You are on page 1of 16

Complications of Central Venous Catheterization

Roberto E Kusminsky, MD, MPH, FACS

It is estimated that millions of central venous catheters higher is reached, and fresh-frozen plasma in patients
(CVCs) are inserted yearly in US hospitals.1 The pro- with elevated prothrombin and partial thromboplas-
found impact of the complications associated with CVC tin times. Administration of antihemophilic globulin
use is so important that efforts to minimize and prevent before subclavian vein (SCV) catheterization has led
their occurrence should be a routine element of quality to reports with similar conclusions in patients with
improvement programs. This review aims at centralizing hemophilia.13 Even heparinization does not appear to
the evidence currently available and presenting it as a increase the risk of bleeding or hematoma during
ready reference that could assist in estimating the mag- internal jugular vein (IJV) insertion.14 Although co-
nitude of the problem and formulating prevention ini- agulopathies are not a clear contraindication,15 the
tiatives. Additionally, emphasis is placed on the grow- IJV or femoral vein (FV) appears to be the compress-
ing body of information that supports the use of ible access site chosen by many authors for patients
ultrasonography-assisted insertion (UAI) as a superior with coagulation disorders.16,17
technique to decrease adverse events from CVC inser- 5. Large catheter size, such as those used for dialysis,
tion. From a clinical and practical point of view, which appears to influence the risk of vascular complica-
better correlates with usage issues, CVC complications tions of insertion.18
are best classified as secondary to insertion, indwelling, 6. Failure to catheterize is influenced by factors such as
and extraction practices. experience,2,3,19 previous catheterizations, previous
catheterization attempts, and previous operation or
radiotherapy in the anatomic region of interest.4,6
RISK FACTORS 7. Unsuccessful insertion attempts are the strongest pre-
The incidence of mechanical complications is modified dictor of insertion complications.6 Overall rates of
by a variety of factors: unsuccessful insertion attempts for IJV access have
been reported at 12%20 and 12% to 20% for SCV
1. Inexperience, variably defined but with a consistent and IJV in adults19 and infants weighing ⬍ 10 kg.21
relationship between less experience and the rate of Among patients who fail attempts at catheterization,
complications.2,3 complications develop in 28%.6
2. Number of needle passes, with the incidence of com-
plications rising with two venopunctures2-5 to a six- Overall incidence
fold increase with three or more.6 Complications associated with CVC insertion fluctuate
3. Body mass index ⬎ 30 or ⬍ 20,4,7 previous catheter- according to their definition and the correlation with the
izations, and severe dehydration or hypovolemia are multiple factors that influence their occurrence, ranging
factors that increase risk. between 5% and 19%.19,22 Femoral catheterization has a
4. Coagulopathies do not appear to increase the risk of higher incidence of mechanical complications than SCV
percutaneous insertion8-11 if appropriate precautions or IJV access,22 and can be associated with severe injury
are taken,12 such as transfusing thrombocytopenic if an inadvertent femoral artery puncture is too high and
patients with platelets until a count of 50,000 or is followed by anticoagulation.23 IJV and SCV catheter-
ization carry similar risks of mechanical complications,1
Competing Interests Declared: None.
although IJV insertion has been reported to have a
Received October 24, 2006; Revised January 16, 2007; Accepted January 17, higher incidence of mechanical complications than SCV
From the Department of Surgery, West Virginia University, Robert C Byrd in elective24 and emergency situations.25 A prospective,
Health Sciences Center, Charleston Division and Charleston Area Medical comparative study suggests that during cardiac arrest the
Center, Charleston, WV.
Correspondence address: Roberto E Kusminsky, MD, MPH, FACS, West
catheterization success rate can be higher for SCV than
Virginia University, 3110 MacCorkle Ave, Charleston, WV 25304. for FV access.26

© 2007 by the American College of Surgeons ISSN 1072-7515/07/$32.00

Published by Elsevier Inc. 681 doi:10.1016/j.jamcollsurg.2007.01.039
682 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

ally been linked to a lower incidence of pneumothorax

Abbreviations and Acronyms than IJV access.51
CVC ⫽ central venous catheter Delayed pneumothorax has been reported to occur in
FV ⫽ femoral vein
0.5%44,52 to 4% of the insertions,45 but the incidence is
IJV ⫽ internal jugular vein
SCV ⫽ subclavian vein quite a bit lower in some studies.53 Symptoms com-
UAI ⫽ ultrasonography-assisted insertion monly appear within 6 hours but not in all patients,53
which calls for the need to exercise caution and increased
awareness in those cases where the insertion was diffi-
Because the complication rate decreases with train- cult,54 despite the ostensible early lack of complications.
ing,27,28 designing a standardized method of CVC inser- A standardized treatment algorithm of CVC-induced
tion29 is a logical process to promote prevention and pneumothorax can lead to good results with safety, im-
decrease the incidence of adverse events.1,30,31 Standard- provements in patients’ comfort, and decreases in length
ization can also establish management guidelines for of stay in adults32,55-57 and children.58 Such an algorithm
some complications that commonly follow CVC inser- should include elements of awareness and treatment of
tion, such as pneumothorax.32 Standardization can es- reexpansion pulmonary edema,59,60 particularly if pa-
tablish a best-practice approach based on evidence, and tients are treated on outpatient basis.57 Re-expansion
it can provide an answer to the questions sometimes pulmonary edema is estimated to occur in 1% to 14% of
raised about the competence of house officers. patients with pneumothorax.59,61
The advantages of UAI of CVCs have been reported Clinician-performed bedside ultrasonography allows
as far back as 1978,33 and the body of literature support- the diagnosis of pneumothorax to be made immediately,
ing its adoption continues to expand. There is now with a high degree of sensitivity and with better accuracy
abundant evidence to establish UAI as the safest method than supine chest films and equal to that of CT scan.62-64
to prevent or decrease overall and specific complications This approach has not yet gained widespread accep-
of insertion. Reports of the advantages of ultrasonogra- tance, is operator-dependent, and patient selection and
phy over the anatomic landmark method support the equipment can influence the results.65
findings of risk reduction20,34 and improved cannulation Malpositioning of a CVC has been associated for
success20,34-36 for all access sites—FV37, SCV, IJV36—in years with problems of local toxicity, perforation, and
adults and children36,38 and in different settings.39 In venous thrombosis and its sequelae. In the past, a con-
addition, the gap between experienced and inexperi- siderable percentage of catheters were left within the
enced operators has been reported to disappear when right atrium,66 but today the consensus in the literature
UAI is used.40 Conversely, UAI can be of help to a skillful opposes this practice67 because of the increased risk of
operator who is otherwise unable to cannulate.41 There perforation. The debate about the validity of this recom-
are reports disputing these results,42 although some of mendation continues to surface68,69 and many believe
the discrepancies have been reported in studies in which that the purported advantages of a CVC tip in the
ultrasonography was not used in real-time mode.6 atrium are associated with minimal risks.69-71 These dis-
agreements produce difficulties with the interpretation
Insertion complications of the true incidence of malposition, particularly if the
Pneumothorax is one of the most common complica- analysis includes information derived from older series,
tions of CVC insertion, reportedly representing up to when the definition of malposition, catheter length, and
30% of all mechanical adverse events.43,44 Its incidence angle of incidence was not a common element of discus-
varies between 0%7,24 and 6.6%,45,46 with higher inci- sion, and when repositioning was not a major concern.72
dences when the number of needle passes increases,4 in Today, malposition includes the recognition that an an-
emergency situations,47-49 and when the catheters in- gle of incidence of the CVC tip against the wall of the
serted are large, such as those used for dialysis.45 A 1% to vessel ⬎ 40 degrees carries an increased risk of perfora-
1.5% incidence is more consistently reported.6,32,50 Most tion.73 To avoid the tip from abutting against the wall of
of the evidence points toward a higher incidence of the vein at an inappropriate angle, it is best to approach
pneumothorax when the SCV is cannulated, as com- left-sided insertions with a 20-cm catheter and the right-
pared with the IJV.5,24 SCV catheterization has occasion- sided ones with a 16-cm catheter74,75 in adult patients.
Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization 683

