Minimally Invasive Approach to Managing Brachiocephalic Trunk Cannulation Complicating Central Venous Catheterization: A Case Report

Minimally Invasive Approach to Managing Brachiocephalic Trunk Cannulation Complicating Central Venous Catheterization: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Minimally Invasive Approach to Managing Brachiocephalic Trunk Cannulation Complicating Central Venous Catheterization: A Case Report Haihui Deng, Bin Chen, Deti Peng, Fuwen Pang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4870102/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Oct, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted 17 You are reading this latest preprint version Abstract Background Central venous catheterization, crucial for device insertion, monitoring, medication, and fluid resuscitation, commonly uses the subclavian, internal jugular, and femoral veins. Despite its general safety, complications like arterial puncture can be life-threatening, requiring rapid diagnosis and treatment. Case presentation A 74-year-old woman with a cerebral infarction underwent right subclavian vein catheterization. The catheter was mistakenly placed in the brachiocephalic trunk, with its tip in the ascending aorta, as confirmed by computed tomography and digital subtraction angiography. Due to high surgical risks, catheter replacement was chosen instead of surgery or endovascular treatment. One month after the initial placement, the catheter was replaced with a smaller one, and another month later, it was removed without complications. Follow-up scans showed no leakage, and the patient’s vitals remained stable. Three months later, no abnormalities were observed. Conclusion This case demonstrates the effective use of a catheter replacement technique as a minimally invasive repair method when other options are impractical. Ultrasound guidance is also recommended to improve the procedure's accuracy and safety. Central venous catheterization Brachiocephalic trunk Cannulation Catheter replacement Figures Figure 1 Figure 2 Background Central venous (CV) catheterization is a vital procedure used for various purposes, including device insertion (such as pacemakers and implantable cardioverter-defibrillators), hemodynamic monitoring, the administration of medications, and rapid fluid resuscitation[1,2]. Subclavian vein, internal jugular vein and femoral vein are commonly used access routes. Although CV catheterization is widely practiced and generally considered safe, numerous complications such as arterial puncture, hemothorax, pneumothorax, and infection have been reported[3]. Among these, accidental arterial cannulation can be particularly life-threatening[4]. Rapid diagnosis and prompt treatment are essential when this complication arises. This case describes a patient who underwent unintended cannulation of the brachiocephalic trunk during CV catheterization. The complication was addressed through a catheter replacement approach, which involved an exchange of the CV catheter and the establishment of a sinus tract for successful repair. Case presentation A 74-year-old female patient with a large cerebral infarction and hypertension underwent central venous catheterization via the right subclavian vein using a 7-F double-lumen catheter at our hospital. Due to blood backflow from the right subclavian vein catheter, the infusion was paused. Blood gas analysis from the catheter showed 7.509 of pH, 93.2 mmHg of PO 2 , 36.5 mmHg of PCO 2 , 99.4% of SO 2 , 5.6 mmol/L of base excess, and 3.2 mmol/L of lactate. It was suspected that the catheter had been mistakenly placed in an artery. A computed tomography (CT) scan and digital subtraction angiography (DSA) both indicated that the catheter had entered the brachiocephalic trunk, with its tip located in the ascending aorta (Fig. 1 A, 1 B; Fig. 2 A, 2 B). Prolonged arterial catheter placement poses risks like bleeding, infection, and thrombosis. Additionally, the puncture site is near the origins of the right subclavian and right common carotid arteries, complicating endovascular treatment. Surgery was recommended but declined due to the patient's condition and the family's concerns about the high risk associated with the procedure. Since the patient was asymptomatic and the puncture site showed no issues, regular catheter care and changes were advised, with plans to remove the catheter once a sinus tract forms. One month later, the CV catheter was replaced with a 5-F single-lumen catheter under DSA guidance. Follow-up DSA and CT scans showed no leakage from the brachiocephalic trunk (Fig. 1 C, 1 D; Fig. 2 C, 2 D). A month after, the catheter was removed with DSA confirming no leakage, and no issues were observed during withdrawal. Another month later, the catheter was removed. DSA showed no leakage from