Iatrogenic Posterior Mediastinal Hematoma Secondary to Internal Jugular Vein Cannulation: A Case Report

Abstract

Mediastinal hematomas following internal jugular vein (IJV) cannulation is relatively a rare complication with a very few cases reported in the literature. We hereby report a case of posterior mediastinal hematoma in a 21-year-old primigravida who underwent exploratory laparotomy postcesarean section. In this patient, anatomical landmark guided central venous catheter insertion through the right IJV was attempted using modified Seldinger's procedure in intensive care unit (ICU) after the surgery. A total of three attempts were made. The procedure was abandoned since there was resistance felt during guidewire insertion. A routine postprocedural chest radiograph and subsequent high-resolution computed tomography (HRCT) showed a large posterior mediastinal hematoma that developed as a result of injury to the IJV and carotid artery during the procedure. The patient was hemodynamically stable throughout and hence managed conservatively. The hematoma resolved completely over a duration of 6 weeks. This case is being reported for its relative rarity and to signify the importance of obtaining a routine postprocedure chest radiograph and to state that even mediastinal hematoma can be managed conservatively in asymptomatic patients.

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

“…Inadvertent venous injury during internal jugular vein catheterization has been reported to occur in the puncture site, subclavian vein, superior vena cava, innominate–superior vena cava junction, azygos vein, and right atrium 7,14,19,23,33 . The venous injury may occur when the guidewire becomes stuck in the vessel wall and subsequent insertion of a dilator or a catheter causes a linear laceration, or the dilator or catheter is advanced violently without the guidewire guidance 23,26,33 .…”

“…6,26,28,29,36 Inadvertent venous injury during internal jugular vein catheterization has been reported to occur in the puncture site, subclavian vein, superior vena cava, innominatesuperior vena cava junction, azygos vein, and right atrium. 7,14,19,23,33 The venous injury may occur when the guidewire becomes stuck in the vessel wall and subsequent insertion of a dilator or a catheter causes a linear laceration, or the dilator or catheter is advanced violently without the guidewire guidance. 23,26,33 Fluoroscopy guidance can be used to identify the anatomic location of the guidewire and observe the entire course of the guidewire as it is advanced so as to ensure that it follows a proper anatomic pathway and is not trapped against the vein.…”

“…Vascular complications of internal jugular vein catheterization by insertion site may be due to several reasons such as inexperience, the number of attempts at needle insertion, the use of relatively larger gauge needle, severe dehydration, morbid obesity, and coagulopathy. 23 Inadvertent arterial injury during internal jugular vein catheterization is the most common cause of hematoma formation at this puncture site. The most frequent site of arterial injury is the carotid artery.…”

“…[5][6][7][8] 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][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.…”

“…2 Although formation of a hematoma due to the bleeding complication at this puncture site is rare, 3,4 many unusual case reports are found in the literature. [5][6][7][8] 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][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.…”