Selected Techniques Accidental Superior Vena Cava Access to Central Venous System Lately Disclosed by Thoracotomy Adamu Issaka, Bedrettin Yildizeli, and Mustafa Yuksel, Istanbul, Turkey
We report the case of a 51-year-old woman who underwent hemicolectomy for colon cancer and subsequent hepatic metastasectomy for liver metastases. Right percutaneous infraclavicular subclavian venous port catheterization was performed during the initial operation for chemotherapy. She received chemotherapy after each operation with no reported complications. During a right thoracotomy for lung metastases 2 years after the catheter placement, we noticed the catheter perforating the right subclavian vein and directly entering the superior vena cava. To prevent hemorrhaging during catheter removal, we initially performed the lung metastasectomy, after which we decided to intrathoracically remove the catheter. No complication was observed. To the best of our knowledge, this case is the first of its kind to be reported in the published literature.
INTRODUCTION Central venous catheter insertion for diagnostic and therapeutic purposes is a common and indispensable clinical procedure associated with immediate and late complications. Prolonged venous access devices are needed in cancer patients for chemotherapy. The most commonly noticed complications during catheter insertion are pneumothorax and malposition of the catheter tip. Although the incidence of catheter-related complications has been reported to be as high as 10%, serious or fatal events are rare.1e5 There have been reports of catheter perforation the subclavian vein or the aorta, causing cardiac tamponade.6 To
Department of Thoracic Surgery, Faculty of Medicine, Marmara University, Istanbul, Turkey. Correspondence to: Adamu Issaka, MD, Department of Thoracic Surgery, Marmara University Hospital, Fevzi Cakmak Mahallesi, Mimar Sinan Cadde No: 41, 7. Kat Ust Kaynarca, 34899 Pendik, Istanbul, Turkey; E-mail:
[email protected] Ann Vasc Surg 2014; 28: 1045–1047 http://dx.doi.org/10.1016/j.avsg.2013.05.013 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: December 12, 2012; manuscript accepted: May 16, 2013; published online: December 23, 2013.
our knowledge, there have been no reports of uncomplicated catheter perforating the subclavian vein with direct entry into the superior vena cava. This was accidentally noticed 2 years later during a right thoracotomy for lung metastasectomy and intrathoracically removed with double pursestring technique.
CASE REPORT A 51-year-old female patient with colon cancer underwent right hemicolectomy and simultaneous insertion of a right percutaneous infraclavicular subclavian venous port catheter 2 years earlier. She received six cycles of chemotherapy through the venous catheter, which was uneventful. A year after the initial operation, the patient was found to have liver metastases, and she underwent hepatic metastasectomy followed by nine cycles of chemotherapy through the same venous port catheter. Routine follow-up 2 years after the initial operation revealed two lung metastatic nodules in the right lower lobe. Physical examination revealed symmetrical pectus excavatum deformity. In addition to the metastatic lesions, which indicated pathologic uptake on positron emission tomography/computed tomography (PET/CT), a retrospective examination of the CT revealed symmetrical pectus excavatum deformity and the presence of 1045
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Fig. 1. CT shows symmetrical pectus excavatum and the presence of a catheter in an extravascular path inside the thorax and perforating the superior vena cava to become intravascular.
a catheter in an extravascular path inside the thorax and perforating the superior vena cava to become intravascular (Fig. 1). She was referred to our department for lung metastasectomy. Right lateral mini-thoracotomy was performed. Exploration revealed four metastatic lesions in the lower, middle, and upper lobes. Displacing the upper lobe medially revealed a white foreign body at the apex of the thoracic cavity. Careful examination revealed a 5-cm portion of exposed catheter in the apex of the thorax perforating the right subclavian vein and directly entering the superior vena cava (Fig. 2). Lung metastasectomy and lymph node sampling was performed, after which we decided to intrathoracically remove the catheter. A 4-0 pledgeted purse-string polypropylene suture was placed on the superior vena cava around the entrance of the catheter; the catheter was pulled out from the superior vena cava and the suture was tied in place. Another 4-0 pledgeted purse-string polypropylene suture was placed on the subclavian vein around the exit of the catheter from the right subclavian vein and the distal part of the catheter was pulled well into the thoracic cavity and cut very close to the subclavian vein and the suture then tied in place. This avoided any hemorrhage from the two veins. The distal part of the catheter was then removed from the thorax and the cut end remained in the right subclavian vein. The remaining part of the port catheter was removed subcutaneously in the supine position after closing the thoracotomy. There was no complication and patient was discharged on the fifth postoperative day.
DISCUSSION Central venous catheterization is a commonly performed procedure and, like all other invasive procedures, has a range of complications, including pneumothorax, inadvertent arterial perforation, hematoma, air embolism, vein perforations, arrhythmias, brachial plexus injury, and catheter malpositioning. The most common complication is pneumothorax. Cardiac tamponade is the most lethal complication associated with central line insertion, with a mortality rate of 65% to 90%.6 It occurs when the venous access device perforates the pericardial cavity through the wall of the vein, artery, or the heart. One case of ascending aortic perforation from a central venous line insertion has been reported.6 In our case, the catheter perforated the subclavian vein and directly entered the superior vena cava with a 5-cm portion of catheter exposed in the thorax. A single attempt during the insertion with the needle and subsequent placement of the guide and catheter may have prevented hemorrhage. Also, the presence of pectus excavatum may have caused an anatomic difficulty in the infraclavicular approach to the subclavian vein. If not noticed and managed during thoracotomy, outpatient removal of such a catheter may have resulted in hemothorax, which could have been fatal. There was one report in which the
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a thoracotomy approach. An ultrasound-guided insertion would have prevented the perforation. Ultrasound-guided vascular access has been shown to increase the success rate and reduce complications.8 The use of ultrasound during the insertion would have prevented or detected this type of complication. Generally, catheter placement should be done by an experienced physician using fluoroscopic guidance and ultrasound to reduce the risk of complications, and the catheter position must be verified postoperatively by chest X-ray. The tips of all removed catheters must be checked to insure they are intact. REFERENCES
Fig. 2. Intraoperative view of the catheter perforating the right subclavian vein and entering the superior vena cava.
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