Vascath misplacement

Reviewed and revised 14 July 2015

OVERVIEW

• unfortunate complication with possible serious sequelae for the patient
• well recognized but uncommon
• similar issues apply to inadvertent intra-arterial placement of central lines, however effects are typically less serious as the catheter is of smaller diameter

POTENTIAL COMPLICATIONS

• bleeding (hypovolaemia, haemothorax)
• fistula formation (if internal jugular was transfixed before entering the carotid artery)
• haematoma formation with compression of surrounding structures
  • Airway obstruction (trachea)
  • Cerebral venous outflow obstruction
  • Jugular venous thrombosis due to stasis
  • Haemomediastinum
  • Compromised cardiac function due to RV compression by down-tracking haematoma
  • Peripheral nerve compression injuries (e.g. vagus nerve, phrenic nerve, brachial plexus roots)
  • Esophageal compression
• vascular injury
  • Pseudoaneurysm
  • Carotid dissection
  • Retrograde aortic dissection
  • Arteriovenous fistula
  • Occlusion by flap, catheter or thrombus
• cerebral injury
  • ischaemic stroke (luminal occlusion by vascath +/- thrombus formation)
  • atherembolic stroke (disruption of atherosclerotic plaque)
  • thromboembolic stroke
  • air embolism
• inadvertent administration of drugs before position recognized (e.g. vasopressors, or sclerosing agents such as thiopentone) [more likely with CVCs rather than vascaths)

RECOGNITION

Clinical assessment

• potentially asymptomatic
• local swelling and bleeding
  • airway compromise (neck swelling, stridor, respiratory distress, impaired gas exchange)
  • dysphagia
  • vagal effects (bradycardia, hypotension)
• focal signs consistent with stroke
• discomfort or abnormal noise heard ipsilaterally on flushing a line placed in the carotid

Investigations

• arterial blood gas
• arterial waveform and blood pressure when transduced
• intra-arterial placement on bedside ultrasound
• abnormal position on CXR
• evidence of complications (e.g. infarct on CTB, haemothorax on CXR)

MANAGEMENT

Immediate

• early recognition is important
• notify vascular surgeon as surgical haemostasis is typically required given size of the hole in artery (direct closure or patching)
• leave catheter in situ unless causing vascular insufficiency to the brain
• if surgical repair not indicated and catheter removed then prolonged pressure must be maintain on artery until surgical assessment has been made (be aware of potential problems: carotid body compression and distal flow)
• patient may need to be intubated (due to risk of airway compromise probably already is given is in multi-organ failure)
• correct coagulopathy (cessation of anti-platelets and anti-coagulants, blood products, factor VIIIa)

Post-removal of line

• assess end organ injury (brain function – clinically +/- imaging)
• keep intubated until haematoma and swelling settles
• extubate after ensuring coagulopathy resolved and airway not threatened
• may need placement of a vascath at another site to facilitate renal replacement therapy

Other issues

• root cause analysis
• discussion with proceduralist (non-judgemental, supportive)
• open disclosure with family and patient
• follow up with family and trainee
• education (e.g. ultrasound guidance teaching)
• hospital event form
• full documentation

References and links

Journal articles

• Nair S, et al. A case of accidental carotid artery cannulation in a patient for hemofilter: complication and management. Brit J Med Pract 2.3 (2009): 57-58. [Free Full Text]