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Successful bleeding control by a combined conventional surgical approach and video-assisted surgery: a case report
Maurizio Cheli1, Daniele Alberti, Tartufari Adriana
1Department of Pediatric Surgery, Ospedali Riuniti di Bergamo, Italy.
Insights
Central venous catheter (CVC) placement can cause rare but severe vascular injuries. A combined surgical approach using thoracotomy and VATS successfully managed a life-threatening thoracic hemorrhage in a pediatric patient.
Area of Science:
- Pediatric Intensive Care
- Interventional Radiology
- Thoracic Surgery
Background:
- Central venous catheter (CVC) placement is common in critically ill children but carries risks of vascular injury.
- Prompt evaluation for iatrogenic damage is crucial when hemodynamic instability arises post-procedure.
Observation:
- A 12-year-old boy developed tachycardia, hypoxemia, and hypotension after CVC placement.
- A large left hemothorax was identified, and interventional radiology failed to control the bleeding.
Findings:
- Urgent anterolateral thoracotomy revealed a tear near the left subclavian artery.
- Hemorrhage was definitively controlled using video-assisted thoracic surgery (VATS) after initial attempts failed.
Implications:
- This case highlights the potential for severe thoracic vascular injury during CVC placement.
- A combined surgical approach, including VATS, can be effective in managing these life-threatening complications.
Abstract:
The use of central venous catheters (CVCs) nowadays is a routine practice in the treatment of severely acute-diseased children. However, the procedure still carries a risk of morbidity, and severe complications are reported. When respiratory and/or hemodynamic instability develop after the procedure, prompt patient evaluation to exclude iatrogenic damage is mandatory, regardless of the primary patient condition. If a vascular injury related to CVC placement procedure is detected, the availability of an interventional radiologist and/or any surgical facilities plays an important role in the management of this life-threatening complication. We report the case of a 12-year-old boy hospitalized in the Pediatric Intensive Care Unit of our hospital for a severe motorveicle accident, who, about 30 minutes from the percutaneous CVC placement, developed tachycardia, hypoxemia, and hypotension. A chest X-ray confirmed the right positioning of the catheter, the presence also of a large left hemothorax. Interventional radiology took place, but it failed to stop the bleeding. Urgent anterolateral thoracotomy was performed while the patient was kept in a supine position because of a cervical spine luxation. During surgery, bleeding was found coming from the thoracic dome and because of a tear next to the left subclavian artery. Access to that area was technically difficult; after blood and clots were removed, multiple attempts to obtain the hemostasis failed, and definitive control of the hemorrhage was achieved only by video-assisted thoracic surgery (VATS). The postoperative period was uneventful. In this study, the authors discuss the management of this kind of complication and the value of a combined surgical approach (conventional, with a minimal access surgery procedure such as VATS) in the treatment of thoracic vascular injuries related to the insertion of a percutaneous CVC. To the best of our experience, this is the first time in which this combination of procedures has been reported in the literature.