the brachiocephalic trunk, and during the slow withdrawal process, no significant leakage into surrounding tissues or vessels was observed (Fig. 2 E, 2 F). The patient’s vital signs were stable, and no hematoma or swelling was observed. Follow-up CT scans showed no bleeding (Fig. 1 E, 1 F), and hemoglobin levels remained stable (87–115 g/L). The 3-month follow-up showed no abnormalities. Discussion 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. Conclusion We report a rare and challenging case of brachiocephalic trunk cannulation after CV catheterization. This case illustrates the successful use of a CV catheter replacement approach for brachiocephalic trunk repair, highlighting its effectiveness as a minimally invasive treatment when surgical or endovascular options are unavailable. Furthermore, US guidance is recommended to enhance the accuracy and safety of CV catheterization. Declarations Acknowledgements Not applicable Authors’ contributions Deng HH and Chen B contributed equally to this work. All of the authors read and approved the final manuscript Funding Financial support was provided by the National Natural Science Foundation of China (82074384). Availability of data and materials Data sharing not applicable to this article as no datasets were generated or analysed during the current study. Author Contributions Deng HH and Chen B contributed equally to this work. The treatment plan was designed by Pang FW, Deng HH and Chen B. Patient treatment was performed by Deng HH, and Chen B. Deng HH and Pang FW wrote the manuscript. Deti Peng and Pang FW participated in manuscript revision. All authors approved the final version of the manuscript. Ethics approval and consent to participate Not applicable Consent for publication Informed consent was obtained from the patient Competing interests The authors declare that they have no competing interests References Kolikof J, Peterson K, Baker AM (2024) Central Venous Catheter. Shin HJ, Na HS, Koh WU, Ro YJ, Lee JM, Choi YJ, Park S, Kim JH (2019) Complications in internal jugular vs subclavian ultrasound-guided central venous catheterization: a comparative randomized trial. INTENS CARE MED 45: 968–976. Soltes GD, Barth MH, Roehm JO (2003) Preventing complications of central venous catheterization. NEW ENGL J MED 348: 2684–2686, 2684–2686. Cohen JE, Moshe Gomori J, Anner H, Itshayek E (2014) Inadvertent subclavian artery cannulation treated by percutaneous closure. J CLIN NEUROSCI 21: 1973–1975. Rezayat T, Stowell JR, Kendall JL, Turner E, Fox JC, Barjaktarevic I (2016) Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back. WEST J EMERG MED 17: 216–221. Gawecki W, Dabrowski P, Smuszkiewicz P (2006) [Central venous catheter as a reason of bleeding after tracheotomy]. POL J OTOLARYNGOL 60: 593–597. Bell J, Goyal M, Long S, Kumar A, Friedrich J, Garfinkel J, Chung S, Fitzgibbons S (2020) Anatomic Site-Specific Complication Rates for Central Venous Catheter Insertions. J INTENSIVE CARE MED 35: 869–874. Dornbos DR, Nimjee SM, Smith TP (2019) Inadvertent Arterial Placement of Central Venous Catheters: Systematic Review and Guidelines for Treatment. J VASC INTERV RADIOL 30: 1785–1794. Akkan K, Cindil E, Kilic K, Ilgit E, Onal B, Erbas G (2014) Misplaced central venous catheter in the vertebral artery: endovascular treatment of foreseen hemorrhage during catheter withdrawal. J VASC ACCESS 15: 418–423. Coroleu LD, Meca SM, Rodriguez-Otero LC, Masaller JM (2019) Detection and management of inadequate vascular access device implantation in the subclavian artery. Radiologia (Engl Ed) 61: 510–513. Kably IM MD (2015) Endovascular Management of Iatrogenic Subclavian Artery Catheterization During Single-Incision Chest Port Placement. Vascular Disease Management E20-E25. Zhang J, Lv Y, Tian H (2019) Treatment of inadvertent subclavian artery cannulation with a percutaneous vascular closure device. Journal of Interventional Medicine 2: 164–165. Ben MI, Ben FL, Ben MM, Miri R, Mleyhi S, Mami I, Zairi I, Denguir R (2021) Endovascular Management of a Subclavian Arterial Injury During Central Venous Catheter Placement for Hemodialysis. OPEN ACCESS EMERG M 13: 273–277. Mohandes M, Moya BG, Fuertes M, Moreno C, Fernandez L, Bonet G, Scardino C (2021) Rescue Angioplasty in Subclavian Artery After Percutaneous Closure Device Failure in an Inadvertent Misplacement of A Central Venous Line. HEART VIEWS 22: 76–78. Park S, Jeong B, Shin JH, Kim JH, Kim JW, Gwon DI, Ko GY, Chen CS (2020) Interventional treatment of arterial injury during blind central venous catheterisation in the upper thorax: experience from two centres. CLIN RADIOL 75: 151–158. Guilbert M, Elkouri S, Bracco D, Corriveau MM, Beaudoin N, Dubois MJ, Bruneau L, Blair J (2008) Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J VASC SURG 48: 918–925. Goksel OS, El H, Onalan A, Alpagut U (2012) Successful removal of a malpositioned hemodialysis catheter into the aortic arch. J VASC ACCESS 13: 543. