30th Annual Scientific Meeting of HKCR 2022

Interventional radiological management of inadvertent arterial injury

after central venous catheterization and retained foreign body
Dr SC Wong , SY Lam, KH Stephen Wong, HF Chan, LF Cheng. Radiology Department, Princess Margaret Hospital
Introduction
Complications related to central venous line catheterization, such as inadvertent arterial injury (resulting in hemorrhage, pseudoaneurysm
formation, arterial occlusion, arteriovenous fistulation, etc) , catheter dislodgement or retained intravascular medical devices may entail significant
morbidity or mortality. Interventional radiological management has emerged as a safe and effective first line management with minimal
invasiveness, which is often better tolerated by critically ill patients with avoidance of major surgical repair.

Warning signs that may suggest post catheterization arterial injury Initial management
• Reflux of pulsatile or fresh blood within the catheter - Refrain from immediate withdrawal of malpositioned
• Neck hematoma catheter, which can exert tamponade effect to reduce
• Abnormal course of venous catheter hemorrhage before definitive hemostatic measures and
• Acute neurological deficit provide endovascular access to the injured vessel.
• Recurrent episodic wound bleeding - Urgent imaging (eg. CT angiography) to
1) delineate the course of malpositioned catheter or
Interventional radiological treatment options of arterial injury
localize retained vascular device,
(can be sequential or combined approach) 2) evaluate for vascular complications and
3) guide treatment planning
• For arterial injury: see chart on left side
• For retained foreign body: consider
venous access site (eg IJV/ CFV),
extraction route, size/ type of retrieval
tool available
- Multidisciplinary collaboration involving interventional
radiology team, vascular surgeons and parent clinical
team.

1A 1C 2A 2B 2C

Fig. 1 ) Right subclavian artery pseudoaneurysm (Fig 1A arrow in CTA
with 3D reformat) complicating IJV catheterization. Successful
percutaneous needle puncture of PsA with thrombin injection
performed under ultrasound guidance (Fg 1B orange arrow) and real
time monitoring. Completion DSA (1C) confirmed obliterated
pseudoaneurysm with patent subclavian, vertebral and internal
mammary arteries (IMA). Superficial location and narrow neck of PsA
(1B) are favourable factors for successful percutaneous embolization.
3A
Fig 2) Malpositioned triple lumen central venous catheter into right
subclavian artery (arrow in DSA in Fig 2A). Limited neck dissection by
vascular surgeons to gain access for deployment of vascular closure device
and repair of internal jugular vein. Removal of malpositioned catheter
over a 0.035 Terumo guidewire. Repair of right subclavian artery by
Proglide Perclose device (arrow in Fig 2B ).Patent right subclavian artery
on completion right subclavian angiogram (Fig 2C). Note the deployment
of a safety guidewire (260cm Amplatz superstiff guidewire ( Asterisk in Fig
2B) as a fail-safe measure for urgent balloon tamponade or stenting in
3B case of unsuccessful vascular closure.

Fig 3) Another case of post catheterization right subclavian artery

pseudoaneurysm (arrow in DSA in Fig 3A), with successful 4A 4B 5A 5B
treatment by covered stent (arrow in Fig 3B) deployment distal to Fig 4) Retained Hickman catheter fragment in right atrium (4A), with retrieval by
vertebral arteries origin, preserving patency of the subclavian, 6Fr En-snare (4B) deployed through transjugular route. Fig 5) Retained guidewire
vertebral arteries and IMA. coating post right IJV catheter removal (5A), retrieval with biopsy forceps (arrow
in 5B ) through vascular sheath at right IJV (star in 5B)
Conclusion
Interventional radiological treatment of central venous line complications and retrieval of retained foreign body with multidisciplinary
collaboration is an effective, minimally invasive first line management option with reduced morbidity and enhanced patient recovery.
References. 1) KTF Ng, CM Chau, HF Chan, LF Cheng, KF Ma, KM Chan. Percutaneous Repair of Inadvertent Brachiocephalic Arterial Puncture by Closure Device: A Case Report. Hong Kong J Radiol 2020 Jun;23(2):134-8. 2) Lo AX, Hon TY, Luk WH, Loke TK, Lo SS, Chan JC. Ultrasound-guided thrombin injection for pseudoaneurysms: a case series at a local hospital. Hong Kong Med J. 2012;18(4):333-337. 4
3)Woodhouse JB, Uberoi R. Techniques for intravascular foreign body retrieval. Cardiovasc Intervent Radiol. 2013;36(4):888-897. doi:10.1007/s00270-012-0488-8. 4) Madhusudhan, Kumble Seetharama et al. “Interventional Radiology in the Management of Visceral Artery Pseudoaneurysms: A Review of Techniques and Embolic Materials.” Korean Journal of Radiology 17 (2016): 351 - 363.