Just as catheter length bears a direct relationship to tip 0.3% of patients; the incidence is higher when cardiac
position,76 such might be the case as well with catheter congenital abnormalities are present.88 In children cath-
diameter and tip malposition in children ⬍ 10 kg.77 eterized through a FV, unusual but serious complica-
When a CVC is inserted without image-guided assis- tions secondary to misplacement might be preventable
tance, as it regularly happens, the initial estimate of in- by postprocedure films and contrast injections.89 Pediat-
sertion depth must be made in the clinical setting fol- ric peripherally-inserted central catheters inserted with-
lowing unreliable anatomic landmarks. One such out image guidance require repositioning of the tip in as
approximation is made by premeasuring to a central des- many as 85% of the patients.90
tination point located just above one-third of the dis- Vascular injuries during CVC insertion encompass a
tance between the manubrium and the xyphoid, where wide spectrum of complications, with arterial puncture
the caval-atrial junction can be expected to be. It is com- the most common. It occurs more frequently with IJV
mon practice, then, to assess the final position of the and FV22,91 access than with SCV,50 and even though this
catheter’s tip radiologically, accepting that the pericar- complication is usually self-limiting, it should not be
dial reflection is below the carina.74 A more precise mea- dismissed as inconsequential because it can lead to sub-
surement emerges from the study by Aslamy and col- stantial morbidity92 or death,93,94 even if the puncturing
leagues,78 which establishes convincingly that the right needle is of a relatively small gauge95 or the catheter is
tracheobronchial angle is the most reliable landmark to correctly placed in its intended venous location.96
assure that a catheter’s tip is at least 2.9 cm above the Puncture of the carotid artery during IJV catheteriza-
pericardial reflection, even if it appears to lie within the tions attempts averages 6% in prospective studies,97 al-
cardiac silhouette. Similarly, 20% of catheter tips con- though higher rates have been reported with the land-
firmed to be in the atrial-caval junction by transesopha- mark method20,91 and as high as 18% to 25% in
geal echocardiography are still visualized in the midpor- infants.21,91 Of greater clinical significance is the fact that
tion of the right atrium on supine chest films.79 From a up to 40% of carotid punctures are associated with a
practical point of view, it is prudent to judge the final hematoma; 10 of 25 in one study.20 This, in conjunction
position of the catheter in light of the fact that the tip with manual pressure, has been interpreted as the mech-
practically always migrates, peripherally, as demon- anism responsible for the appearance of cerebrovascular
strated by changes between supine and upright postpro- neurologic deficits97-99 and death.100 Puncture of the sub-
cedure imaging.71,80 clavian artery during SCV catheterization attempts oc-
In general, there appears to be less opportunity for curs in 0.5% to 4% of the patients.6,22,50 Hemothorax
malposition with jugular than with subclavian access.50 after CVC insertion is mostly an expression of an inad-
Subclavian entry is followed by misplacement of the vertent arterial injury, which has been reported to occur
CVC into the ipsilateral jugular vein in up to 15% of the approximately in 1% of central catheterizations,50 some-
catheterizations.81 This can be avoided in a major frac- times leading to uncommonly severe consequences, such
tion of patients by simply assuring that the J tip of the as quadriplegia.101
guidewire is pointing caudad during insertion.82 Addi- It stands to reason that the best way to care for arterial
tionally, turning the head toward the insertion side nar- perforations during CVC insertion is to avoid them, and
rows the os of the IJV,83 and manual compression of the the first preventive step to be taken is to recognize that
jugular can avoid misdirection as well while the guide- the needle entering the vessel is actually in a vein. More
wire is threaded.84 UAI has been reported to be effective often than not, the operator can rapidly determine that
in detecting anatomic variants85 and in steering the suc- the vessel is an artery because of pulsatile back flow, but
cessful placement of the tip to avoid catheter misplace- that is not always the case. A variety of methods, and
ment in adults86 and children.87 their pros and cons, have been described to facilitate
Postprocedure films are useful to check for complica- recognition of an inadvertent arterial puncture,102,103 but
tions and misplacement.81 Congenital anatomic varia- none is foolproof. UAI remains the best prevention prac-
tions can confound the radiologic interpretation of the tice currently available,1,20,35,40 although these advantages
tip’s location. Of these, the most common clinically sig- are not universally reproduced.104
nificant anomaly of the great systemic veins is the per- Large-bore arterial perforation or cannulation of the
sistence of a left superior vena cava, which is seen in carotid or subclavian occurs in approximately 0.1% to
684 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

