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Objectives: The incidence of posterior vessel wall puncture (PVWP) during central line placement with possible subsequent injury to structures lying behind the vein is unknown. At times the internal jugular vein lies immediately anterior to the carotid artery rather than lateral to it, leading to potential arterial puncture should the needle pass through the vein completely. The objective of this study is to evaluate the incidence of PVWP during simulated ultrasound (US)-guided vessel cannulation.Methods: Enrolled subjects were emergency medicine resident and attending physicians. Subjects performed US-guided venous access on simulated blood vessels within gelatin-based US phantoms. While blinded to the purpose of the study, each subject performed successful cannulation of the vessel on separate phantoms, with wire placement confirmed by expert review of a follow-up US. Each phantom was subsequently deconstructed to manually inspect for PVWP.Results: Thirty-five subjects with a range of experience in the technique participated, each performing both transverse and long-axis approaches for a total of 70 cannulations. The overall incidence of PVWP was 34% (95% confidence interval [CI] = 22.9% to 45.1%).Conclusions: This study found a high incidence of inadvertent PVWP during simulated US-guided vessel cannulation in this model. ACADEMIC EMERGENCY MEDICINE 2010; 17:1138-1141 ª 2010 by the Society for Academic Emergency MedicineKeywords: ultrasonography, shock, critical care, emergency medicine, patient simulation A rterial puncture during central venous catheter placement is a known complication of the procedure, with reported incidence up to 11%. 1,2While ultrasound (US) guidance has been shown in several studies to decrease arterial puncture, 1-3 the identification of this event is based on the presence of forceful, pulsatile blood flow from the needle after removal of the syringe. Occult arterial injuries occur when the artery is punctured during the course of the procedure without resultant pulsatile flow through the needle.4 Both recognized and occult arterial injuries may result in significant complications.When using a landmark technique for internal jugular venous access, many practitioners intentionally pass through-and-through the vessel and access the lumen when withdrawing the needle. The use of US allows for direct visualization of the internal jugular vein and internal carotid artery, but commonly demonstrates the vein superficial to the artery. 5 In this scenario, any posterior vessel wall puncture (PVWP) that occurs could result in arterial injury. The objective of this study was to measure the incidence of PVWP during US-guided vessel cannulation using a phantom model. METHODS Study DesignThis was an observational study to assess the incidence of PVWP in a simulated model. The study was approved by the institutional review board.

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