Balloon-Assisted Percutaneous Thrombin Injection for Treatment of Iatrogenic Left Subclavian Artery Pseudoaneurysm in a Critically Ill COVID-19 Patient

Abstract

Background. Central venous catheter represents an important tool in the management of critically ill patient. In this report, we described a COVID-19-positive case who had COVID-related complications and iatrogenic left subclavian artery pseudoaneurysm after central venous catheter insertion. Case Presentation. A 58-year-old male patient presented with a high-grade fever, myalgia, and shortness of breath due to COVID-19 infection. He required mechanical ventilation support and hemodialysis. He also developed uneventful deep vein thrombosis and myocardial infarction. As a complication of central line insertion, the patient developed pseudoaneurysm that originated from the subclavian artery with significant bleeding and large hematoma. Balloon-assisted percutaneous thrombin injection was done under ultrasound guidance. The patient was extubated 2 days later with no evidence of flow in the pseudoaneurysm. However, he lost movement in the left arm secondary to the compression of the brachial plexus from the pseudoaneurysm/hematoma, and therefore, 1.5 litres of the hematoma was evacuated in the operating room through a lateral left chest wall incision along the anterior axillary line to relieve the compression over the brachial plexus. The patient declined surgical reconstruction of the brachial plexus, and the flaccid paralysis of the arm did not recover during the follow-up. Conclusion. This is a case of unusual complications of COVID infection and iatrogenic left subclavian artery pseudoaneurysm postcentral vein cannulation. Balloon-assisted percutaneous thrombin injection for treatment of left subclavian artery pseudoaneurysm is feasible; however, delayed diagnosis could be associated with long-term or permanent disability.

Endovascular treatment of an iatrogenic right subclavian artery pseudoaneurysm associated with an arteriovenous fistula

“… 7 When an arterial complication occurs, the management should be tailored to the patient's anatomy and condition. 6 According to Guilbert et al., 1 catheters of <7F located in compressible areas of the neck can be removed safely; otherwise, an intervention should be considered, In this case, a simple pull/pressure technique was not an option considering the CVC size (12F), the presence of a large pseudoaneurysm and its proximal localization. Open repair would have required a median sternotomy or thoracotomy to obtain a proximal control.…”

“… 3 The literature reporting iatrogenic SAP consists of few case reports. 4 , 5 , 6 Open surgical procedures including direct repair, ligation, or bypass are the most commonly described treatment, although, in high-risk patients, endovascular interventions or thrombin injections have been described as safe options. 6 In this case report, we describe a strategy involving the placement of covered stents and coiling to exclude an SAP.…”

Thrombin and Thrombin‐Incorporated Biomaterials for Disease Treatments

“…Delayed diagnosis can lead to long-term/permanent disability [134] Cancer therapy Thrombin DNA nanorobot with aptamer on the outside and thrombin in the internal cavity Tumor-specific intravascular thrombosis, leading to tumor necrosis and tumor growth suppression [157] Post-surgical cancer treatment Thrombin Sprayable thrombin solution and fibrinogen solution containing aCD47@CaCO 3…”

“…Al-Thani et al reported a COVID-19 patient who developed complications related to SARS-CoV-2 infection and iatrogenic left subclavian artery pseudoaneurysm after central venous catherization. [134] With the ultrasound guidance, balloon-assisted percutaneous thrombin injection was applied. After 2 days, there was no flow in the pseudoaneurysm and the patient was extubated.…”

Vascular findings in CTA body and extremity of critically ill COVID-19 patients: commonly encountered vascular complications with review of literature

“…Iatrogenic pseudoaneurysm is an exceedingly rare complication; Al-Thani et al presented one case of subclavian artery pseudoaneurysm induced by central venous catheter insertion [ 58 ]. The vessel wall weakness due to underlying endotheliitis secondary to both the COVID-19 virus itself in addition to vascular intervention/procedures might be the causative factor.…”