Internal mammary artery injury complicating a Surfacer inside-out central venous catheterization

We report the case of a near fatal arterial injury in a patient undergoing an inside-out catheter placement through an occluded central venous system using the Surfacer device (Bluegrass Vascular). The right internal mammary artery was inadvertently lacerated during the procedure, leading to cardiovascular collapse. The patient was rescued by transfusion, placement of a chest tube, and coil embolization of the right internal mammary artery. Postprocedure analysis of intraoperative cone beam computed tomography revealed that this injury was predictable on imaging, underscoring the need for advanced imaging guidance to enhance the safety of this procedure.