1% of cases.18,91,105-108 Uncommon as it is, this compli- aortic perforation describe multiple insertion attempts
cation is associated with potentially devastating conse- and have been right-sided,133,135 although a left-sided en-
quences: approximately 30% of these patients can be try does cause this injury as well. The diagnosis of an
expected to become symptomatic—bleeding,109 neuro- aortic injury and the estimation of its extent requires
logic findings or other sequelae106,108—and if so, the careful assessment, as is the case with any arterial injury
mortality rate reaches 20% to 40%.18,105,107 Stroke or after attempted venous catheterization; it is not uncom-
neurologic deficits associated with large-bore arterial in- mon for a chest x-ray to be misleading,106,136 and often
jury can be estimated to occur in 27% of the patients106 the artery is entered after the vein is perforated.106,109,121
and is reported often,97,100,110,111 particularly in associa- Ultrasonography and CT scanning have been used with
tion with infusions through the cannulated artery.112,113 success, but the more central the injury the best way to
Most arterial large-bore perforations can be attributed study the damage is a contrast study, if there is time.
to the unsafe manipulation of the dilators,105,114-117 Both percutaneous closure137 and balloon tamponade138
which should only be used to widen the skin and SC have been described as a treatment approach to aortic
tissues but frequently are inserted unnecessarily far, injuries.
sometimes even causing ventricular perforation.118 Injuries to the pulmonary artery result more com-
Other possible mechanisms of injury include kinking of monly from the use of pulmonary artery catheters,139-141
the guidewire resulting in misdirection of the dilator and although occasionally the vessel is punctured directly
perhaps insertion of the wire outside the vessel.119,120 during CVC insertion attempts.142 The estimated inci-
Arterial puncture and perforation during CVC inser- dence of pulmonary artery catheter-associated injury—
tion appears to be mostly a right sided phenome- hemorrhage and infarct—is 0.1% to 0.2%, with a mor-
non,91,121,122 which coincides with the anatomic differ- tality rate of 42%.139,141
ences of the vascular system at either side of the midline. Pseudoaneurysms143, AV fistulas144 and vertebral ar-
On the right, the subclavian-jugular venous junction tery injuries145 are rare complications of inadvertent ar-
overlies the subclavian artery, making this vessel more terial perforation or cannulation. AV fistulas can develop
prone to injury than it is on the left. The right SCV shortly or years after catheterization attempts.144 They
enters the innominate at a sharper angle than its coun- have been estimated to occur in 0.2% of IJV146 and 0.6%
terpart on the left, which would make it then more vul- of SCV catheterization attempts.147 Vertebral artery in-
nerable to perforation if a firm dilator is inserted too juries are sometimes associated with acute neurologic
deeply.105,121 injury, but more frequently they have a delayed presen-
Whatever management choices are made to treat tation as a fistula after SCV or IJV attempts, or as a
these arterial complications, it is prudent to leave the pseudoaneurysm.148
offending catheter in place until the next step is The treatment of most pseudoaneurysms of central
taken.103,106,116,123 Individual patient circumstances arteries has evolved into progressively less invasive and
might dictate the selection of surgical procedure,106 effective approaches.148,149 Ultrasonography-guided per-
thrombin injection,124 percutaneous suture devices,125 cutaneous thrombin injection has been used in the ca-
stent graft placement,126 or balloon tamponade123 as the rotid artery,150 but this technique is viewed with unease
best way to handle these emergencies. because of its potential for embolization into the cerebral
Perforation of the aorta during CVC insertion ap- circulation.149 Similarly, the use of stents to treat
pears in the literature more often than would have been pseudoaneurysms and AV fistulas is a reasonable ap-
expected,127-130 suggesting some degree of underreport- proach if the grafts do not obstruct the takeoff of the
ing. It sometimes presents with a simultaneous perfora- vertebral or carotid arteries,148 although stenting the ca-
tion of the superior vena cava.130 If the perforation oc- rotids directly to treat these problems has been
curs within the pericardial reflection there will be an successful.151
associated cardiac tamponade, in which case the mortal- Dysrhythmias accompany CVC insertion fairly often
ity rate reaches 90%.131,132 Aortic injuries, as with arterial and more so when pulmonary artery catheters are used.
perforations in general, are also attributable to the im- Even palpation and pressure on the carotid artery during
proper use of the dilator, although they can also occur insertion of a pulmonary artery catheter has resulted in
with a needle133 or a large catheter.134 Most reports of ventricular fibrillation and cardiac arrest.152
Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization 685

The incidence of cardiac ectopy during catheteriza- incidence of brachial plexus punctures is approximately
tion is clearly related to the guidewire insertion depth, 1.7% and can be decreased substantially by UAI.20
reaching 75% as the wire is advanced between 25 cm Horner syndrome has been reported to occur in 2%
and 32 cm from an IJV entry site, the usual finding of IJV cannulations,111 but this appears to be somewhat
being the occurrence of premature atrial contractions.153 high an incidence, inconsistent with the realities of cur-
Ventricular ectopy can be triggered in up to 25% of rent clinical practice. Other reports describe the syn-
patients, suggesting the possibility that a malignant ar- drome in 2 of 1,000 patients undergoing pulmonary
rhythmia could arise.154 Only a small percentage of all artery catheterization152 and CVC insertions,16 which
arrhythmias are symptomatic155 and almost invariably appears to be a more reliable estimate. This complication
these difficulties cease after the guidewire is withdrawn. is occasionally permanent152 and perhaps likelier to oc-
Occasionally, serious problems arise during guidewire cur with larger-sized catheters,166 and is sometimes cou-
insertion in patients at risk, such as a complete heart pled with other neurologic manifestations, such as vocal
block,156 and even sudden death.157 cord paralysis.167
Indwelling catheters have been reported to cause ar- Incidence of lymphatic injuries during CVC insertion
rhythmias in 0.9% of patients, with some necessitating is difficult to assess, because most of the available litera-
therapeutic intervention in addition to removal.158 ture is limited to isolated reports, although it is estimated
Rarely, inserting a guidewire in a patient with an im- that 25% of overall cases of chylothorax are a result of
planted cardioverter device can lead to the most unusual surgical injury.168 Chylothorax and chylopericardium
situation of inducing an arrhythmia while delivering a can occur as a complication of venous thrombosis in-
shock to the operator.159 duced by a CVC169-171 or by direct damage to the lym-
phatic ducts.168,172,173 Traditional thinking suggests that
The rarity of serious sequelae and the usually transient
lymphatic injuries are associated with left IJV or SCV
nature of the arrhythmias induced by CVC insertion
insertions and represent thoracic duct damage.168,174,175
commonly permeate institutional cultures with feelings
Interestingly, a right-sided approach can lead to lym-
that these consequences are negligible. In the past, the
phatic duct harm in adults176 and children.172 Right su-
medical literature reported seeking out ectopy during
praclavicular access has been associated with a 0.5%
guidewire insertion as a marker of correct positioning.160
incidence of lymphocutaneous fistula.177 The supracla-
Considering the possibility of inducing ventricular ec-
vicular approach appears to be associated with a higher
topy,154 efforts to avoid overinsertion of the guidewire than expected rate of lymphatic injury, in the range of
would be a prudent strategy. 1%.178,179 Notably, UAI does not appear to prevent this
In contrast with CVCs, pulmonary artery catheters complication.174,177,180
induce dysrhythmias in 72% of the patients,141 with ven- Over the past several years, innovative and well–
tricular ectopy in 65% to 68% of them.141,152 Three per- thought-out methods of treating these complications
cent of all pulmonary artery catheters have persistent have emerged. Proposed and successfully tried therapies
PVCs requiring therapy141 and ventricular tachycardia include the use of nitric oxide,181 thoracoscopic fibrin
develops in 1.5%, with one-fourth of these patients re- glue application,182 and percutaneous embolization with
quiring cardioversion.140 platinum microcoils.183-185
The neurologic complications of CVC insertion Guidewire loss during insertion of a CVC is a rare
more commonly reported—excluding cerebrovascular event, occurring approximately twice in several thou-
accidents—include brachial plexus injury and Horner sand catheterizations.186 Guidewires can loop and be-
syndrome. Brachial plexopathies can follow IJV161 or come entrapped,187 stick inside the inserted catheter,188
SCV162 catheterization, and are mostly transient, partic- knot and fracture,189 and embolize producing acute ar-
ularly if the local anesthetic is the cause of the symp- terial insufficiency190 or paradoxically through a patent
toms.161 Multiple punctures or hematoma163 can lead to foramen ovale.191 Straight-tipped guidewires can cause
progressively worsening symptoms resulting sometimes cardiac perforation.192 Occasionally, a lost wire presents
in permanent damage.99,164,165 Typically, IJV insertions in a most bizarre manner: protruding through the
are associated with injury to the upper trunk161 and SCV skin.193 Entrapment of a guidewire within a vena cava
access with the lower trunk163 of the brachial plexus. The filter is a serious complication of vascular access that can
686 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

