A Subclavian Artery Injury, Secondary to Internal Jugular Vein Cannulation, Is a Predictable Right-Sided Phenomenon

Abstract

The most common arterial injury associated with internal jugular vein (IJV) cannulation is carotid artery puncture. Although uncommon but not rare, subclavian artery injuries have been reported (1–6), but no report has recognized that it is the right-sided phenomenon. We present a case of right subclavian artery injury associated with cannulation of the IJV and review the literature about similar complications with the intent of demonstrating that this problem is coincidentally a right-sided phenomenon because of specific anatomical differences between the right and the left subclavian artery. Case Report A 66-yr-old man presented to the University of Massachusetts-Memorial Medical Center, Worcester, with a 1 day history of lower abdominal pain and a low-grade fever. His medical and surgical history was significant for coronary artery disease, hypertension, and coronary artery bypass grafting. His clinical examination was consistent with acute sigmoid diverticulitis that was confirmed by an abdominal-pelvic computed tomography (CT) scan. Coincidentally, the CT scan extending up to the lower chest also demonstrated a type B dissecting aneurysm (likely chronic). At that time, he had uncontrolled hypertension with a blood pressure (BP) of 230/110 mm Hg and was admitted to the surgical intensive care unit for an aggressive medical management of his hypertension with IV nicardipine. A central venous triple lumen catheter (TLC) insertion was attempted by an emergency medicine resident via the right IJV using the anterior approach with a modified Seldinger’s technique. Dark, nonpulsatile, venous blood was obtained during needle placement and aspiration, and the guidewire was inserted without difficulty. A dilator was advanced without apparent resistance over the guidewire and then removed. The TLC was then advanced over the guidewire, and the guidewire was withdrawn. No blood could be aspirated from any of the ports of the TLC; therefore, the catheter was removed. Soon thereafter, the patient complained of chest pain and became diaphoretic, tachypneic, and hypotensive with a systolic BP of 80 mm Hg. The BP increased after infusion of 500 mL of lactated Ringer’s solution. A chest radiograph revealed (Fig. 1) a significant hemothorax. A tube thoracostomy was performed, and 300 mL of blood was drained. However, the chest tube continued to drain blood (more than 100 mL/h over the next few hours). The patient received 5 U of blood and was taken to the operating room (OR) for exploration 6 h after the injury. Two liters of blood were evacuated through a right anterior thoracotomy approach, and a dilator-sized hole in the first part of subclavian artery was identified and suture repaired. No signs of bleeding came from the adjacent IJV. His postoperative course was remarkable for a non-Q wave myocardial infarction. The patient was later discharged from the intensive care unit on postoperative Day 5.Figure 1: Upright chest radiograph with right-sided hemothorax.Discussion We present a case of subclavian artery injury secondary to IJV cannulation. The actual incidence and frequency of this injury are unknown because cases are probably underreported. A literature review identified five confirmed and two likely cases of subclavian artery injury during attempted IJV cannulation (1–6). Most of these complications (2–5) occurred in the OR. Powell and Beechey (2) reported a resuscitation that required 38 U of blood, 24 U of fresh frozen plasma, and 20 U of platelets, whereas the patient described by Beilin et al. (5) required 22 U of blood and 10 U of fresh frozen plasma. Oropello et al. (6) presented two deaths presumably caused by this injury because both patients developed acute hypotension and a hemothorax, but neither underwent an autopsy. There have been sporadic and unusual cases of IJV cannulation resulting in right ascending cervical artery injury (7) and right vertebral artery injury (8) that could have similar clinical presentation. Injuries to the right thyrocervical trunk and the posterior right common carotid artery at its take-off have been reported; however, all presented as delayed neck masses or pseudoaneurysm (9). Notably, all the subclavian artery injuries reported thus far (eight cases including ours) are right sided. Whereas the unilateral nature of these cases may be related to IJV punctures being more frequently performed on the right side, our supposition is that this complication is a right-sided phenomenon. The specific anatomical layout makes the right and not the left subclavian artery prone to injury. In our case and three other reported cases where operative findings were described (1–3), the location of this injury is similar. The right subclavian artery branches from the brachiocephalic trunk medial to the IJV, whereas the left subclavian artery arises from the aortic arch and turns laterally to the IJV (see diagram in Fig. 2) (10). This exact anatomical relationship makes left-sided subclavian artery puncture physically unlikely. This relationship is further supported by four reported cases including ours that demonstrate a typical location of the injury corresponding to that of the proximal portion of the right subclavian artery (hatched mark in Fig. 2). The recognition of subclavian artery injury associated with the right-sided IJV cannulation has two clinical implications. First, the typical clinical presentation or the triad of right-sided IJV cannulation, acute hypotension, and chest radiograph evidence of hemothorax should warn the clinician of a possible subclavian arterial injury. Other diagnoses such as tension pneumothorax or cardiac tamponade could present with sudden hypotension, but neither would have all the components of the aforementioned triad. Second, the typical location of the injury (the proximal part of subclavian artery) may suggest that a cervical approach to repair this injury may be possible, and that may allow the thoracic surgeon to spare the patient the morbidity associated with a thoracotomy incision.Figure 2: Diagrammatic drawing of right subclavian artery in relation to the internal jugular vein (IJV).The operative finding of a subclavian arteriotomy the size of a dilator suggested that the dilator was advanced too far through the vein and punctured the adjacent subclavian artery. In some of the other reported cases (1–3), a cannula over a large-bore needle was used, whereas others (4,5,7–9) involved a TLC, but no descriptive injury findings were specified. Oropello et al. (6) speculated that whereas the guidewire was in the correct intravascular right position, the stiff dilator went over the wire and through the vein wall, thereby causing the injury (see diagram in Fig. 3). However, we hypothesize that the guidewire probably punctured the vein extraluminally, which allowed the dilator to follow and injure the artery. Although the actual mechanism is not known, several cautionary points can be made when attempting an anterior IJV approach, particularly on the right side. First, because of the right-sided IJV and subclavian artery anatomical relationships, the needle should be cephalad closer to the apex of the two heads of the sternocleinomastoid muscle or at least one to two inches above the clavicular head. Second, because the dilator causes the serious arterial injury, it should not be advanced more than to just dilate the skin and subcutaneous tissue (and not the vein).Figure 3: Diagrammatic drawing of a possible mechanism dilator-induced injury (with author permission).In conclusion, IJV cannulation is a common procedure that is performed both at the bedside and in the OR. Understanding the association between right-sided IJV catheterization and subclavian artery injury coupled with its specific clinical presentation may lead to an early diagnosis and intervention and reduce morbidity or mortality.