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF (2015) Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. COCHRANE DB SYST REV 1: CD6962. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF (2015) Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. COCHRANE DB SYST REV 1: CD11447. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Oct, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 15 Sep, 2024 Reviews received at journal 05 Sep, 2024 Reviews received at journal 05 Sep, 2024 Reviewers agreed at journal 02 Sep, 2024 Reviewers agreed at journal 01 Sep, 2024 Reviewers agreed at journal 31 Aug, 2024 Reviews received at journal 31 Aug, 2024 Reviews received at journal 30 Aug, 2024 Reviewers agreed at journal 28 Aug, 2024 Reviewers agreed at journal 27 Aug, 2024 Reviews received at journal 26 Aug, 2024 Reviewers agreed at journal 26 Aug, 2024 Reviewers agreed at journal 26 Aug, 2024 Reviewers invited by journal 26 Aug, 2024 Editor assigned by journal 21 Aug, 2024 Submission checks completed at journal 21 Aug, 2024 First submitted to journal 06 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4870102","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":354189355,"identity":"804cf488-af4f-4618-ade3-40b38915b313","order_by":0,"name":"Haihui Deng","email":"","orcid":"","institution":"Shenzhen Traditional Chinese Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haihui","middleName":"","lastName":"Deng","suffix":""},{"id":354189356,"identity":"91e932a9-e844-4a0c-af62-a76e5b028b64","order_by":1,"name":"Bin Chen","email":"","orcid":"","institution":"Shenzhen Traditional Chinese Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Chen","suffix":""},{"id":354189357,"identity":"3c3d0525-87de-40b8-a49b-32ea5128371c","order_by":2,"name":"Deti Peng","email":"","orcid":"","institution":"Shenzhen Traditional Chinese Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Deti","middleName":"","lastName":"Peng","suffix":""},{"id":354189358,"identity":"41822404-728c-48a3-a265-fd84e4beaacd","order_by":3,"name":"Fuwen Pang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYDACZijN3sB8AEhJyBCrxYCB5wBbAkgLD7F2gbTwGIBYhLUYHOc9+OHjjj95PBI5n1/dqLHgYWA/fHQDXi2H+ZIlZ54xKOaRyN1mnXMM6DCetLQb+LRINvOYMfO2GSTul87dZpzDBtQiwWNGWMtfoJYe6Zxnxjn/iNDCzwzUwgjRwvw4t404LcaSvW3GxTzyz8yYc/skeNgI+YWN/4zhh59tcnk8PIcff875VifHz374GF4tMJAA0i4BNoQY5TAtzB+IVT0KRsEoGAUjCwAAYV4/Q0wVcCcAAAAASUVORK5CYII=","orcid":"","institution":"Shenzhen Traditional Chinese Medicine Hospital","correspondingAuthor":true,"prefix":"","firstName":"Fuwen","middleName":"","lastName":"Pang","suffix":""}],"badges":[],"createdAt":"2024-08-06 17:30:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4870102/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4870102/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-024-00744-9","type":"published","date":"2024-10-08T15:57:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66654071,"identity":"885faf3e-3857-40ee-8277-4ccc56702a47","added_by":"auto","created_at":"2024-10-15 07:58:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":743231,"visible":true,"origin":"","legend":"\u003cp\u003eContrast-enhanced computed tomography (CT) scan of CV catheterization. Three days after catheter misplacement (\u003cstrong\u003eA, B\u003c/strong\u003e), the double-lumen catheter (white arrow) entered the brachiocephalic trunk (red arrow) via the right internal jugular vein (arrowhead). Twenty-eight days after replacing it with a single-lumen catheter (\u003cstrong\u003eC, D\u003c/strong\u003e), no hematoma is observed. One month after removing the single-lumen catheter (\u003cstrong\u003eE, F\u003c/strong\u003e), CT confirms no signs of hematoma.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4870102/v1/4fbd85da02f1335aeca57a00.png"},{"id":66654070,"identity":"70f9ecee-be02-4a07-93ec-73ab93f3867e","added_by":"auto","created_at":"2024-10-15 07:58:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":806377,"visible":true,"origin":"","legend":"\u003cp\u003eDigital subtraction angiography (DSA) of CV catheterization. \u003cstrong\u003eA, B\u003c/strong\u003e: Three days post-misplacement, DSA showed the double-lumen catheter in the ascending aorta (white arrow) and its proximity to the right common carotid and subclavian arteries (arrows). \u003cstrong\u003eC, D\u003c/strong\u003e: Twenty-eight days later, after single-lumen replacement, DSA showed no contrast leakage. \u003cstrong\u003eE\u003c/strong\u003e: One month later, DSA reveals contrast leakage along the sinus tract (white arrow) with the catheter retracted (black arrow). \u003cstrong\u003eF\u003c/strong\u003e: Pressure application shows no leakage, allowing for catheter removal.