Ventricular perforation associated with central venous introducerdilator systems

Abstract

Purpose: Cardiac perforation is a recognised complication of guidewire-introducer techniques. These two new cases of right ventricular perforation implicate the dilator-introducer: one directly and the other due to presumed guidewire buckling.Clinical Features: An 85-yr-old man underwent fight subclavian cannulation for triple-lumen and pulmonary artery (PA) catheter insertion before coronary artery surgery. Tachycarclia (120 bpm) and hypotension (60130 mmHg) evolved over the next 40 rain and resolved with evacuation of 200 ml of clot from the pericardial sac. A ragged 4 mm laceration of the ventricular wall was localised and oversewn without further consequence.A 60-yr-old man with inferior vena caval thrombosis was scheduled for Greenfield filter insertion. The right internal jugular vein was cannulated using the guidewire-introducer technique. Introduction of the introducer-dilator system precipitated cardiovascular collapse. Resuscitation was unsuccessful and post-mortem revealed right ventricular perforation and pericardial tamponade.Conclusion: These cases suggest that shorter introducer-dilators would be safer and probably equally efficacious. The need for a high index of suspicion and rapid therapeutic intervention is also highlighted.Objectif : La perforation cardiaque est une complication bien connue de l'utilisation du guide m~taJlique pour le cath&Erisme. Deux cas de perforation ventriculaire droite mettent ici en cause le dilatateur-introducteur dont la premiere directement, la deuxiEme par enroulement possible du guide m~taJlique. Conclusion : Ces cas portent h croire que que des introducteurs-dilatateurs plus courts seraient moins dangereux et peut-&re aussi efficaces. La nEcessitE de demeurer vigilant et d'intervenir rapidement est soulign4e.

The Vessel Dilator for Central Venous Catheter Placement: Forerunner for Success or Vascular Misadventure?

“…Dilator shaft width has been reported to vary from 6 to 12 French [10], with lengths of 10–19 cm [10] and 6–21 cm [11]. For most procedures, the length of dilators provided in CVC kits has been reported as excessive [10–13]. Depth markings along the dilator's length are lacking.…”

“…A number of cases of dilator‐related and suspicious dilator‐related and/or dilator/sheath‐introducer‐related complications have been discussed in the literature [10–13,15–29]. Jobes et al [16] reported inadvertent intra‐arterial placement of a 20‐gauge catheter/sheath‐introducer intended for internal jugular placement, which upon removal required local pressure for an “insignificant hematoma.” The patient was initially stable but died 12 hours later of exsanguination and a right hemothorax.…”

“…Porter et al [12] described two cases of ventricular perforation attributed to dilator/introducer systems. In the first case, during elective coronary artery surgery in an 85‐year‐old man, hypotension and tachycardia occurred after the use of a 23 cm introducer.…”

“…While no vascular access procedure is completely free of potential complications, in order to minimize the incidence of complications, suggestions and recommendations for the use of dilators and dilator/sheath‐introducer systems are offered in the medical literature. They include confirming guidewire placement within the SVC [23–24,32]; differentiating the arterial and venous pressure waveforms prior to dilation or catheter insertion [28,29]; attaching a sterile extension tube to the initial cannulating needle/catheter and withdrawing blood that is permitted to flow back into the vessel, thereby confirming venous cannulation [30,33]; avoiding excessive force [10,13] and deep insertion [10,11,13,23]; using a smaller rather than a larger dilator when there is a choice [10]; minimizing the use of long dilators [12]; limiting the length of dilators to 10 cm [10]; advancing the tip of the dilator only as far as necessary to enter the target vessel and dilating the track sufficiently to permit subsequent insertion of the more flexible catheter [11]; inserting no further than 5 cm beyond the point of subclavian vein entry [13]; applying no more than 8 cm total dilator penetration depth as the usual maximum [10]; never advancing the dilator tip farther than the tip of the guidewire [11,13,23]; using ultrasound for vessel identification [18–22,33] and for reducing the possibility of fistula formation [18]; and following up with radiography when there is questionable device tip location [13,24,25]. It was also recommended that a vascular surgeon be consulted and that the dilator or large needle remain in situ after suspecting inadvertent intra‐arterial placement.…”

Severe vascular complications of central venous line placement

“…Generally, the complications are divided into early and late categories. Early complications include pneumothorax and chylothorax [2], injury of carotid or subclavian arteries or even aortic arch [3], arteriovenous fistula [4], ventricular perforation [5], pericardial tamponade [6], air embolization, blindness [7], stroke and arrhythmias. Late complications include infection, thrombosis, pericardial effusion, and late mediastinal hemorrhage due to erosion of the vessels [8].…”