Percutaneous Closure of the Inadvertent Subclavian Artery Puncture During Central Venous Catheterization

Introduction

We report the use of an Angio-Seal™ Vascular Closure Device (St. Jude Medical, Minnetonka, MN) to close the arterial puncture site of the left subclavian artery (LSA) during inadvertent central line placement.

History

A 56-year-old male presented with a history of severe peripheral vascular disease (PVD) and non-healing ulcer of the right foot and toes. He underwent a right femoral-to-posterior tibial bypass graft. During the preparation for intubation, a 7 Fr triple-lumen catheter was inadvertently placed in the left subclavian artery at the infraclavicular level. Arterial access and arterial wavelength were confirmed immediately. The catheter was left in place with heparinized flush. Due to the tenuous vascular condition of the patient, it was beneficial for the patient to remain heparinized after the procedure.

Procedure

Arterial access was achieved in the right common femoral artery with a 4 Fr micropuncture set system (Cook Inc, Bloomington, IN) followed by a 4 Fr sheath. Because the patient had a poor left brachial pulse with severe PVD, femoral access was selected. A 4 Fr headhunter catheter was placed in the proximal left subclavian artery in order to visualize the puncture site, assess its closure and provide a rapid means to occlude the vessel, should active extravasation occur. The 0.018" guidewire from the Angio-Seal system was advanced through the triple lumen catheter followed by the Angio-Seal sheath. The accompanying delivery system, including the reabsorbable collagen plug and anchor, were then deployed. There was a slight resistance while pulling back the thin tamper tube, which may have been pushed against the clavicle and the collagen plug. Contrast injection was performed immediately after Angio-Seal deployment and revealed a small amount of extravasation. After a few minutes, a repeat angiogram showed hemostasis with no limitation of flow in the subclavian artery. The vascular surgery team performed a one-month follow up. Under ultrasound evaluation, the left arm and shoulder showed no evidence of pseudoaneurysm or decreased flow. The patient exhibited improvement of the right foot ulcer as well.

Discussion

Management of penetrating and blunt trauma to the subclavian artery has traditionally been in the realm of surgical treatment. However, as Demetriades et al stated, there is a high mortality, 14.8–32%, depending upon the condition of the patient.¹ An alternative approach to these technically challenging injuries was offered with the advent of endovascular treatment modalities. There have been several well-written reports on endovascular management of arterial injuries involving the subclavian artery.^2–4 One of the most common means has been the placement of a covered stent. Because of the distal subclavian location of this injury, a self-expandable covered stent would have the better choice. Still, the long-term patency is an area of concern given the proximity of the clavicle and first rib, resulting in constant compression of the stent. Furthermore, there appears to be a high rate of severe stenotic and occlusive lesions that tend to develop with young patients undergoing covered stents for subclavian injuries. So for minor inadvertent injuries of the subclavian artery, covered stents may not be warranted. A second option would have been to pull the catheter and hope to hold pressure over the entry site to cause hemostasis. This method has been used successfully in the past. However, compression was not an option in this case because of the concern with maintaining a heparinized patient, as well as the puncture location, which was just inferior to the clavicle. The third option of using a percutaneous closure device included the use of the Angio-Seal, which was used versus the Perclose suture-mediated closure vessel device (Abbott Vascular Devices, Redwood City, CA). Nicholson et al reported 4 cases of 9 patients who responded well to the use of either of these closure devices.5 Interestingly, they successfully used an Angio-Seal device in the treatment of an inadvertent carotid artery puncture. Given the oblique long tract through the skin and the sudden vertical direction into the artery, it was assured that the Angio-Seal sheath would track easier into the vessel. A fourth option would be to advance a percutaneous angioplasty balloon catheter over a wire, temporarily occlude the vessel for 2–4 minutes and then recheck. This technique, using a standard angioplasty balloon catheter (slightly larger diameter than the vessel itself), can also work quite well. This was considered as well should the closure device option have failed.

Conclusion

Central venous access has become an increasingly common procedure in modern medicine. Inadvertent iatrogenic injury to an adjacent major artery during attempted central venous cannulation is an uncommon but potentially lethal complication. We reported a interesting application of a percutaneous closure device to treat an iatrogenic puncture wound to the subclavian artery.

Correspondence: wholey@uthscsa.edu