lead to displacement or fracture of the intravascular de- rhexidine preparation, use of full sterile garb precau-
vice, but clinician awareness and careful technique could tions, and CVC removal as soon as possible. This
make this a largely preventable problem.194 educational module includes a checklist to ensure adher-
The cornerstone of safe guidewire insertion is to avoid ence to evidence-based guidelines.206,207 Other preven-
kinking105,188 and potentially lethal injury,117-120 simulta- tive measures found to be effective additions to the pre-
neously assuring that resistance during insertion or re- viously mentioned bundle include voiding routine
moval is met with cautious response.187 Under these cir- catheter exchanges and the use of antibiotic ointments
cumstances, the needle-guidewire ensemble must be on the entry site, plus the use of clorhexidine impreg-
removed and the procedure reinitiated. To do otherwise nated sponges to dress the insertion area.200 Some studies
substantially increases the risks of wire fracture and its suggest that adhering to these measures eliminates the
serious sequelae.190,191 difference in infection rates seen in all three insertion
Despite admonitions that guidewire loss is a totally sites.208 Gram-positive infections and those involving
preventable situation if the operator makes sure to hold implanted reservoirs practically always require removal
onto the wire during insertion and to inspect it after of the catheter.209
removal,189,195 these and other precautions are not The use of antimicrobial impregnated catheters is still
enough to avoid the problem entirely. An easily inserted debated by some authors,210 and the Center for Disease
guidewire, normally shaped after removal, can still be Control and Prevention guidelines recommends the use
associated with fracture and embolism196 and multiple of antimicrobial-impregnated CVCs in selected clinical
films might not demonstrate the complication,197 so the situations,200 but a strong body of evidence justifies their
diagnosis of a retained foreign body is commonly de- use.207 In a persuasively written viewpoint, Crnich and
layed.198 Attempts to design a safer guidewire have been Maki207 provide an excellent summary of the numerous
reported, with good results.199 sound studies demonstrating that a substantial number
of blood stream infections can be prevented—40%
Indwelling complications at least—with the use of short-term antimicrobial-
Infection is the main complication of indwelling cathe- impregnated CVCs.
ters, with an incidence of approximately 5.3 per 1,000 Thrombosis induced by CVCs is a frequent occur-
catheter days and an attributed mortality of 18% (0% to rence, ranging between 33%1 and 59% of indwelling
35%).200 Most infections arise from the skin insertion catheters, although clinical symptoms develop in just a
site or the catheter hub, depending on the indwelling small percentage of patients.211 The pathogenesis is mul-
time, and are then perpetuated by biofilm, a bacterial- tifactorial, but endothelial injury, turbulence of the ve-
derived community embedded in a matrix of extracellu- nous flow and catheter thrombogenicity211 play a role, as
lar polymeric substances that they produce.201 This de- does the composition of the infusate212 and the charac-
terminant factor could explain the favorable results seen teristics of the disease process. A fibrin sheath develops
with the injection of hydrochloric acid to treat CVC within 24 hours of catheter insertion, and although this
infections.202 sheath contributes to catheter occlusion, it does not pre-
FV catheters have a higher risk of infection than SCV dict subsequent deep vein thrombosis of the vessel,203
or IJV catheters,1 as do noncuffed catheters compared but all CVCs are subjected to malfunction as a result of
with cuffed ones.200 Because the risk of infection is this fibrin casing.213
heightened by thrombosis,203,204 efforts to render the The rate of CVC-induced thrombosis is lower for
catheters less thrombogenic have included heparin- SCV than for IJV and FV access.1 The rate of thrombosis
coating, but the risk of activating heparin induced is reported at 1.9% for SCV access22 and 22% to 29%
thrombocytopenia makes their use imprudent.205 after 4 to 14 days of indwelling time214 for a femoral
Catheter-related bloodstream infections can be pre- CVC.22,204 Location of the CVC tip within an inlet vein
vented: in an elegantly designed study, Berenholtz and increases the likelihood of catheter-associated thrombo-
colleagues206 instituted sequential measures in an ICU sis 16 times,215 but malfunction is lessened when the
population, bringing the incidence of infection down to catheter lies in a high-flow central vein.216 Superior vena
virtually zero. Currently, this “bundle” of standard ac- cava obstruction can be a substantial problem, estimated
tions includes educating caregivers in hand hygiene, clo- to occur in 1/1,000 indwelling devices.217
Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization 687

