Endovascular Management of Arterial Injuries Related to Venous Access: A Retrospective Review of 10‑Year Single-Center Experience

Abstract

Purpose: Retrospective review of the pattern and management techniques of arterial injuries related to central venous access with long-term outcomes. Materials and Methods: Between January 2007 and November 2017, a total of 20 patients (13 females) were included with the mean age of 63 (28-89 years) and mean body mass index of 25.75 (13.3-36.5). Venous access procedures included central venous catheter (CVC) placement, dialysis line insertion, or endovascular venous procedures. The study excluded patients who had arterial injuries related to arterial access, such as postarterial line placement, postangiography, or percutaneous coronary interventions. Results: Iatrogenic arterial injuries occurred after attempted venous access procedures involving the common femoral vein (n = 18) and subclavian vein (n = 2). Injuries were related to CVC placement (n = 5), temporary dialysis catheter (n = 14), and inferior vena cava filter insertion (n = 1). Nine patients had transarterial venous catheter insertion complicated by active bleeding from pseudoaneurysm and arteriovenous fistula. Other injuries included isolated fistula (n = 3), isolated pseudoaneurysm (n = 4), isolated branch injury (n = 2), and intra-arterial insertion (n = 2). Endovascular management included stent-graft placement (n = 14), embolization of bleeding vessel (n = 2), and thrombin injection for pseudoaneurysm (n = 2). Conservative management with manual compression achieved hemostasis in two patients. Technical success was achieved in 100%. One patient required repeat angiography and embolization of bleeding branch vessel following stent-graft placement to control bleeding fistula and pseudoaneurysm. Clinical success was achieved in all patients. Procedure-related complications included puncture site hematoma (n = 1) and partially occlusive thrombus/spasm of deep femoral artery after stent-graft placement. Six patients (33%) died within 20 days after the procedure (3-20 days) due to other comorbidities. Three additional patients (16%) died during the same hospital admission at the time of the procedure (38-114 days). There were no reported complaints related to possible stent-graft stenosis or occlusion at mean follow-up time of 5 years (50 days-8.64 years) in all seven patients who survived after stent-graft placement procedure. Conclusion: Despite technically successful endovascular management of arterial injuries related to venous access in critically ill patients, the mortality rate remains high due to other comorbidities. Allowing for the small sample size, stent-graft placement for arterial injuries in this cohort of patients appears to be an effective option with high long-term patency rate.

Narrative review of vascular iatrogenic trauma and endovascular treatment

“…When venous access is attempted, there is a risk of inadvertent arterial access or arterial injury. Without ultrasound guidance the risk of accidental arterial access is 15%, but with ultrasound guidance the risk drops to 1% (85,86). When accidental arterial access occurs, management usually involves endovascular or open surgical removal and vessel repair (85,86) (Figure 19).…”

“…When accidental arterial access occurs, management usually involves endovascular or open surgical removal and vessel repair (85,86) (Figure 19). Other factors that contribute to arterial injury include previous radiotherapy, obesity, lack of operator experience, previous surgery at site of vascular access, and multiple venous access attempts (85,86). In addition to inadvertent arterial access other potential complications include hematoma, (85,86).…”

“…Iatrogenic injury during bone marrow biopsy is rare, but has been reported in the literature (95). Reported cases of arterial injury include circumflex iliac artery, iliolumbar artery, superior gluteal artery, median sacral artery, and anterior hypogastric artery (86,(96)(97)(98)(99)(100)(101). Although complication is rare, the most commonly reported complications include infection, hemorrhage, nerve injury, fracture, or needle tract seeding (95) (Figure 21).…”