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Percutaneous repair of punctured subclavian artery under fluoroscopy.

T he insertion of central venous catheters is a necessary but occasionally dangerous procedure for critically ill patients. It has been estimated that the complication rates range from 1% to 15% (1). The common approaches include internal and external jugular, subclavian, and femoral. The subclavian route is preferred because of its known lower infection rate and its ease of anchoring the catheter to an immobile surface, which is also more remote from body secretions (2). However, the complication of puncturing the adjacent artery is more serious than with other approaches because it cannot be externally compressed. Thus, the insertion of a catheter via the subclavian route is absolutely contraindicated in patients with coagulopathy. Surgical repair is difficult because of the poor exposure to the deep space behind the subclavian vein and the scalenus anterior muscle (3). We report a case in which the subclavian artery was inadvertently punctured in the intensive care unit (ICU) and was repaired percutaneously under radiologic guidance. A 46 yr-old-man suffered C5–6 quadriplegia after a motor vehicle accident 22 yrs ago. He was obese and had a mild kyphoscoliosis. A chronic diverting colostomy was in place because of past nonhealing sacral decubitus ulcers. The patient was admitted to the hospital because of bilateral pneumonia and was subsequently intubated and ventilated in the ICU. A left subclavian catheter was inserted upon admission without complication. However, he remained septic after 7 days, despite broad-spectrum antibiotic coverage. His temperature was 40°C, his white blood cell count was 14.2, and his hemodynamic status was labile, partly because of his autonomic dysfunction. The decision was made to change the central venous catheter to the right subclavian vein and repeat the septic workup. The patient was sedated, put in Trendelenburg position, prepared, and draped in the usual fashion. Under local anesthesia, the search needle was inserted 2 cm caudal to the clavicle and gradually advanced toward the suprasternal notch. On the second attempt, nonpulsatile blood was obtained and a double lumen catheter was inserted in the usual manner. Soon afterward, it was discovered that normal saline could not be infused through the same catheter via gravity and pulsatility was observed at the interphase between the blood and the crystalloid fluid. Blood gases via the new central catheter showed a pH of 7.47, PO2 of 86, PCO2 of 40, HCO3 of 28, at 40% oxygen. A chest radiograph (Fig. 1) was not helpful in confirming the presence or absence of arterial catheterization. Subsequent angiogram confirmed its erroneous location (Fig. 2). The catheter was kept in its place, and a new femoral venous catheter was inserted without complication. After surgical and radiologic consultations, it was decided that a percutaneous closure device should be tried to close the artery (4), because a CT scan showed that it was cleanly punctured and no adjacent hematoma was found. After obtaining consent from the patient and his wife, the patient was transferred to the angiography suite under sedation and full mechanical ventilation with vascular surgeons standing by. As a precaution, an angiographic catheter was inserted via the right common femoral artery into the right subclavian artery past the point of puncture (Fig. 3). An exchange length guidewire was then placed into the artery. This was done so that an occlusion balloon could be easily and quickly positioned across the subclavian arterial puncture site if it was not completely sealed by the percutaneous sealing device. The misplaced subclavian arterial catheter was withdrawn over a standard angiographic wire, and the artery was sealed with an Angio-Seal device (Sherwood, Davis and Geck, St. Louis, MO) in the following steps. First, the 8-Fr sheath supplied with the kit was advanced into the artery. Through this, a 2 10 1 mm polyglycolic acid suture anchor was placed inside the artery and cinched against the arterial wall by tugging on a 2-0 resorbable suture. While maintaining traction on the suture, a 26-mg collagen plug was tamped against the outer aspect of the arterial wall adjacent to the puncture site, and finally, this was held in place by tension on a tamper placed over the suture (Fig. 4). After 20 mins, the suture was cut and the patient was transferred back to the ICU with no external manifestations of his previous catheter apart from the now-sealed puncture site on the skin. Total procedure time was 32 mins; total fluoroscopy time was 3 mins, 16 secs. During the procedure, the patient was hypertensive, and 100 mg of labetalol was required to maintain his systolic pressure below 170 mm Hg so that hemorrhage from the subclavian artery could be minimized. He recovered uneventfully overnight, and there was no further evidence of bleeding. His hemoglobin remained stable at 140 g/L. An additional 1 L of saline and dopamine at 5 g/kg/min for 4 hrs was given on return to the ICU to counteract the residual effect of the labetalol. Subsequent cultures of blood and catheter tip showed negative results. From the Departments of Medicine (JT) and Radiology (MM, LM), Vancouver General Hospital, UBC Site, Vancouver, BC, Canada.