1. D&C Case Presentation January 26, 2012

2.  Malpositioned central venous catheter  Right subclavian vein laceration  Right subclavian artery laceration  Procedure:  Central venous catheter insertion  Deceased donor liver transplant

3.  63yo woman  Cirrhosis due to Hepatitis C  Moderate/Severe decompensation:  MELD 24 – Cr 1.76 ; Bilirubin 5.2; INR 1.4; Na 138  Weekly paracentesis for refractory ascities  Encephalopathy  Presented for Liver transplant on Jan 14  Donor – 34yo man – DCD donor

4.  Taken to the operating room for deceased donor liver transplant  Central venous catheter  MAC (9.0 Fr)  Swan-Ganz catheter  Chest X-Ray

7.  Arterial puncture  Pneumothorax  Arrythmia  Thoracic Duct Injury  Guidewire Loss  Cardiac Perforation Evens SRT. Surgical Pitfalls: Prevention and Management. Philadelphia: Saunders. 2009.

8. 1.Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation. 1993;87:1557-1562. 2.Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med. 1995;23:692-697. 3.Mallory DL, McGee WT, Shawker TH, Brenner M, Bailey KR, Evans RG, et al. Ultrasound guidance improves the success rate of internal jugular vein cannulation. A prospective, randomized trial. Chest. 1990;98:157-160. 4.Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg. 1991;72:823-826. 5.Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med. 1997;29:331-336.

9.  BG Denys et al from Pitt, 1993  Prospective study, 1230 patients  Landmark versus Ultrasound guided:  Longer access times (44 sec versus 10 sec)  More attempts (2.5 versus 1.2)  Decreased successful cannulation on first attempt (38.4 versus 82%)  More carotid punctures (25 versus 8)

11. French JLH, Raine-Fenning NJ, Hardman JG, Bedforth NM. Pitfalls of ultrasound guided Vascular access: the user of three/four-dimensional ultrasound. Anaesthesia, 2008:63; 806-813.

13.  Liver transplant proceeds  Pause prior to bile duct to check for bleeding  Abdomen dry  Chest tube with minimal output  ~30 minutes later – hypotension  Chest now has high output  Thoracic consulted – Sternotomy

17.  Subclavian ligation is well tolerated  Thoracic EndoVascular Aortic Repair (TEVAR)  Left subclavian may be occluded with or without bypass from left carotid

18.  WWII – ligation resulted in 25% gangrene  Vietnam registry:  Mortality 5 to 10% (earlier series up to 30%) ▪ All due to hemorrhage  5-10%: distal ischemia, gangrene, pseudoaneurysm formation, AV fistula, limb loss  Graham et al – 1980  93 patients from 1955 to 1978  Mortality 4.7%; Neurological deficit accounted for major early and late morbidity

21. Intimal flap found at reoperation Left subclavianRight subclavian