Central Venous Catheter Placement Gone Awry: A Case Report of Right Internal Jugular Central Line Entering Subclavian Artery.

ABSTRACT

While central venous access is necessary for a variety of situations including inadequate peripheral venous access, medication administration, hemodynamic monitoring, vasopressor administration, and hemodialysis, complications during the insertion process are not uncommon. In the United States, in both critically ill medical patients and surgical patients, millions of central venous catheters are inserted yearly. Complications occurring during or immediately following insertion include cardiac, pulmonary, and vascular injuries as well as issues with catheter placement. This case report describes a rare malposition of the central venous cannula into the subclavian artery. Few case reports of accidental subclavian artery catheterization have been published following internal jugular vein insertion. While arterial puncture is a well-recognized complication, accidental subclavian artery catheterization is even rarer than carotid artery cannulation. In the literature review, only two documented case reports for reference were found. There are severe risks associated with arterial cannulation including atherosclerotic plaque dislodgement, stroke, hemothorax, pseudoaneurysm, arteriovenous fistula formation, and death. This case follows a 78-year-old man who was brought in by emergency medical services (EMS) minimally responsive with hemodynamic instability - hypothermic, hypotensive, and tachycardic. The emergent decision was made to proceed with central venous catheter placement in the emergency department and placement was initially confirmed with radiologic evidence. Over the admission course, the patient had improvement in hemodynamic instability with minimal change in mental status, however, the need for further testing revealed the central line that was previously functioning without difficulty was arterial. Imaging demonstrated catheter traversed the internal jugular vein and inserting into the right subclavian artery requiring emergent transfer for vascular and cardiothoracic surgery intervention. While a rare complication, this case, differing from previously documented reports due to the delay in discovery, exemplifies how further investigation may be warranted to confirm catheter placement prior to removal to reduce the risk of life-threatening situations.