Abstract

Introduction: Involuntary catheterization of the subclavian artery during an attempt at central venous access is a well-known complication. Historically, these patients are managed with an open surgical approach and repaired under direct vision through an infraclavicular/or supraclavicular incision.

Depending on the situation and the exact location of the arterial lesion, a covered stent, vascular closure device, tract embolization, or gradual reduction of catheter size may be used trans arterial. The method of treatment will depend on a variety of factors.

As for an open approach, the location and anatomy of the subclavian artery pose challenges in surgical exposure, which often require sternotomy or clavicular resection for adequate exposure of vessel and adequate vascular control and perform a primary closure or failing that a Vaso-vessel anastomosis.

Objective: Presentation of a clinical case at the General Hospital of Ticomán, of the Ministry of Health of Mexico City, of an inadvertent lesion of the subclavian artery secondary to the placement of a Central Venous Catheter to all the surgical community

Results: Male patient of 32 years of age, with a history of chronic alcoholism since the age of 19, who goes to the emergency department presenting nausea accompanied by vomiting of gastrobiliary content on more than 10 occasions, as well as intolerance to the oral route, oppressive type abdominal pain of predominance in epigastrium with intensity 9/10, with irradiation towards right hypochondrium, vital signs within normal parameters to physical examination is found with paleness of integuments, with moderate dehydrating, localized abdominal pain in epigastrium and right hypochondrium, Murphy present, positive pancreatic points, being diagnosed with Moderately Severe Acute Pancreatitis of ethyl origin, adverse event is reported for multiple failed attempts in right subkey, as well as multiple failed attempts in left subclavian with metal guide entrapment so it is control x-ray in which metal guide screwing is observed at the level of the 2nd intercostal space, patient is sent to Vascular Surgery, where metal guide is removed and left subclavian central venous catheter is placed without complications, Radiographic control is taken observing Right hemothorax of more than 50% so endopleural probe is placed with an expenditure of 1250cc to its placement of frank hematic appearance, with hemodynamic deterioration, so surgical treatment of urgency performing right anterolateral thoracotomy/Right Subclavian Vascular Examination/Right Subclavian Artery Primary Closure/Middle Sternotomy/Placement of Right Endopleural Probe in 5^th Intercostal Space.

Discussion: The insertion of central venous catheters into the subclavian vein was first described by Aubaniac in 1952. Since then, millions of central venous catheters have been placed each year by medical and surgical specialists in the femoral, internal jugular, and subclavian veins. Involuntary catheterization of the subclavian artery during an attempt at central venous access is a well-known complication. Historically, these patients are managed with an open surgical approach and repair under direct vision through an infraclavicular and/or supraclavicular incision.

Inadvertent arterial puncture with a small-caliber needle is usually benign and occurs in about 5% of cases. The consequences can be much more severe if a large-caliber catheter is placed in the artery (> 7 French), and this is estimated to occur in 0.1 to 0.8% of cases. Accidental artery canalization has traditionally been treated with open surgery, using a supraclavicular and/or infraclavicular approach.

Complications described in the literature by the placement of a central venous catheter include arteriovenous fistulas, pseudoaneurysms, hemothorax, and pneumothorax. A recent case series and a review by Guilbert., et al. showed that immediate removal of the blind catheter from the artery with external compression resulted in a higher complication rate of 47% and a mortality rate of 12%.

Conclusion: Failed insertion attempts are the strongest predictor of complications. Complication rates from failed insertion attempts for a CVC are higher for access through the subclavian vein compared to the internal jugular vein. There are several therapeutic options to successfully manage iatrogenic lesions of the subclavian either through an open approach or endovascular management.

Keywords: Injury; Artery; Subclavian; Central Venous Catheter; Hemothorax

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