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4870102/v1/83ce21244c05bb18c9b32f60.png"},{"id":66654073,"identity":"33303734-c62b-49da-8eed-c8d0f2bc8be0","added_by":"auto","created_at":"2024-10-15 07:58:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2048782,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4870102/v1/dee67091-3f6a-471d-bb45-f47ed1d8b4a2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimally Invasive Approach to Managing Brachiocephalic Trunk Cannulation Complicating Central Venous Catheterization: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eCentral venous (CV) catheterization is a vital procedure used for various purposes, including device insertion (such as pacemakers and implantable cardioverter-defibrillators), hemodynamic monitoring, the administration of medications, and rapid fluid resuscitation[1,2]. Subclavian vein, internal jugular vein and femoral vein are commonly used access routes. Although CV catheterization is widely practiced and generally considered safe, numerous complications such as arterial puncture, hemothorax, pneumothorax, and infection have been reported[3]. Among these, accidental arterial cannulation can be particularly life-threatening[4]. Rapid diagnosis and prompt treatment are essential when this complication arises.\u003c/p\u003e \u003cp\u003eThis case describes a patient who underwent unintended cannulation of the brachiocephalic trunk during CV catheterization. The complication was addressed through a catheter replacement approach, which involved an exchange of the CV catheter and the establishment of a sinus tract for successful repair.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 74-year-old female patient with a large cerebral infarction and hypertension underwent central venous catheterization via the right subclavian vein using a 7-F double-lumen catheter at our hospital. Due to blood backflow from the right subclavian vein catheter, the infusion was paused. Blood gas analysis from the catheter showed 7.509 of pH, 93.2 mmHg of PO\u003csub\u003e2\u003c/sub\u003e, 36.5 mmHg of PCO\u003csub\u003e2\u003c/sub\u003e, 99.4% of SO\u003csub\u003e2\u003c/sub\u003e, 5.6 mmol/L of base excess, and 3.2 mmol/L of lactate. It was suspected that the catheter had been mistakenly placed in an artery. A computed tomography (CT) scan and digital subtraction angiography (DSA) both indicated that the catheter had entered the brachiocephalic trunk, with its tip located in the ascending aorta (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Prolonged arterial catheter placement poses risks like bleeding, infection, and thrombosis. Additionally, the puncture site is near the origins of the right subclavian and right common carotid arteries, complicating endovascular treatment. Surgery was recommended but declined due to the patient's condition and the family's concerns about the high risk associated with the procedure. Since the patient was asymptomatic and the puncture site showed no issues, regular catheter care and changes were advised, with plans to remove the catheter once a sinus tract forms.\u003c/p\u003e \u003cp\u003eOne month later, the CV catheter was replaced with a 5-F single-lumen catheter under DSA guidance. Follow-up DSA and CT scans showed no leakage from the brachiocephalic trunk (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). A month after, the catheter was removed with DSA confirming no leakage, and no issues were observed during withdrawal. Another month later, the catheter was removed. DSA showed no leakage from the brachiocephalic trunk, and during the slow withdrawal process, no significant leakage into surrounding tissues or vessels was observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF). The patient\u0026rsquo;s vital signs were stable, and no hematoma or swelling was observed. Follow-up CT scans showed no bleeding (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF), and hemoglobin levels remained stable (87\u0026ndash;115 g/L). The 3-month follow-up showed no abnormalities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccidental arterial puncture occurs in approximately 1.3% of subclavian approaches and can sometimes result in acute hemorrhages and hemothorax[5\u0026ndash;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.\u003c/p\u003e \u003cp\u003eThe 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].\u003c/p\u003e \u003cp\u003eIn 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\u0026mdash;beyond the 6\u0026ndash;7 cm operational range of these devices\u0026mdash;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.\u003c/p\u003e \u003cp\u003eUtilizing 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\u0026ndash;74%, decreases arterial punctures by 72\u0026ndash;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.