Hrev_master Veins and Lymphatics 2015; volume 4:5098 [Veins and Lymphatics 2015; 4:5098] [page 29] Venous anomalies as potentially lethal risk factors during ordinary catheterization Savino Occhionorelli,1 Sergio Gianesini,1 Lorenzo Marinelli,2 Marianna Daniele,2 Sara Chierici,2 Paolo Zamboni1 1Vascular Disease Center, University of Ferrara; 2Department of Forensic Medicine, University of Ferrara, Italy Abstract Venous malformations are rare but possible findings too, constituting a further risk factor for central venous catheter procedures. Herein we describe a case of death because of an innominate vein perforation by a catheter that incidentally was tucked into a sacciform mal- formation. Even if the technology advance- ment is constantly offering us new investiga- tion tools, up to now diagnostic options are limited in the detection of those malforma- tions that could potentially lead to dramatic complications as the described one. The pres- ent work raises the awareness about rare venous anomalies and their potential clinical implications. A proper literature review and diagnostic implementation proposal are reported. Introduction Nowadays, central venous access (CVA) is used on a daily basis worldwide.1 The Seldinger technique for the access has demon- strated to be safe and easy.2 Nevertheless, rare but possible mechanical severe complications have been reported.3 Venous malformations are rare but possible findings too, constituting a further risk factor for CVA-induced complica- tions.4 We herein present an unlucky case of death because of a innominate vein perfora- tion by a catheter that incidentally were tucked in a sacciform malformation. Related review of the literature is reported. Case Report A 77-year old female was scheduled for revi- sion of an excessively shunting brachiocephal- ic dialysis-access. Her anamnesis reported atrial fibrillation with warfarin prophylaxis, dilatative and hypertensive right cardiomyopa- thy, Sjögren syndrome, chronic renal failure leading to a dialytic treatment since 7 years before. A neck venous Doppler ultrasound (DUS) investigation was performed in order to evalu- ate the feasibility of CVA placement. The scan- ning revealed a right internal jugular vein (IJV) thrombosis and a physiological left venous district. While waiting for the scheduled arteriove- nous-fistula revision, after the administration of 500 IU of human prothrombin complex because of a 2.01 international normalized ratio value, an echo-guided QuintonTM catheter (11 Fr; Covidien AG, Dublin, Ireland) place- ment was performed on the left IJV by means of a standard Seldinger technique. The echo- guide was kept all along the vein poking and guidewire positioning, in order to verify the procedure correctness. The catheterization was performed by an expert anesthesiologist. After the guide wire placement the catheter was introduced, finding a moderate resistance after just a few centimeters. The catheter was than retracted and easily positioned at the sec- ond try. The final correct catheter position was confirmed. Some minutes later the patient begun to wag and to pale, suddenly turning pulseless but with a normal cardiac activity, as testified by the constant electrocardiogram monitoring. Despite immediate cardio-pulmonary resusci- tation (CPR), asystole occurred. Atropine and adrenaline were administered, together with red blood cells. Initially the patient responded, while an emergent X-ray demonstrated a massive hemothorax. The computed tomography revealed a left subclavian vein leakage on the posterior surface. An emergent angiography was performed, detecting a bleeding from the left innominate vein. A VACS II Balloon Catheter (Osypka AG, Rheinfelden-Herten, Germany) was positioned in correspondence of the leaking point, so stopping the active bleeding. Despite the procedure and the massive CPR (atropine 4 vials, adrenaline 6 vials, saline solution and colloids 6000 cc, red blood cells 8 IU to counteract a hemoglobin lowest level of 4.3 g/dL) the patient was declared dead 2 h after the CVA placement, without even the time to undergo an emothorax drainage. The autopsy revealed an innominate vein venous malformation that was located 3.8 cm distally to the CVA insertion point, at 1.2 cm from the IJV-innominate vein confluence. The venous anomaly was a circular aneurismal like dilation, presenting a 0.9 cm diameter and a 0.7 cm depth. At its caudal margin a 0.3 cm long linear full-thickness perforation was detected (Figure 1). The forensic scientist report analyzed the adverse event that occurred (the innominate vein rupture), pointing out both the unpre- dictability and inevitability of the fact. No fur- ther legal actions were undertaken. Discussion and Conclusions As testified by their worldwide use, CVA options have significantly improved the treat- ment chance and quality of a significant num- ber of patients.3,4 Nevertheless, since it is very beginning, CVA use has been linked to rare but potentially severe complications.5 According to the literature, mechanical adverse events include