1. Nikul V. Patel, MD1; M. James Lozada, DO2
A Rare Cause of Hemorrhagic Shock: Right Internal Mammary Artery (RIMA) Injury during Ultrasound-guided Right Internal Jugular (RIJ) Central Venous Catheterization
Nikul V. Patel, MD1; M. James Lozada, DO2
1-The University of Texas Medical Branch at Galveston, 2-Northwestern University Feinberg School of Medicine
Anesthesiology
Right hemopneumothorax seen on initial post procedure CXR
Introduction
Discussion
More than 5 million central venous catheters (CVC) are inserted annually in the United States.1 Significant arterial injury is estimated to occur in 0.1%-1% of central venous cannulation attempts.2 Real-time ultrasound- guided venipuncture of the internal jugular vein decreases the rate of arterial injury compared to the landmark approach.3 Unintended injury to the right internal mammary artery (RIMA) during central venous cannulation is exceedingly rare.4 A literature search identified only three such case reports, with none reaching the severe morbidity we present in this case.
Internal mammary artery injury is a rare complication of traumatic chest injury, sternotomy, or CVC placement.5
Successful treatment of arterial injury using catheter removal and compression, endovascular methods, and open surgical repair is 5.6%, 94.6%, and 100%, respectively in a recent systematic review.1
A suggested algorithm for management of arterial injury during central venous catheter insertion is applicable when arterial injury is suspected.
Our patient developed hemorrhagic shock after unsuspected RIMA injury during RIJ central venous catheterization.
Initial endovascular repair failed, delaying definitive diagnosis and treatment, causing significant morbidity.
Case Presentation
General: 46 year-old African American female
PMHx: Left MCA aneurysm rupture and SAH, seizures, obstructive hydrocephalus
Neuro deficits: expressive aphasia, right hemiparesis
CC: Uncontrolled seizures requiring neurological ICU admission
Conclusions
Dynamic ultrasound guidance during central venous catheterization does not eliminate the possibility of inadvertent arterial injury.
A deep vascular injury may not show obvious signs of bleeding or hematoma.
A patient who becomes acutely hemodynamically unstable following central venous catheterization may have an arterial injury, even if CVC is successfully placed.
There remains a lack of published guidelines or clear evidence on how best to manage arterial injury during CVC placement.
Endovascular approach has high success rates.
Open surgical repair remains the most successful approach, with no complications reported in a large systematic review1, and should be considered the technique of choice in a rapidly exsanguinating patient.
Difficult PIV access prompted neurosurgical resident to perform central venous catheterization
Ultrasound-guided RIJ CVC placement with Arrow 7F triple lumen CVC
Complicated by patient movement then successfully sewed in to RIJ
Patient rapidly became hypotensive, tachycardic, and hypoxemic
CXR demonstrated acute right hemopneumothorax
Emergent chest tube drained 2L of blood within minutes
Massive Transfusion Protocol (MTP) initiated and patient taken emergently for endovascular repair with right proximal subclavian artery stent
The patient acutely worsened 3h later returning emergently to OR
Right anterolateral thoracotomy identified briskly-bleeding RIMA injury
The patient required six rounds of MTP, including 43 units of pRBCs, 43 units of FFP, 7 doses of cryoprecipitate, 8 doses of platelets, and 3 vials of recombinant Factor VIIa
References:
Dixon, O, et al. A Systematic Review of Management of Inadvertent Arterial Injury During Central Venous Catheterization. J Vasc Access. 2017;18(2):
Bowdle A. Vascular Complications of Central Venous Catheter Placement: Evidence-based Methods for Prevention and Treatment. J Cardiothorac Vasc Anesth. 2014;28(2):
American Society of Anesthesiologists Task Force. Practice Guidelines for Central Venous Access. Anesthesiology. 2012;116(3):
Kindelan, J, et al. Endovascular Coiling of an Internal Mammary Artery Pseudoanuerysm Following Placement of an Internal Jugular Central Venous Catheter. Military Medicine. 2010;175(8):
Mazeh, H, et al. Internal Mammary Artery Injury During Central Venous Catheter Insertion for TPN: Rare but Fatal. Nutrition. 2010;26: