1Husameddin El Khudari, 1Darrel Ceballos, 1Andrew J Gunn, 1Souheil Saddekni
1University of Alabama at Birmingham, Birmingham, United States
A 56-year-old female patient with a history of breast cancer, respiratory failure, and refractory ARDS requiring Extracorporeal Membrane Oxygenation. During the placement of a left internal jugular vascular catheter, she became severely decompensated requiring maximum vasopressor dose. Imaging revealed a mispositioned catheter that exits the left innominate vein and courses along the pericardium to terminate in the left pleural space, resulting in a large hemothorax, moderate hemopericardium with pneumomediastinum, and collapsed left lung.
Procedure summary: Subclavian venogram showed extravasation at the proximal inferior aspect of the left innominate vein. A wire was then passed through the mispositioned catheter. A 16 mm balloon catheter was placed across the vascular injury site. The mispositioned catheter was removed and the balloon was inflated for approximately 15 minutes. Subsequent venogram demonstrated improved however persistent extravasation. Then a 12 French vascular sheath was advanced into the extravasation tract. Next, the tract was embolized using two vascular plugs followed by 5 minutes of balloon catheter inflation. Follow up venogram showed complete occlusion of the extravasation tract.
Major venous injury during central line placement is a rare but potentially lethal complication. Related literature is limited to case reports. Emergent surgical intervention is often needed and ranges from direct repair to vascular reconstruction or even ligation of major veins. This can be time-consuming and extensive especially in unstable patients. Endovascular interventions provide a less invasive, relatively faster alternative. Endovascular stenting is one approach to treat such injuries; however, it requires anticoagulation use with its inherent risks. Embolizing the extravasation tract is an alternative, that can be done safely and effectively by using Vascular plugs.