Critical upper limb ischemia due to thrombus in the right subclavian artery: An uncommon complication of right internal jugular vein cannulation

Abstract

Internal jugular catheterization is associated with arterial puncture in 6.3–9.4% of cases and subclavian artery (SCA) injuries are probably under-reported. Several complications like hemothorax, delayed presentation of hemomediastinum due to SCA injury have been reported. We report a case of critical upper limb ischemia due to SCA thrombosis developing a few hours after a difficult right internal jugular vein cannulation without any evidence of initial arterial injury with the finder or introducer needle and which was successfully treated by surgical thrombectomy. Arterial trauma should be kept in mind during subsequent manipulations and at all stages, particularly if a technical difficulty arises during the procedure. Although the ultrasound (US) was not used in this case, US should be used not just to identify the vein, but also to verify guide-wire and catheter insertion. High index of suspicion is necessary for detection of postprocedure thrombosis of SCA. Close monitoring for neurologic and vascular sequelae after the procedure is suggested in all difficult catheter insertions, even without a direct arterial puncture.

Acute upper limb ischemia as a complication of tunneled hemodialysis catheter placement via the right internal jugular vein

“…Acute upper limb ischemia is a very rare complication of IJV catheterization with only two previously reported cases in English language. 6,7 The present report describes a third case. Jung et al 6 reported occurrence of AULI 20 min after accidental arterial puncture with an 18 Gauge introducer needle during IJV cannulation.…”

“…They speculated that AULI was caused by direct needle injury of the right subclavian artery resulting in occlusive thrombosis. 6 Vemuri and Narendra 7 observed AULI in a patient 6 h after inadvertent placement of a 7 French central line in the right subclavian artery during attempted IJV cannulation. Our patient did not undergo angiographic imaging, therefore, it is not possible to identify the underlying mechanism of arterial thrombosis, whether it was caused by direct needle injury of the subclavian artery, or advancement of guidewire within the subclavian artery.…”

“…9 In accordance with that, our patient, along with two previously reported patients, experienced AULI during or after right IJV cannulation attempts. 6,7,9…”

“…9 In accordance with that, our patient, along with two previously reported patients, experienced AULI during or after right IJV cannulation attempts. 6,7,9 Ultrasound guidance has been reported to be associated with decreased rates of arterial puncture during IJV cannulation. 4,5 DUS is helpful for assessing patency of jugular and subclavian veins, determining their relationship with adjacent structures, and guiding the introducer needle and guidewire within the vein.…”

“…[3][4][5] Acute upper limb ischemia (AULI) caused by inadvertent arterial puncture during internal jugular vein (IJV) cannulation is a very rare complication. 6,7 The present report describes the case of a patient who experienced right upper limb ischemia caused by subclavian artery thrombosis developed during placement of a tunneled HD catheter via the right IJV. attempts of AV fistula creation on both upper limbs.…”