Question 23

College Answer

Arterial puncture is a well recognised but uncommon complication of central venous catheter insertion. The potential complications include all those associated with venous/arterial puncture, as well as specific ones associated with the large hole in the artery. Damage to associated structures (nerves [eg. vagus], pleura, oesophagus and trachea!) can result in specific problems (either directly or indirectly from compression [eg. haematoma]). A large bore catheter in a blood vessel can result in air embolus (worse if arterial) or even embolus of atheromatous material (stroke risk). Specific problems related to the arterial site include: toxicity of inadvertently administered drugs (before actual position recognised), higher risk of significant haematoma and blood loss (augmented by coagulopathy especially if removed/dislodged). Referral to surgeons
with vascular experience is essential to facilitate definitive management because of the size of the hole in the artery (suture repair, patch repair etc). If surgical repair is not considered indicated, prolonged pressure for haemostasis has associated potential problems (carotid body, distal flow), and haematoma formation likely.

Discussion

Well, this is embarrassing.

LITFL have a nice page on this topic.

Additonally, the BJMP has an article with a case report of precisely this sort of complication. The author has done a literature search, and presents a list of complications which have been reported in the papers in association with this problem:

• Haematoma formation
  • Airway obstruction; plus the airway will be difficult with the larynx displaced off midline 
  • Cerebral venous outflow obstruction
  • Jugular venous thrombosis due to stasis
  • Haemomediastinum
  • Compromised cardiac function due to RV compression by down-tracking haematoma
• Vascular injury
  • Pseudoaneurysm
  • Carotid dissection
  • Retrograde aortic dissection
  • Aortic valve damage 
  • Arteriovenous fistula
  • Occlusion by flap, catheter or thrombus
• Cerebral injury
  • Ischaemic stroke
  • Atheroembolic stroke
  • Thromboembolic stroke
  • Air embolism
• Peripheral neurological injury
  • Compression damage to the vagus nerve
  • Compression damage to the phrenic nerve
  • Damage to the brachial plexus roots

Interestingly, having spoken to some of the vascular surgeons about such complications, the general opinion seems to be that if you have already dilated the artery and inserted the vas cath, the best thing you can do is suture it in position and leave it there until they arrive. Apparently that is somehow better than taking it out and then putting pressure on a carotid with a vas-cath-sized hole in it.

​​​​​​​How to deal with this problem:

• Prevent further complications
  • ​​​​​​​Keep the catheter in situ
  • Clamp the lumens
  • Label it clearly as "not for use"
  • Assess the urgency of removal and repair, i.e ischaemic stroke symptoms, ongoing bleeding, aortic dissection, known high grade carotid stenosis on the contralateral side, etc
  • Assess the extent of haematoma with imaging: ideally CT, but ultrasound may be enough
  • Correct any coagulopathy
• Deal with the need for vas cath
  • ​​​​​​​Consider the placement of another vas cath into a venous structure at a different site, depending on the urgency for CRRT in this patient
  • Amend the CRRT protocol accordingly to expose this patient to minimal or no anticoagulation (i.e. use pre-dilution or citrate only)
• Deal with the need to remove the vas cath
  • ​​​​​​​Determine the extent of the damage by combination of ultrasound, CT imaging and CXR (eg. to define the tip position)
  • Consult vascular surgeon to repair the carotid puncture, if that's all there is
  • Consult cardiac surgeon to repair any aortic arch damage
• Deal with the consequences for staff and family
  • Debrief with the staff member who inserted the vas cath
  • Offer education and discussion to cover any knowledge gaps
  • Notify appropriate incident management body regarding the insertion
  • Commence the open disclosure process with the patient and family

Nair, Sanil, et al. "A case of accidental carotid artery cannulation in a patient for hemofilter: complication and management." British Journal of Medical Practitioners 2.3 (2009): 57-58.