Varying degrees of occlusion induced by CVCs are as a hydrothorax,228,229,234 which is bilateral in up to one-
associated with varying degrees of stenoses,218 although third of patients.235
as many as 30% of the patients without previous cath- A useful predictor of impending perforation is the
eterizations might have clinically significant venous an- radiographic confirmation of a curled-up catheter tip,
atomic abnormalities—greater than 50% stenoses and which occurs in approximately 4% of placements,236 and
angulations—that could increase the risks of catheteriza- sometimes requires a lateral chest film for visualiza-
tion.219 Twice as many patients—60%—will have de- tion.237 Myriad reports discuss the likelihood of perfora-
fects if they have been catheterized previously,219 partic- tion by indwelling catheters as a function of the entry
ularly through a subclavian approach.204 Longer catheter side, because most of the cases reported have been asso-
dwell times increase development of central vein abnor- ciated with left-sided CVC insertions,228 which results in
malities,220 as expected. Stenoses induced by large-bore a more horizontal position of the catheter shaft and
catheters are reported in the range of 40% to 50%, and abutting of its tip against the vein wall when the catheter
higher if the CVC has been infected.221 Narrowing de- is of insufficient length. The pathogenesis of this com-
velops mostly behind the clavicle, an area difficult to plication must be attributed to the steady pressure and
visualize with ultrasonography.222 friction exerted on the vessel wall by the catheter tip
In cancer patients, CVCs cause vessel thrombosis in eventually leading to erosion, the same way a decubitus
41% of the patients, with postphlebitic syndrome devel- ulcer forms. So, abutting the vein wall or curling of a
oping in 15% to 30% of them and pulmonary embolism catheter tip that does not normally have a curvature, is
developing in 11%.203 Morbidity and mortality of jugu- basically a signal that the CVC tip is compressing the
lar and subclavian thrombosis appears to be similar.223 vein and should be repositioned to lie parallel to the
vessel wall by whatever maneuvers are required. Unfor-
Although treatable, longterm relief for central venous
tunately, this cannot always be accomplished by staying
occlusive disease is rarely achieved.224 Despite this, the
above the pericardial reflection.
consensus in the medical literature indicates that routine
This information then leads to the simple question of
antithrombotic therapy for oncologic patients with
why is it that pigtailed venous catheters are not being
CVCs is not warranted,225 a conclusion that is likely
used more often? In an intelligently conceived study,
applicable to patients without cancer.
Gravenstein and Blackshear238 demonstrated that a pig-
Fibrin sheath stripping and urokinase infusion work
tail catheter is 100 times less likely to perforate than
equally well to salvage catheter patency,226 and appropri- straight-tipped catheters. There is also additional com-
ate differentiation between a fibrin sheath and thrombo- pelling evidence to support the use of pigtail catheters:
sis is necessary before the initiation of therapeutic ma- studies in a porcine model have shown that central access
neuvers.213 There is increasing interest in endoluminal with looped catheters can eliminate the vein wall injury
brushing as a method to regain patency of occluded process for substantial periods as compared with straight
catheters.227 catheters.239 This also suggests that a thrombus at the tip
Vascular erosion and perforation of an indwelling of the catheter—a common cause of dysfunction—
CVC can be associated with cardiac tamponade, de- might be less likely to develop if the tip does not lie in
pending on whether the perforation occurs below or direct contact with the vein wall. So far, clinical experi-
outside the pericardial reflection. Perforation without ence with catheters contoured in this manner is limited
tamponade occurs in 0.4% to 1% of catheterizations, but favorable.240,241
with a resulting mortality rate of 12%.228,229 Erosion fol- Catheter fracture and embolization is reported to oc-
lowed by tamponade is estimated to take place in 0.2% cur in 0.5%186 to 3% of patients203 with indwelling
of patients,230 with an associated mortality under these CVCs. Embolization can lead to arrhythmia242 with car-
circumstances of nearly 90%.131,132 Use of peripherally diac arrest,243 pulmonary embolism with hemoptysis,244
placed catheters in neonates carries an overall reported perforation, thrombosis, and infection, for an overall
mortality rate of 0.7%,231 because of the disproportion- morbidity rate of 71%245 and a mortality of 30% to
ate higher risk of cardiac tamponade with these type of 38%.245,246 Compression of the central catheter between
lines.232 Although perforation without tamponade can the clavicle and the first rib causes the pinch-off syn-
present as a hemothorax,233 it manifests most commonly drome,247 clinically manifest by a functional occlusion
688 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

linked to postural changes. The mechanical shearing ter266,267 or guidewire.268 Breakage is frequently a result of
forces on the catheter can, over time, lead to fracture and excessive traction force,246 although the catheter material
embolization. This syndrome is estimated to occur in can sometimes be faulty and ruptures or dilates.269 Acci-
1% of patients,248 and it is important to differentiate it dental CVC removal is a serious problem because of the
from other causes of catheter obstruction, which can be associated risks of hemorrhage and air embolism, and it
done by detecting telling radiographic findings. Because occurs between ⬍ 1% and 7.5% in ICU popula-
raising the arms or shrugging opens the costo-clavicular tions270,271 and in children.269 Rarely, extraction of a
angle, the films should be taken with the patient upright CVC placed in the ipsilateral side of a patient with an AV
and with arms by the side.248,249 Catheter fracture can fistula for dialysis can lead to hemothorax.272 Central
also occur by shearing from the insertion needle or dur- catheters attached to the vein are more commonly a
ing extraction.250 This information suggests that a safer consequence of dwell time273 and the constellation of
way to remove a SCV catheter should include elevation histologic changes associated with fibrin formation.274
of the patient’s arm as traction is applied. Occasionally, a stuck catheter might be a result of frac-
tures in the material.275 This complication has been re-
Extraction complications ported in adults,276 children,277 and with peripherally
Although air embolism can occur during insertion of a inserted lines.278
CVC,251 it is perhaps more commonly seen as a compli-
cation of catheter extraction.252 It is reported to occur in Technical considerations and discussion
0.13%251 to 0.5%3,253 of CVC insertions, with tunneled Over the years, a plethora of reports and adjunct com-
catheters inserted through a peel-away sheath a likelier mentary have highlighted the myriad complications that
source of this complication.251 The associated mortality can befall patients receiving a CVC, in an effort to em-
is substantial, ranging between 23%252 and 50%,254 of- phasize effective prevention opportunities. In this con-
ten if not always connected to neurologic deficits of text, UAI can help the operator decide the relationship
varying degree.255 between artery and vein,41,279 how often the venous anat-
One-hundred milliliters of air can pass through a 14- omy is abnormal,280 which vessel is best to use,281 how
gauge needle in 1 second,255 so it is imperative to be much the head should be turned,282 and the effect of
aware of this possibility during cannulation of any vessel patient position on the diameter of the vein.283
and during catheter exchanges and removal.256 Air em- UAI is not infallible, and certain complications and
bolism has occurred during accidental hub disconnec- precautions require constant operator alertness. Arterial
tion,257 through a residual catheter track,258 as a worri- puncture, for example, can still occur with UAI,20 and
some factor during home infusion therapy,259 and has the methods described to ascertain if a catheter is inside
been reported to lodge in the coronary circulation.260 It an artery are not foolproof, but they are reasonable and
is occasionally a result of inadvertent arterial cannula- effective. Routinely measuring blood gases or attaching
tion, in which case, neurologic sequelae are frequent. the catheter to a transducer is not always practical, nor
During venous catheterization, the path leading the air can physicians realistically be expected to use these tech-
embolus to produce a cerebrovascular accident appears niques on every patient. A simple method to detect ar-
to be mostly by pulmonary shunting or through a patent terial placement might be to return to the standard of
foramen ovale.252,261 When air embolism is recognized, if running saline solution through the line before using a
the usual therapeutic maneuvers—left lateral Trendelen- volumetric pump,112 a practice that perhaps can be re-
burg, air aspiration, 100% oxygen—are not effective, suscitated as part of a standardized method of insertion.
hyperbaric oxygen treatment could be of help.262 Im- Final position of the CVC tip is particularly impor-
proved designs of protective insertion sheaths appear tant in relationship to the complications seen with an
capable of decreasing the incidence of this grave compli- atrial location, or when the tip is curled on itself 236,237
cation.263 Technique standardization should include ed- and exerts pressure against the vessel’s wall. Regardless of
ucation about prevention of air embolism during CVC how rational some arguments in favor of an atrial loca-
insertion30 and removal.255,264 tion might be, the sine qua non of any procedure is
Other extraction complications include breakage,265 patient’s safety, and the mortality of an atrial perforation
separation from the hub,246 and knotting of the cathe- and tamponade makes any such debate a rather gratu-
Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization 689

