Missed carotid artery cannulation: a line crossed and lessons learnt

Area of Science:

• Neuroscience
• Vascular Surgery
• Anesthesiology

Background:

• Central venous catheterization is a common procedure with potential complications.
• Iatrogenic carotid artery injury is a rare but serious adverse event during central venous catheter insertion.

Observation:

• A case report detailing inadvertent placement of a central venous catheter into the right common carotid artery.
• Subsequent intra-aortic infusion of propofol led to neurological injury.

Findings:

• Radiological imaging confirmed bilateral ischemic infarcts in the posterior fossa and right cerebral artery territories.
• Findings were consistent with an embolic source, likely from the inadvertent arterial cannulation.

Implications:

• Discussion explores causes, sequelae, management, and prevention strategies for iatrogenic carotid artery injury.
• A proposed algorithm for managing iatrogenic carotid artery cannulation is presented to improve patient safety.