significant hemorrhage and attempts should be made to close the arteriotomy by either surgical or endovascular approaches.6,7,11 This case had several unusual features. The skeletal deformities, including severe kyphoscoliosis, rotation of the thorax and Duchenne muscular dystrophy likely predisposed the patient to inadvertent arterial puncture. In addition, the distorted anatomy made the case more challenging from a procedural and technical standpoint. Moreover, the patient did not have good surgical options and was deemed an extremely high-risk case for open surgical repair. The use of angiography from a separate arterial site prior to attempting percutaneous arterial closure proved vital in our case. Given the challenging body habitus, we were able to confirm the origins of the major vessels in relation to the arteriotomy site. We also noted unsuccessful Perclose device positioning due to a lack of “back-bleeding”, which may have been due to the abnormal body habitus. This necessitated removal of the device while maintaining wire position under fluoroscopic guidance, and immediate deployment of the Angio-Seal device. Device exchange and resulting possible trauma may have contributed to clot formation at the site of the arteriotomy. Alternatively, the collagen plug may have entered the lumen of the artery due to the abnormal anatomy and the angle of deployment, which may have resulted in thrombus formation in the vessel.
Preloading an appropriately-sized balloon in the guide catheter sheath prior to deployment of the closure device was also critical to a successful outcome. Although this was intended to tamponade the artery in the case of failed closure and bleeding, it proved pivotal in rescuing the suddenly occluded subclavian artery after deployment of the collagen-based closure device. Immediate balloon angioplasty restored flow to the patient’s acutely ischemic arm with minimal delay. Angiography after reperfusion allowed for immediate identification and removal of clot at the arteriotomy site and restoration of flow. This clot formation may have occurred in situ due to the closure device, vessel wall trauma from exchanges of devices, collagen plug deposition in the vessel or to cessation of flow during balloon inflation. Regardless of the mechanism of thrombosis, sheath and balloon placement in the brachiocephalic artery and clot extraction likely averted catastrophic limb ischemia in this patient.
Prior reports have detailed several strategies for achieving hemostasis after inadvertent subclavian artery puncture. Intra-arterial balloon tamponade has been reported; however, it is poorly tolerated due to significant discomfort from arm ischemia and does not eliminate the risk of inadequate hemostasis.12–14 In-situ clot formation may also occur proximal to the inflated balloon, risking carotid or systemic embolization. Since the development of various closure devices, other techniques have been described. Successful Angio-Seal device closure, as well as Perclose suture-based device closure, and a few other endovascular approaches have been described in cases of inadvertent arterial sheath insertion.15–26 A covered stent graft may also be considered in these situations, and use of a covered stent graft has been reported in the literature.27 In our case, the subclavian artery was small in diameter since our patient weighed only 27 kilograms, and may not have accommodated covered stent grafts used in the peripheral vasculature. Some reports make the use of closure devices in these situation sound fairly routine. However, our case demonstrates the importance of vigilance in gaining alternative arterial access and preprocedure planning for immediate balloon tamponade for inadequate hemostasis or for balloon angioplasty in the case of abrupt vessel closure. Our case was further complicated by markedly distorted chest anatomy, requiring significant recalculations in approach during the case. It is to be noted that closure devices are approved for use in femoral arteries and have not been extensively studied in the pediatric population.
Conclusion. We report a successful strategy for percutaneous management of an inadvertent subclavian arterial puncture and catheter placement during attempted subclavian central venous catheter insertion. Performing the procedure with angiographic imaging of the arteriotomy site from another approach is vital to provide an alternative bailout strategy for both closure device failure resulting in hemorrhage, or for complications due to deployment such as abrupt vessel closure. Operators should be flexible in their approach to these uncommon, but potentially disastrous, situations and plan each procedure on its merits.
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