An Accidental Arterial Puncture and Anticoagulation after Internal Jugular Vein Catheterization Resulting in Massive Hematoma and Airway Compromise

Abstract

Central Venous Catheterization is a common procedure in daily clinical practice. The internal jugular, subclavian and the femoral veins are the most frequently catheterized central veins. Pneumothorax, hematothorax, arterial puncture, hematoma, nerve lesions, damage to the left thoracic duct, and air embolism are among the main mechanical complications. Nowadays, there are two techniques in daily clinical use: the traditional technique and the ultrasound guided technique.The traditional technique relies on the use of anatomical landmarks, but the failure rate is high-even in experienced hands. Furthermore, several different complications range from mechanical problems (5-19% of cases) to infections and thrombotic events (2-26%). There is compelling evidence that ultrasound-guided CVC insertion via the internal jugular veins is associated with higher success rates and fewer mechanical complications compared with the traditional techniques based on external anatomical landmarks.We report a clinical case of 76-years-old female patient requiring urgent placement of a central venous catheter and unrecognized arterial puncture and subsequent heparin overdose with nearly fatal outcome.eral venous access, administration of parenteral nutrition, vascular access in patients whose peripheral veins are difficult to catheterize, and procedures that require access to large-caliber vessels [1]. The central vessels that are most frequently catheterized are the internal jugular, subclavian, and femoral veins.The traditional CVC insertion technique relies on the use of anatomical landmarks rather than ultrasound guidance. But even in experienced hands, the traditional technique is associated with a high failure rate and several complications ranging from mechanical problems (5-19% of cases) to infections and thrombotic events (2-26%) [1][2][3][4].Pneumothorax, hematothorax, arterial puncture, hematoma, nerve lesions, damage to the left thoracic duct, and air embolism are among the main mechanical complications [5]. The incidence of complications increase 6-fold after the third insertion attempt [1]. Other risk factors that are known to increase the incidence of complications are an inexperienced operator, the presence of anatomical variants as well as co-existing medical conditions such as clotting disorders, pulmonary emphysema, hypovolemia, or difficulties related to conditions under which the procedure is performed (i.e. an emergency) [5].

Life‐threatening airway obstruction due to retropharyngeal and cervicomediastinal hematomas following transjugular intrahepatic portosystemic shunt procedure for acute variceal bleeding in cirrhosis.

“…The most frequent site of arterial injury is the carotid artery. Other reported sites of injury include the innominate (brachiocephalic) artery, subclavian artery, aortic arch, descending thoracic aorta, vertebral artery, thyroid artery, 6,25–29 transverse cervical artery, 30 and thyrocervical trunk 31,32 . The arterial injury occurs when the puncture needle goes through the internal jugular vein into the carotid artery, or the needle penetrates the artery that is very close to the internal jugular vein, or the guidewire travels through the internal jugular vein and its posterior wall into the carotid artery 6,26,33 .…”

“…Such hematomas could occur in the cervical, 5,6,9,15,18,20 retropharyngeal, 10,11,12,16 or mediastinal 7,13,14,17,19,21,22,23 regions, with the presentation varying widely, from asymptomatic 9,11,17,18,20,21 to life‐threatening 5–7,12,13,15,16,19,23 . However, it is extremely rare that the hematoma simultaneously involves the retropharyngeal and cervicomediastinal regions, and causes life‐threatening airway obstruction after internal jugular vein catheterization 24,25 . We report a rare and unique case that presented with life‐threatening airway obstruction due to retropharyngeal and cervicomediastinal hematomas following TIPS procedure for acute variceal bleeding in cirrhosis.…”

“…[5][6][7]12,13,15,16,19,23 However, it is extremely rare that the hematoma simultaneously involves the retropharyngeal and cervicomediastinal regions, and causes life-threatening airway obstruction after internal jugular vein catheterization. 24,25 We report a rare and unique case that presented with life-threatening airway obstruction due to retropharyngeal and cervicomediastinal hematomas following TIPS procedure for acute variceal bleeding in cirrhosis.…”