arterial puncture (5%), catheter malposition (4%), catheter unsuc- cessful placement (4%), subcutaneous hematoma (1%), cardiac arrest (less than 1%), pneumothorax (1%), hemothorax (1%).3,6 Aspirating blood from the catheter must be considered as not the only needed sign for cor- rect placement: the catheter tip could be out- side the vein, draining a blood collection caused by the vessel injury. For this reason infusion rates and diminished outflow from the catheter are adjunctive signs to be taken in immediate consideration. Venous malformations represent an intrigu- ing topic, often underestimated in its epidemi- ology. According to the literature this condition can be present as structural/morphological and hemodynamic/functional anomalies with an incidence of 1.2.7,8 As initially reported by Gadallah in 1995, awareness of venous malformations is a key element prior to whatever catheterization.4 As pointed out by this forensic scientist report, up to now the diagnostic options are unluckily limited in the detection of such increased risk elements, while no specific cor- relations have been reported among specific anamnesis and the described venous anomaly. Correspondence: Sergio Gianesini, Vascular Disease Center, University of Ferrara, via Aldo Moro 8, 44128 Cona (FE), Italy. Tel.: +39.349.8012304. E-mail: sergiogianesini@hotmail.com Key words: Venous malformations; cerebral venous return; central venous catheters. Received for publication: 8 March 2015. Revision received: 24 April 2015. Accepted for publication: 27 April 2015. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright S. Occhionorelli et al., 2015 Licensee PAGEPress, Italy Veins and Lymphatics 2015; 4:5098 doi:10.4081/vl.2015.5098 No n c om me rci al us e o nly Case Report [page 30] [Veins and Lymphatics 2015; 4:5098] Nevertheless the technology advancement is constantly offering us new investigation tools. In this contest we can postulate that an emerg- ing role of intra-venous ultrasound (IVUS) could happen in the near future. This investigation technique is already available in the highly specialized vascular centers, where it demonstrated to be as effec- tive as a traditional DUS in the detection of venous wall anomalies.9 The herein described case suggests the need of changing the inevitability and unpre- dictability of this kind of lethal adverse event in a so common procedure. Surely not removing a not performing catheterization before further diagnostic assessments is the first advice to avoid imme- diate bleeding from an alternatively patent per- foration.10 The awareness of the described possible vascular malformations opens a discussion regarding the emergent diagnostic protocols, eventually giving direct access to the angio- graphic suite once a bleeding is detected. Another aspect to be taken into considera- tion from now on is the opportunity to access the jugular vein while the contralateral is obstructed. Further investigations are suggested to evaluate the choice of an adequately soft and flexible tip and an immediate routine X-ray control could be integrated by an accurate sonographic assessment, with or without con- trast media, and/or an IVUS assessment to avoid a catastrophic scenario. References 1. O’Grady, Naomi P. Guidelines for the pre- vention of intravascular catheter-related infections, 2011. Atlanta, GA: Healthcare Infection Control Practices Advisory Committee; Centers for Disease Control and Prevention; 2011. Available from: http://stacks.cdc.gov/view/cdc/5916/ Accessed: 6 February, 2014. 2. Higgs ZC, Macafee DA, Braithwaite BD, et al. The Seldinger technique: 50 years on. Lancet 2005;366:1407-9. 3. Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med 2006;21:40-6. 4. Gadallah MF, White R, Vickers B, et al. Awareness of internal jugular, subclavian, superior vena cava and femoral venous anomalies may reduce morbidity of acute venous catheter procedures. Clin Nephrol 1995;44:345-8. 5. Apps MCP, Clark JMF, Skeater SJ. Hydrothorax, a complication of the inser- tion of central venous cannulae. Intens Care Med 1977;3:41-3. 6. Bardosi L, Mostafa SM, Wilkes RG, et al. Contralateral haemothorax: a late compli- cation of subclavian vein cannulation. Br J Anaesth 1988;60:461-3. 7. Tasnadi G. Epidemiology and etiology of congenital vascular malformations. Semin Vasc Surg 1993;6:200-3. 8. Lee BB, Baumgartner I, Berlien P, et al. Diagnosis and treatment of venous malfor- mations. Consensus document of the International Union of Phlebology (IUP): updated 2013. Int Angiol 2014 [Epub ahead of print]. 9. Scalise F, Farina M, Manfredi M, et al. Assessment of jugular endovascular mal- formations in chronic cerebrospinal venous insufficiency: colour-Doppler scan- ning and catheter venography compared with intravascular ultrasound. Phlebology 2013;28:409-17. 10. Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. Br J Anaesth 2013; 110:333-46. Figure 1. Innominate vein Doppler ultrasound-not detectable saccular malformation where the catheter tip were tucked in, causing the vessel perforation. No n c om me rci al us e o nly