Accidental arterial puncture occurs in approximately 1.3% of subclavian approaches and can sometimes result in acute hemorrhages and hemothorax[5–7]. Arteries commonly affected include the carotid, subclavian, brachiocephalic, vertebral, and aorta. Although there are no standardized guidelines for addressing arterial injuries resulting from CV catheterization, it is important to consider the artery's anatomy and lesion, patient comorbidities, and the feasibility and risks of the intervention before deciding on the treatment approach[8,9]. When an artery injury occurs at a site where compression is feasible, it can be effectively managed by removing the needle and manual external compression. However, if the injury occurs at a non-compressible site, such as arterial cannulation, complications like cervical-thoracic hematoma, hemothorax, pseudoaneurysm, arteriovenous fistula, and cerebrovascular accident can arise[10]. Such complications pose significant management challenges and require careful consideration of various strategies.
The main treatment options for arterial cannulation include surgical intervention, endovascular procedures, or a combination of both. Surgery is preferred if the injury is accessible and the patient is stable. For critically ill patients, endovascular methods like occlusion balloons, percutaneous closure devices, and stents may be more suitable[4]. A case of accidental right subclavian artery catheterization was effectively managed with an occlusion balloon, demonstrating its utility for arterial injuries during CV catheterization[11]. Additionally, percutaneous closure devices have successfully sealed arterial punctures by compressing the site with an absorbable anchor inside the artery and an external collagen sponge [10,12]. Some authors have suggested an endovascular approach with a stent-graft, which has proven successful in treating these types of injuries[13,14]. Careful patient selection is crucial: a stent-graft is most suitable when blood flow beyond the injury is intact, the artery has a straight course, and its diameter is adequate for stent placement to prevent distal ischemia[15].
In our case, given the patient's deep arterial cannulation site, merely removing the catheter and applying external compression could lead to additional complications. Furthermore, this method is contraindicated for catheters 7-Fr and larger, as it may cause uncontrollable bleeding, pseudoaneurysm, and arteriovenous fistula[16]. The patient, who was elderly and had suffered a large area cerebral infarction resulting in hemiplegia, was in a generally poor condition. Considering the high risk associated with surgery such as severe pulmonary infection, surgery was deemed too risky. The balloon can temporarily control bleeding, but if a hematoma or pseudoaneurysm develops after its removal, a covered stent may be needed. Given that the brachiocephalic trunk puncture site is less than 1 cm from the origins of the right subclavian and common carotid arteries, placing a covered stent could obstruct these arteries and lead to ischemic events. Inserting two covered stents would be technically challenging, costly, and might face issues with stent sizing and availability. Furthermore, the tortuous anatomy of the brachiocephalic trunk also increases the difficulty of balloon and stent placement. In principle, a ProGlide vascular closure device or a vascular plug could be used for repair. However, with an 8 cm distance from the puncture site to the brachiocephalic trunk entry point—beyond the 6–7 cm operational range of these devices—and the depth of the puncture site, monitoring the closure effect would be challenging. Therefore, we ruled out endovascular procedures such as occlusion balloons, stent implantation, and percutaneous closure devices. Considering the patient's lack of symptoms and to minimize trauma and costs while reducing complication risks, we opted to replace the catheter with a smaller one and wait for a sinus tract to form before removal. In previous cases, a hemodialysis catheter mistakenly placed in the brachiocephalic artery was successfully extracted, and the artery was repaired through a minimally invasive upper sternotomy[17]. Compared to the case and the other mentioned treatments, the catheter replacement approach is less invasive and more cost-effective, although it is more time-consuming. After two interventional procedures, the patient experienced no complications like local hematoma, hemothorax, or pseudoaneurysm, and hemoglobin levels remained stable. Thus, with the required expertise, catheter replacement is a practical and safe alternative when surgical or endovascular options are not feasible.
Utilizing appropriate supportive techniques can improve the success of CV catheterization and reduce the risk of complications[2]. Many studies recommend the use of ultrasound (US) guidance for CV catheterization. Ultrasound (US) provides direct visualization of the target vessel and improves catheterization accuracy. It reduces overall complications by 71–74%, decreases arterial punctures by 72–79%, shortens access time by 30.5 seconds, and requires 1.19 fewer attempts compared to the landmarkguided technique, thereby supporting its use in CV catheterization[18,19]. When ultrasonography is unavailable or difficult to access and there is suspicion of arterial perforation, intervention may be guided by anatomical reference points. Blood gas analysis, pressure transduction, and/or chest X-ray are also valuable in confirming catheter positioning.