itous point. Instead, the scientific world needs the con- plications of central venous catheters. J Intensive Care Med
tribution of a method that avoids this lethal complica- 6. Mansfield P, Hohn DC, Fornahe BD, et al. Complications and
tion, and such could be the possibility that emerges with failures of subclavian vein catheterization. N Engl J Med 1994;
the use of venous pigtailed catheters.239 331:1735–1738.
7. Takeyama H, Taniguchi M, Sawai H, et al. Limiting vein punc-
The site of insertion remains an issue of discussion ture to three needle passes in subclavian vein catheterization by
and varied preferences, but in terms of infection preven- the infraclavicular approach. Surg Today 2006;36:779–782.
tion the consensus points toward the SCV as the better 8. Foster PJ, Moore LR, Sankary HN, et al. Central venous cath-
route of access.1 The agreement is not as clear in terms of eterization in patients with coagulopathy. Arch Surg 1992;127:
prevention of mechanical complications, particularly in 9. Mumtaz H, Williams V, Hauer-Jensen M, et al. Central venous
the areas of malposition and pneumothorax.50 catheter placement in patients with disorders of hemostasis.
Side of insertion also remains a contested theme. Am J Surg 2000;180:503–505.
10. Doerfler ME, Kaufman B, Goldenberg AS. Central venous
Many believe that left-sided insertions are burdened catheter placement in patients with disorders of hemostasis.
with a higher probability of superior vena cava perfora- Chest 1996;110:185–188.
tion68 than access through the right side, although the 11. DeLoughery TG, Liebler JM, Simonds V, et al. Invasive line
placement in critically ill patients: do hemostatic defects mat-
important element of catheter length and its relationship ter? Transfusion 1996;36:827–831.
to this problem is not always emphasized. Others 12. Barrera R, Bushra M, Huang Y, et al. Acute complications of
present good evidence that right-sided SCV and IJV central line placement in profoundly thrombocytopenic cancer
patients. Cancer 1996;78:2025–2030.
insertions are likelier to induce arterial injury,114,122 al- 13. Fontes B, Ferreira Filho AA, Carelli CR, et al. Percutaneous
though the left side offers a smoother and more obtuse catheterization of the subclavian vein in hemophiliac patients:
angle of subclavian approach.284 A left-sided approach is report of 47 cases. Int Surg 1992;77:118–121.
14. Petersen GA. Does systemic anticoagulation increase the risk of
reported to be associated with less technical difficulty285 internal jugular vein cannulation? Anesthesiology 1991;75:
and complications122,236 in a statistically significant num- 1124.
ber of patients.286 15. Fisher NC, Mutimer DJ. Central venous cannulation in pa-
tients with liver disease and coagulopathy—a prospective au-
Ultimately, physicians should be cognizant of the dit. Intensive Care Med 1999;25:481–485.
many complications associated with CVCs, recognizing 16. Goldfarb G, Lebrec D. Percutaneous cannulation of the inter-
that the sheer volume of lines used is substantial enough nal jugular vein in patients with coagulopathies. An experience
based on 1,000 attempts. Anesthesiology 1982;56:321–323.
to convert a rare problem into one they will be likely to 17. Lee HS, Quinn T, Boyle RM. Safety of thrombolytic treatment
experience. With this in mind, prevention of even the in patients with central venous cannulation. Br Heart J 1995;
most unusual complication becomes a worthwhile ini- 73:359–362.
18. Wicky S, Meuwly JY, Doenz F, et al. Life-threatening vascular
tiative. The weight of evidence in favor of UAI to de- complications after central venous catheter placement. Eur Ra-
crease the incidence of mechanical complications sug- diol 2002;12:901–907.
gests that this kind of image-guided approach to CVC 19. Sznajder JL, Fabio RZ, Bitterman H, et al. Central vein cath-
eterization. Failure and complication rates by three percutane-
insertion should be made available routinely. ous approaches. Arch Int Med 1986;146:259–261.
20. Denys BG, Uretsky BF, Reddy S. Ultrasound-assisted cannu-
lation of the internal jugular vein. A prospective comparison to
REFERENCES the external Landmark-Guided Technique. Circulation 1993;
1. McGee DC, Gould MK. Preventing complications of central 21. Verghese ST, McGill WA, Patel R, et al. Ultrasound-guided
venous catheterization. N Engl J Med 2003;348:1123–1133. internal jugular venous cannulation in infants. A prospective
2. Bo-Linn GW, Anderson DJ, Anderson KC, et al. Percutaneous comparison with the traditional palpation method. Anesthesi-
central venous catheterization performed by medical house of- ology 1999;91:71–77.
ficers: a prospective study. Cathet Cardiovasc Diagn 1982;8: 22. Merrer J, De Jonghe B, Lefrant JY, et al. Complications of
23–29. femoral and subclavian venous catheterization in critically ill
3. Eisenhauer E, Derveloy RJ, Hastings PR. Prospective evalua- patients. A randomized controlled trial. JAMA 2001;286:700–
tion of central venous pressure (CVP) catheters in a large city- 707.
county hospital. Ann Surg 1982;196:560–564. 23. Sreeram S, Lumsden AB, Miller JS, et al. Retroperitoneal he-
4. Lefrant JY, Muller L, De La Coussaye JE, et al. Risk factors of matoma following femoral arterial catheterization: a serious
failure and immediate complication of subclavian vein cathe- and often fatal complication. Am Surg 1993;59:94–98.
terization in critically ill patients. Intensive Care Med 2002;28: 24. Kaiser CW, Koornick AR, Smith N, et al. Choice of route for
1036–1041. central venous cannulation: subclavian or internal jugular vein?
5. Eisen LA, Narasimhan M, Berger JS, et al. Mechanical com- A prospective study. J Surg Oncol 1981;17:345–354.
690 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

