Endovascular Rescue After Jugular Vein Catheter Complications: A Case Report

Introduction

Internal jugular vein catheterization serves as a vital vascular access method for hemodialysis in patients with renal failure, providing reliable blood flow for treatment. However, this procedure is associated with a range of potential complications. Unintentional arterial puncture is recognized as the most common complication, with an estimated incidence of 6.3% to 9.4% [1]. Accidental puncture of the internal carotid artery occurs more frequently, whereas puncture of the subclavian artery is relatively uncommon. Due to elevated arterial pressure, improper management of arterial puncture may result in substantial hemorrhage and, in severe cases, hypovolemic shock and systemic hemodynamic instability.

The incorporation of real-time ultrasound guidance has become a crucial component of central venous catheterization protocols, substantially improving success rates and reducing the risk of inadvertent arterial puncture [2]. Nonetheless, the clavicle and adjacent osseous structures may impede ultrasound wave transmission, hindering direct visualization of catheter insertion. Here, we report an exceptional case – to our knowledge, the first of its kind – in which a 12.5-Fr dialysis catheter traversed the internal jugular vein and entered the subclavian artery, advancing to the aortic arch immediately distal to the origin of the vertebral artery, despite the use of real-time ultrasound guidance. Compared with standard central venous catheters, the hemodialysis catheter created a substantially larger arteriotomy that was further compounded by the patient’s end-stage renal disease and associated uremia-related coagulopathy, greatly increasing hemorrhagic risk. The arterial defect, accompanied by concomitant venous injury, was successfully treated percutaneously using 2 suture-mediated vascular closure devices, which achieved hemostasis without extending the venous laceration and preserved vertebral artery flow throughout follow-up.

Case Report

A 64-year-old man was admitted to the nephrology department with a diagnosis of chronic renal failure. Because of severe metabolic acidosis and concomitant heart failure, emergency dialysis was considered necessary. After informed consent had been obtained from the patient and his family, ultrasound-guided catheterization of the internal jugular vein was performed using a 12.5-Fr hemodialysis central venous catheter (ArrowGard Blue®, Teleflex).

During a preliminary physical examination conducted before the procedure, 2 prominent superficial veins (possibly tributaries of the external jugular vein) were identified within the clavicular triangle on the right side of the patient’s neck. To avoid these superficial veins, the puncture site was selected at a lower position near the midclavicular line. The initial puncture yielded dark, nonpulsatile blood from the needle. Subsequently, a guidewire was advanced through the needle, and, after local skin dilation, a double-lumen catheter was introduced. During insertion, elevated intraluminal pressure was noted within the catheter. Postprocedural assessment revealed swelling of the neck posterior to the catheter insertion site, extending toward the occipital region.

To verify the diagnosis, blood gas analysis was promptly performed using blood drawn from the catheter, which demonstrated an oxygen partial pressure of 126 mmHg and thus confirmed arterial placement. Subsequent supra-aortic computed tomography angiography with reconstruction demonstrated that the catheter on the right side of the neck had traversed the right internal jugular vein, entered the posterior midportion of the right subclavian artery, and extended along the right subclavian artery into the brachiocephalic trunk and aortic arch (Figures 1, 2).

In light of these findings, a multidisciplinary consultation resulted in the decision to proceed with immediate emergency intervention. In the hybrid operating room, under general anesthesia, a 1.5-m guidewire (Blackeel®, APT Medical) was introduced through the original sheath into the subclavian artery, permitting exchange of the sheath. Subsequently, 2 suture-mediated vascular closure devices (Perclose®, Abbott Medical) were sequentially deployed over the guidewire, with sutures preplaced. The sutures were then tightened to seal the defect in the right subclavian artery.

After 15 min of compression, no clinically significant hemorrhage was observed at the wound site. A pressure dressing was applied using elastic bandages. The procedure was completed without difficulty, and estimated blood loss was approximately 30 mL.

