Intraoperative vascular and pulmonary complications
Inadvertent arterial puncture The anatomical proximity of vessels (e.g., the internal jugular vein IJV runs anterior to the carotid artery) creates a risk of arterial puncture. This is especially dangerous during subclavian vein access, as the subclavian artery is not amenable to effective manual compression.
- Prevention: using micropuncture needle kits.
- Management: upon puncture, remove the needle and apply firm compression (5–10 minutes, 10–15 minutes for the carotid artery). If a non-compressible zone is injured or a large-bore catheter has already been inserted, use closure devices (e.g., off-label Angio-Seal), balloon tamponade, stenting, or surgical intervention.
Central vein rupture Occurs during forceful advancement of rigid introducers without proper fluoroscopic guidance. The maximum risk is observed when navigating the bend of the brachiocephalic vein via the subclavian approach, which can lead to massive pleural hemorrhage.
Pleural puncture The lung apex lies slightly above the clavicle. Too low a puncture can cause pneumothorax or hemothorax (the risk is especially high in pulmonary emphysema). Prevention: avoiding "blind" puncture in favor of ultrasound guidance (in-plane approach). If a large pneumothorax occurs, pleural cavity drainage is indicated.
Venous air embolism (VAE) and arrhythmias
Venous air embolism When a catheter is inserted during inspiration, air can be sucked in through the introducer (a characteristic sound is heard). A large air bolus blocks the right ventricular outflow tract, causing respiratory and circulatory arrest. Risk factors: low circulating blood volume (CBV), low central venous pressure (CVP), and formation of a short subcutaneous tract.
- Treatment: ask the patient to cough, place them in the left lateral decubitus position with the upper body elevated (Durant’s manoeuvre), administer 100% non-rebreather mask oxygen, and apply strong aspiration to the catheter. In case of massive embolism, call a resuscitation team.
- Prevention: valved introducers, reverse-Trendelenburg position (reverse-Trendelenburg), breath-holding, or humming by the patient during placement.
Arrhythmias Occur when the guidewire enters the right atrium and mechanically irritates the atrioventricular (AV) node. This causes tachycardia and chest pain. Usually, simply pulling the guidewire back is sufficient. If hypotension develops, intravenous adenosine is administered and the resuscitation team is called.
Delayed complications and catheter dysfunction
Fibrin Sheath Protein scar tissue covered by endothelium can form around the catheter within a week. It blocks the catheter holes and fixes it to the vessel. The "valve effect" occurs: solutions can be infused, but blood cannot be aspirated. Diagnostics: linography (contrast injection through the catheter). Treatment: thrombolysis, wire-guided catheter exchange with balloon venoplasty, or mechanical removal (stripping) of the sheath using an endovascular snare (snare) via femoral access.
Thrombosis and infection
- Lumen thrombosis occurs due to inadequate flushing. Treated with aspiration or administration of tissue plasminogen activator (r-TPA). Vessel thrombosis manifests as arm edema and requires anticoagulant therapy.
- Infection presents with redness, hyperthermia, and cellulitis along the catheter tract. In immunosuppressed patients, the catheter is often mistakenly removed when searching for a fever source without apparent local signs.
Mechanical problems
- Costoclavicular pinch syndrome (costoclavicular pinch): with a medial subclavian approach, the catheter is compressed between the first rib and the clavicle, leading to its fracture.
- Fragment embolization: broken-off catheter parts migrate into the right heart chambers or pulmonary arteries. Retrieved using an endovascular snare.
- Tip migration: particularly characteristic of left-sided approaches. The tip may loop, for example, into the azygos vein arch.
Diagnostic evaluation (Imaging)
To assess the position of long-term catheters, plain chest radiography or CT scout images (CT scout images) are used, and in complex cases, multiplanar reconstruction (MPR). In the radiology report, the physician must indicate:
- The exact type of inserted catheter.
- The localization of its tip (normally the cavoatrial junction; for hemodialysis, the upper part of the right atrium).
On follow-up CT scans after interventions, the radiologist must purposefully rule out pneumothorax, catheter tip fracture, venous thrombosis, and massive pulmonary embolism (PE).
Briefly: answers to topical questions
What are the absolute contraindications to central venous catheterization?
Absolute contraindications to central venous catheterization include:
- inflammation at the planned access site;
- recent surgery at the access site.
How does thrombosis of a cannulated central vein clinically manifest?
Catheter-related vessel thrombosis clinically manifests as arm edema. Imaging modalities are used to confirm the diagnosis.
Which specific drugs are used for thrombolysis in catheter lumen thrombosis?
To restore patency in catheter lumen thrombosis, intraluminal administration of fibrinolytic agents is used:
- recombinant tissue plasminogen activator (r-TPA) is injected into the catheter lumen;
- alteplase is used at a concentration of 1 mg/mL with a 40-minute dwell time;
- urokinase is used at a concentration of 5000 IU/mL with a 40-minute dwell time.
Class and exam questions
Why must the patient lie supine during catheter removal?
The supine position increases central venous pressure. This may slightly increase bleeding volume from the puncture site, but it critically reduces the risk of fatal venous air embolism.
What to do if the catheter flushes, but blood cannot be aspirated?
This is a classic sign of fibrin sheath formation (valve effect). Linography under fluoroscopy must be performed to confirm the diagnosis, after which thrombolysis, catheter replacement, or endovascular stripping should be considered.
How to prevent pleural puncture during central catheter placement?
"Blind" puncture using anatomical landmarks should be abandoned in favor of real-time ultrasound guidance. It is also important to avoid an overly low puncture site in the supraclavicular fossa.
What else to study on this topic
- Balloon tamponade technique in inadvertent subclavian artery puncture
- Endovascular "stripping" of a fibrin sheath using a snare
- Peculiarities of catheter tip positioning in hemodialysis (Tesio catheters)
- Off-label use of closure devices
- Radiological presentation of air embolism in the azygos arch and pulmonary trunk
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