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe report a rare and challenging case of brachiocephalic trunk cannulation after CV catheterization. This case illustrates the successful use of a CV catheter replacement approach for brachiocephalic trunk repair, highlighting its effectiveness as a minimally invasive treatment when surgical or endovascular options are unavailable. Furthermore, US guidance is recommended to enhance the accuracy and safety of CV catheterization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeng HH and Chen B contributed equally to this work. All of the authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial support was provided by the National Natural Science Foundation of China (82074384).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeng HH and Chen B contributed equally to this work. The treatment plan was designed by Pang FW, Deng HH and Chen B. Patient treatment was performed by Deng HH, and Chen B. Deng HH and Pang FW wrote the manuscript. Deti Peng and Pang FW\u0026nbsp;participated in manuscript revision. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Informed consent was obtained from the patient\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Kolikof J, Peterson K, Baker AM (2024) Central Venous Catheter.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Shin HJ, Na HS, Koh WU, Ro YJ, Lee JM, Choi YJ, Park S, Kim JH (2019) Complications in internal jugular vs subclavian ultrasound-guided central venous catheterization: a comparative randomized trial. INTENS CARE MED 45: 968\u0026ndash;976.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Soltes GD, Barth MH, Roehm JO (2003) Preventing complications of central venous catheterization. NEW ENGL J MED 348: 2684\u0026ndash;2686, 2684\u0026ndash;2686.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Cohen JE, Moshe Gomori J, Anner H, Itshayek E (2014) Inadvertent subclavian artery cannulation treated by percutaneous closure. J CLIN NEUROSCI 21: 1973\u0026ndash;1975.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Rezayat T, Stowell JR, Kendall JL, Turner E, Fox JC, Barjaktarevic I (2016) Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back. WEST J EMERG MED 17: 216\u0026ndash;221.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Gawecki W, Dabrowski P, Smuszkiewicz P (2006) [Central venous catheter as a reason of bleeding after tracheotomy]. POL J OTOLARYNGOL 60: 593\u0026ndash;597.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Bell J, Goyal M, Long S, Kumar A, Friedrich J, Garfinkel J, Chung S, Fitzgibbons S (2020) Anatomic Site-Specific Complication Rates for Central Venous Catheter Insertions. J INTENSIVE CARE MED 35: 869\u0026ndash;874.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Dornbos DR, Nimjee SM, Smith TP (2019) Inadvertent Arterial Placement of Central Venous Catheters: Systematic Review and Guidelines for Treatment. J VASC INTERV RADIOL 30: 1785\u0026ndash;1794.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Akkan K, Cindil E, Kilic K, Ilgit E, Onal B, Erbas G (2014) Misplaced central venous catheter in the vertebral artery: endovascular treatment of foreseen hemorrhage during catheter withdrawal. J VASC ACCESS 15: 418\u0026ndash;423.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Coroleu LD, Meca SM, Rodriguez-Otero LC, Masaller JM (2019) Detection and management of inadequate vascular access device implantation in the subclavian artery. Radiologia (Engl Ed) 61: 510\u0026ndash;513.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kably IM MD (2015) Endovascular Management of Iatrogenic Subclavian Artery Catheterization During Single-Incision Chest Port Placement. Vascular Disease Management E20-E25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Zhang J, Lv Y, Tian H (2019) Treatment of inadvertent subclavian artery cannulation with a percutaneous vascular closure device. Journal of Interventional Medicine 2: 164\u0026ndash;165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ben MI, Ben FL, Ben MM, Miri R, Mleyhi S, Mami I, Zairi I, Denguir R (2021) Endovascular Management of a Subclavian Arterial Injury During Central Venous Catheter Placement for Hemodialysis. OPEN ACCESS EMERG M 13: 273\u0026ndash;277.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Mohandes M, Moya BG, Fuertes M, Moreno C, Fernandez L, Bonet G, Scardino C (2021) Rescue Angioplasty in Subclavian Artery After Percutaneous Closure Device Failure in an Inadvertent Misplacement of A Central Venous Line. HEART VIEWS 22: 76\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Park S, Jeong B, Shin JH, Kim JH, Kim JW, Gwon DI, Ko GY, Chen CS (2020) Interventional treatment of arterial injury during blind central venous catheterisation in the upper thorax: experience from two centres. CLIN RADIOL 75: 151\u0026ndash;158.