25. Steele R, Irvin CB. Central line mechanical complication rate 46. Herbst CA Jr. Indications, management, and complications of
in emergency medicine patients. Acad Emerg Med 2001;8: percutaneous subclavian catheters. An audit. Arch Surg 1978;
204–207. 113:1421–1425.
26. Emerman CL, Bellon EM, Lukens TW, et al. A prospective 47. Steele R, Irving CB. Central line mechanical complication rate
study of femoral versus subclavian vein catheterization during in emergency medicine patients. Acad Emerg Med 2001;8:
cardiac arrest. Ann Emerg Med 1990;19:26–30. 204–207.
27. Martin M, Scalabrini B, Rioux A, et al. Training fourth-year 48. Abraham E, Shapiro M, Podolsky S. Central venous catheter-
medical students in clinical invasive skills improves subsequent ization in the emergency setting. Crit Care Med 1983;11:515–
patient safety. Am Surg 2003;69:437–440. 517.
28. Nip IL, Haruno MM. A systematic approach to teaching in- 49. Pappas P, Brathwaite CE, Ross SE. Emergency central venous
sertion of a central venous line. Acad Med 2000;75:552. catheterization during resuscitation of trauma patients. Am
29. Scott WL. Central venous catheters. An overview of Food and Surg 1992;58:108–111.
Drug Administration activities. Surg Oncol Clin North Am 50. Ruesch S, Walder B, Tramer MR. Complications of central
1995;4:377–393. venous catheters: internal jugular versus subclavian access—a
30. Ely EW, Hite RD, Baker AM, et al. Venous air embolism from systematic review. Crit Care Med 2002;30:454–460.
central venous catheterization: a need for increased physician 51. Miller JA, Singyreddy S, Maldjian P, et al. A reevaluation of the
awareness. Crit Care Med 1999;27:2113–2117. radiographically detectable complications of percutaneous ve-
31. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of nous access lines inserted by four subcutaneous approaches.
physicians-in-training can decrease the risk for vascular cathe- Am Surg 1999;65:125–130.
ter infection. Ann Intern Med 2000;132:641–648. 52. Chang TC, Funaki B, Szymski GX. Are routine chest radio-
32. Laronga C, Meric F, Truong MT, et al. A treatment algorithm graphs necessary after image-guided placement of internal jug-
for pneumothoraces complication central venous catheter in- ular central venous access devices? AJR Am J Roentgenol 1998;
sertion. Am J Surg 2000;180:523–527. 171:335–337.
33. Ullman JI, Stoelting RK. Internal jugular vein location with 53. Tyburski JG, Joseph AL, Thomas GA, et al. Delayed pneumo-
the ultrasound Doppler blood flow detector. Anesth Analg thorax after central venous access: a potential hazard. Am Surg
1978;57:118. 1993;59:587–589.
34. Rothschild JM. Ultrasound guidance of central vein catheter- 54. Slezak FA, Williams GB. Delayed pneumothorax: a complica-
ization. Evidence Report/Technology Assessment No 43. Mak- tion of subclavian vein catheterization. JPEN J Parenter En-
ing Health Care Safer. A critical Analysis of Patient Safety teral Nutr 1984;8:571–574.
Practices. AHRQ, Publication No 01-EO58 2001;245⫺253. 55. Giacomini M, Iapichino G, Armani S, et al. How to avoid and
35. Gann M, Sardi A. Improved results using US guidance for manage a pneumothorax. J Vasc Access 2006;7:7–14.
central venous access. Am Surg 2003;69:1104–1107. 56. Gammie JS, Banks MC, Fuhrman CR, et al. The pigtail cath-
36. Randolph AG, Cook DJ, Gonzales CA, et al. Ultrasound guid- eter for pleural drainage: a less invasive alternative to tube
ance for placement of central venous catheters: A meta-analysis thoracostomy. JSLS 1999;3:57–61.
of the literature. Crit Care Med 1996;24:2053–2058. 57. Gurley MB, Richli WR, Waugh KA. Outpatient management
37. Hilty WM, Hudson PA, Levitt MA, et al. Real-time of pneumothorax after fine-needle aspiration: economic ad-
ultrasound-guided femoral vein catheterization during cardio- vantages for the hospital and patient. Radiology 1998;209:
pulmonary resuscitation. Ann Emerg Med 1997;29:331–336. 717–722.
38. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating 58. Dull KE, Fleisher GR. Pigtail catheters versus large-bore chest
devices for central venous cannulation: meta-analysis. BMJ tubes for pneumothoraces in children treated in the emergency
2003;327:361–364. department. Pediatr Emerg Care 2002;18:265–267.
39. Miller AH, Roth BA, Mills TJ, et al. Ultrasound guidance 59. Rozenman J, Yellin A, Simansky DA, et al. Re-expansion pul-
versus the landmark technique for the placement of central monary oedema following spontaneous pneumothorax. Respir
venous catheters in the emergency department. Acad Emerg Med 1996;90:235–238.
Med 2002;9:800–805. 60. Sue RD, Matthay MA, Ware LB. Hydrostatic mechanism may
40. Geddes CC, Walbaum D, Fox JG, et al. Insertion of internal contribute to the pathogenesis of human re-expansion pulmo-
jugular temporary hemodialysis cannulae by direct ultrasound nary edema. Intensive Care Med 2004;30:1921–1926.
guidance—a prospective comparison of experienced and inex- 61. Beng ST, Mahadevan M. An uncommon life-threatening com-
perienced operators. Clin Nephrol 1998;50:320–325. plication after chest tube drainage of pneumothorax. Am J
41. Denys BG, Uretsky BF. Anatomical variations of internal jug- Emerg Med 2004;22:615–619.
ular vein location: impact on central venous access. Crit Care 62. Maury E, Guglielminotti J, Alzieu M, et al. Ultrasonic exami-
Med 1991;19:1516–1519. nation. An alternative to chest radiography after central venous
42. Martin MJ, Husain FA, Piesman M, et al. Is routine ultrasound catheter insertion? Am J Respir Crit Care Med 2001;164:403–
guidance for central line placement beneficial? A prospective 405.
analysis. Curr Surg 2004;61:71–74. 63. Simon BC, Paolinetti L. Two cases where bedside ultrasound
43. Mitchell SE, Clark RA. Complications of central venous cath- was able to distinguish pulmonary bleb from pneumothorax.
eterization. AJR Am J Roentgenol 1979;133:467–476. J Emerg Med 2005;29:201–205.
44. Plewa MC, Ledrick D, Sferra JJ. Delayed tension pneumotho- 64. Zhang M, Liu ZH, Yang JX, et al. Rapid detection of pneu-
rax complicating central venous catheterization and positive mothorax by ultrasonography in patients with multiple
pressure ventilation. Am J Emerg Med 1995;13:532–535. trauma. Crit Care 2006;10:R112.
45. Plaus WJ. Delayed pneumothorax after subclavian vein cathe- 65. Sistrom C. US in the detection of pneumothorax [letter]. Ra-
terization. J Parenter Enteral Nutr 1990;14:414–415. diology 2003;227:305–306.
Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization 691

