Ultrasound Guidance Does Not Prevent Intracarotid Placement of Central Lines

Abstract

Ultrasound guidance for all central line placements has been advocated in order to avoid vascular complications and misplacement. Ultrasound without sufficient anatomic knowledge, however, does not guarantee technical safety. We report the case of a 55-year-old woman who presented to the hospital with a right cerebellar stroke and diabetic ketoacidosis. A hospitalist physician placed an ultrasound-guided right internal jugular catheter for fluid resuscitation. The postprocedure chest X-ray image was interpreted as a successful placement of right subclavian catheter (Fig 1, A). A computed tomography angiogram was obtained 2 days later as part of the stroke evaluation. This showed the catheter traversing the jugular vein and entering the common carotid artery retrograde into the aortic arch (Fig 1, B). Vascular surgery was consulted. Because the patient had heparin-induced thrombocytopenia with a platelet count of 30,000, she was taken to surgery for open removal (Fig 2, A). After catheter removal, with distal clamping, there was no bleeding from the carotid artery puncture hole. A small transverse arteriotomy removed a 13-mm × 3-mm well-formed clot (Fig 2, B). The jugular and carotid vessels were both repaired primarily, with good flow maintained (Fig 2, C). The patient recovered without any additional neurologic deficits. Ultrasound guidance alone is not sufficient to prevent vascular complications of central line placement. An understanding of vascular anatomy can help prevent such complications and properly diagnose them on chest X-ray imaging. Open surgical removal prevented embolization of a large pericatheter clot that would have occurred with simple removal.Fig 2Artery exposure, thrombus, and repair. A, CVC exposed; B, thrombus; C, repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)