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Guilbert M, Elkouri S, Bracco D, Corriveau MM, Beaudoin N, Dubois MJ, Bruneau L, Blair J (2008) Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J VASC SURG 48: 918\u0026ndash;925.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Goksel OS, El H, Onalan A, Alpagut U (2012) Successful removal of a malpositioned hemodialysis catheter into the aortic arch. J VASC ACCESS 13: 543.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF (2015) Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. COCHRANE DB SYST REV 1: CD6962.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF (2015) Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. COCHRANE DB SYST REV 1: CD11447.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Central venous catheterization, Brachiocephalic trunk, Cannulation, Catheter replacement","lastPublishedDoi":"10.21203/rs.3.rs-4870102/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4870102/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eCentral venous catheterization, crucial for device insertion, monitoring, medication, and fluid resuscitation, commonly uses the subclavian, internal jugular, and femoral veins. Despite its general safety, complications like arterial puncture can be life-threatening, requiring rapid diagnosis and treatment.\u003c/p\u003e\n\u003cp\u003eCase presentation\u003c/p\u003e\n\u003cp\u003eA 74-year-old woman with a cerebral infarction underwent right subclavian vein catheterization. The catheter was mistakenly placed in the brachiocephalic trunk, with its tip in the ascending aorta, as confirmed by computed tomography and digital subtraction angiography. Due to high surgical risks, catheter replacement was chosen instead of surgery or endovascular treatment. One month after the initial placement, the catheter was replaced with a smaller one, and another month later, it was removed without complications. Follow-up scans showed no leakage, and the patient’s vitals remained stable. Three months later, no abnormalities were observed.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eThis case demonstrates the effective use of a catheter replacement technique as a minimally invasive repair method when other options are impractical. Ultrasound guidance is also recommended to improve the procedure's accuracy and safety.\u003c/p\u003e","manuscriptTitle":"Minimally Invasive Approach to Managing Brachiocephalic Trunk Cannulation Complicating Central Venous Catheterization: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 07:58:13","doi":"10.21203/rs.3.rs-4870102/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-15T06:44:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-05T22:02:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-05T16:10:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124172211307331635524852831150573298628","date":"2024-09-03T03:36:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327429277479168807677772613495132213798","date":"2024-09-01T19:22:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304377240593506368177764104654179355268","date":"2024-08-31T16:08:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-31T07:04:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-31T02:14:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73386835601640909387000796762571870551","date":"2024-08-28T14:18:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40035840607381578920288422482634788587","date":"2024-08-27T11:01:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-26T18:41:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15330203187948428727510701789124403985","date":"2024-08-26T16:54:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51150852273773915583003366255082217187","date":"2024-08-26T14:39:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-26T14:14:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-21T17:13:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-21T17:11:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2024-08-06T17:28:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c048c3ca-60c7-4ec2-9385-dd66ca26c4dd","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-15T07:58:13+00:00","versionOfRecord":{"articleIdentity":"rs-4870102","link":"https://doi.org/10.1186/s12245-024-00744-9","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2024-10-08 15:57:31","publishedOnDateReadable":"October 8th, 2024"},"versionCreatedAt":"2024-10-15 07:58:13","video":"","vorDoi":"10.1186/s12245-024-00744-9","vorDoiUrl":"https://doi.org/10.1186/s12245-024-00744-9","workflowStages":[]},"version":"v1","identity":"rs-4870102","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4870102","identity":"rs-4870102","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}