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Published on: April 25, 2014
Internal mammary artery injury after central venous catheterization
Pablo G Eulmesekian1, Augusto Pérez, Pablo G Minces
1Pediatric Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. pablo.eulmesekian@hospitalitaliano.org.ar
Insights
Central venous catheterization can cause rare but life-threatening internal mammary artery injuries. Hypotension during the procedure signals a serious adverse event, requiring prompt diagnosis and embolization for potential life-saving treatment.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Pediatric Critical Care
Background:
- Central venous catheterization is a common procedure in pediatric intensive care units.
- Iatrogenic injuries during central venous catheterization can lead to severe complications.
Observation:
- Two cases of pediatric patients experiencing hypotension and cardiac arrest following central venous catheterization are presented.
- Diagnostic angiography revealed iatrogenic injury to the internal mammary artery in both cases, leading to massive hemothorax.
Findings:
- One patient, a 3-year-old girl, did not survive despite resuscitation efforts.
- A 7-year-old girl with a successful outcome underwent embolization of the injured internal mammary artery.
Implications:
- Injury to the internal mammary artery is a rare but potentially lethal complication of central venous catheterization.
- Hypotension during or immediately after central venous catheterization warrants suspicion of serious adverse events like massive hemothorax.
- Early diagnosis and interventional radiological embolization of the injured internal mammary artery are crucial for life-saving treatment.
Objective:
We describe an infrequent but potentially lethal complication: an iatrogenic injury of the internal mammary artery after central venous catheterization.
Design:
Report of cases.
Setting:
Pediatric intensive care unit.
Patients:
The first patient we report on is a 3-yr-old girl who was severely neurologically damaged and was admitted to the pediatric intensive care unit for aspiration pneumonia and septic shock. Immediately after vein cannulation on the left internal jugular vein, the patient suffered hypotension and cardiac arrest, secondary to an adequately drained massive hemothorax. Restoration of spontaneous circulation was initially achieved, and the patient was transferred to the angiographic suite. Selective angiography during cardiopulmonary resuscitation for a second cardiac arrest revealed a laceration of the internal mammary artery. Resuscitation was not successful, and the patient died. The second case reported is a 7-yr-old girl admitted for bone marrow transplantation. She was electively taken to the angiographic suite for central venous insertion. An infraclavicular approach of the right subclavian vein was attempted, but radioscopy showed the guidewire inside the pleural space. Soon thereafter, the patient became hypotensive and was in shock. Radioscopy showed a large pleural effusion and a massive hemothorax was drained. Selective angiography demonstrated an injured internal mammary artery was embolized. Hemodynamics improved, and the patient was transferred to the pediatric intensive care unit, where she was extubated 12 hrs later.
Interventions:
None.
Conclusions:
Central venous catheter placement in the intrathoracic vein may cause potentially lethal complications in the form of an injury to the internal mammary artery. Hypotension during or immediately after the procedure should be a warning of a serious adverse event, such as massive hemothorax, that may compromise life. Adequate drainage of the pleural cavity may not completely relieve vascular compression if some of the bleeding from an injured internal mammary artery is extrapleural. Early diagnosis and treatment by selective embolization of the injured vessel in interventional radiology is the first therapeutic choice and may be life saving.
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