Hemostasis achieved by postprocedural compression was maintained for 24 h, during which the patient’s vital signs remained stable. Hemodialysis was subsequently initiated via femoral vein catheterization. The patient was discharged after successful transition to a routine dialysis regimen. During follow-up, no evidence of impaired intracranial blood flow was identified.

Discussion

Unintentional arterial cannulation during internal jugular vein catheterization has been sporadically documented in the medical literature [3–6]. After arterial access, direct removal of a 7-Fr sheath is generally considered safe. However, in the present case, direct removal was impractical due to the larger diameter of the 12.5-Fr hemodialysis catheter and the difficulty of achieving effective compression hemostasis at the subclavian artery entry site.

In such situations, open surgical repair is commonly performed. Outcomes have been reported in 2 single-case studies [4,6] that involved local skin incision to allow direct visualization during sheath removal and arterial repair. Nevertheless, this approach is considered more invasive and may require osteotomy of the clavicle or sternum to improve surgical exposure. Additionally, it is associated with potential complications, including injury to adjacent neural structures.

Vascular closure device use has been reported to reduce surgical trauma and costs in individual case reports [3,5]. However, these devices carry inherent risks, including procedural failure and clinically significant hemorrhage. In the present case, the sheath traversed the internal jugular vein to enter the subclavian artery; there was a substantial risk of internal jugular vein laceration and major bleeding during device deployment.

An alternative approach involves endovascular placement of covered stents under interventional guidance; this technique is associated with high safety and success rates [7]. In our case, the arterial rupture was located in a critical region adjacent to the internal carotid artery, and thus it required stents with specialized specifications. The acquisition of such stents is time-consuming, and the urgency of the clinical situation precluded delay. Additionally, stent migration poses a potential threat to intracranial blood supply. Although covered stents may effectively seal the arterial rupture, the associated venous injury would persist. Despite attempts to control the venous defect via compression and local thrombus formation, a substantial risk of secondary bleeding would remain. Therefore, this option was not pursued. Successful arterial closure has also been utilized by vascular surgery departments in China through the sequential downsizing of large-bore sheaths to smaller diameters, combined with tunneled thrombin injection.

Considering these factors, and in the absence of repeated puncture or other high-risk maneuvers during the initial procedure, the decision was made to pursue endovascular suture repair with full preparedness for open surgery if necessary. In the event of suture failure or secondary vessel injury during the procedure, immediate conversion to open surgery would have been performed. Ultimately, the arterial defect was successfully closed without secondary injury to the internal jugular vein or compromise of intracranial blood supply.

This case highlights the critical need for sustained vigilance during internal jugular vein catheterization, regardless of ultrasound guidance. After successful guidewire placement, repeat ultrasound confirmation should be obtained before sheath insertion to verify that the guidewire remains entirely within the venous lumen. Once confirmed, the guidewire position should be maintained without displacement. During advancement of the dilator and sheath, careful manipulation is essential, with immediate cessation of the procedure if resistance is encountered. Any resistance should prompt comprehensive ultrasound reassessment of both guidewire and sheath positions. Forceful advancement must be strictly avoided to minimize the risk of vascular injury. When accidental arterial puncture is suspected, prompt and thorough evaluation is essential for accurate diagnosis. In the present case, inadvertent puncture resulted in traversal of the internal jugular vein with subsequent entry into the subclavian artery. Vascular closure device use in this context proved safe, effective, and minimally invasive. This approach successfully sealed the subclavian arterial defect without exacerbation of the internal jugular vein injury. Follow-up assessments demonstrated no adverse effects on internal carotid artery blood flow, and the patient experienced a favorable recovery.

Conclusions

Internal jugular vein cannulation rarely results in subclavian artery injury. We have reported a case in which a 12.5-Fr catheter traversed the internal jugular vein and advanced to the aortic arch; it was successfully managed using 2 percutaneous suture-mediated closure devices, thereby avoiding open surgery and preserving vertebral artery patency.