66. McGee WT. Central venous catheterization: better and worse 86. Lefrant JY, Cuvillon P, Benezet JF, et al. Pulsed Doppler ultra-
[editorial]. J Intensive Care Med 2006;20:51–53. sonography guidance for catheterization of the subclavian vein:
67. Scott WL. Central venous catheter tip placement and catheter a randomized study. Anesthesiology 1998;88:1195.
occlusion [letter]. Am J Surg 2000;180:78–79. 87. Ohki Y, Tabata M, Kuwashima M, et al. Ultrasonographic
68. Vesely TM. Central venous catheter tip position: a continuing detection of very thin percutaneous central venous catheter in
controversy. J Vasc Interv Radiol 2003;14:527–534. neonates. Acta Paediatr 2000;89:1381–1384.
69. Fletcher SJ, Bodenham AR. Safe placement of central venous 88. Pahwa R, Kumar A. Persistent left superior vena cava: an in-
catheters: where should the tip of the catheter lie? Br J Anaesth tensivist experience and review of the literature. South Med J
2000;85:188–191. 2003;96:528–529.
70. Petersen J, Delaney JH, Brakstad MT, et al. Silicone venous 89. Lavadonsky G, Gomez R, Montes J. Potentially lethal mis-
access devices positioned with their tips high in the superior placement of femoral central venous catheters. Crit Care Med
vena cava are more likely to malfunction. Am J Surg 1999; 1996;24:893–896.
178:38–41. 90. Fricke BL, Racadio JM, Duckworth T, et al. Placement of
71. Kowalski CM, Kaufman JA, Rivitz SM, et al. Migration of peripherally inserted central catheters without fluoroscopy in
central venous catheters: implications for initial catheter tip children: initial catheter tip position. Radiology 2005;234:
positioning. J Vasc Interv Radiol 1997;8:443–447. 887–892.
72. Lumb PD. Complications of central venous catheters [edito- 91. Oliver WC, Nuttall GA, Beynen FM, et al. The incidence of
rial]. Crit Care Med 1993;21:1105–1106. artery puncture with central venous cannulation using a mod-
73. Gravenstein N, Blackshear RH. In vitro evaluation of relative ified technique for detection and prevention of arterial cannu-
perforating potential of central venous catheters: comparison lation. J Cardiothorac Vasc Anesth 1997;11:851–855.
of materials, selected models, number of lumens, and angles of 92. O’Leary AM. Acute upper airway obstruction due to arterial
incidence to simulated membrane. J Clin Monit 1991;7:1–6. puncture during percutaneous central venous cannulation of
74. Stonelake PA, Bodenham AR. The carina as a radiological the subclavian vein. Anesthesiology 1990;73:780–782.
landmark for central venous catheter tip position. Br J Anesth 93. Heard CMB, Fletrcher JE. Potentially fatal subclavian artery
2006;96:335–340. hemorrhage [letter]. Anaesthesiology 1996;51:292.
75. Andrews RT, Bova DA, Venbrux AC. How much guidewire is 94. Benter T, Teichgraber UKM, Kluhs L, et al. Percutaneous cen-
too much? Direct measurement of the distance from subcla- tral venous catheterization with a lethal complication. Inten-
vian and internal jugular vein access sites to the superior vena sive Care Med 1999;25:1180–1182.
cava-atrial junction during central venous catheter placement. 95. MercerJones MA, Wenstone R, Hershman MJ. Fatal subcla-
Crit Care Med 2000;28:138–142. vian artery hemorrhage. Anaesthesiology 1995;50:639–640.
76. McGee WT, Moriarty KP. Accurate placement of central ve- 96. Wolfe BM, Ryder MA, Nishikawa RA, et al. Complications of
nous catheters using a 16-cm catheter. J Intensive Care Med parenteral nutrition. Am J Surg 1986;152:93–99.
1996;11:19–22. 97. Reuber M, Dunkley LA, Turton EPL, et al. Stroke after inter-
77. Janik JE, Conlon SH, Janik JS. Percutaneous central access in nal jugular venous cannulation. Acta Neurol Scand 2002;105:
patients younger than 5 years of age: size does matter. J Pediatr 235–239.
Surg 2004;39:1252–1256. 98. Anagnou J. Cerebrovascular accident during percutaneous
78. Aslamy Z, Dewald CL, Heffner JE. MRI of central venous cannulation of internal jugular vein. Lancet 1982;2:377–378.
anatomy. Implications for central venous catheter insertion. 99. Defalque RJ, Fletcher MV. Neurological complications of cen-
Chest 1998;114:820–826. tral venous cannulation. JPEN J Parenter Enteral Nutr 1988;
79. Chu KS, Hsu JH, Wang SS, et al. Accurate central venous 12:406–409.
port-A catheter placement: intravenous electrocardiography 100. Stewart RW, Hardjasudarma M, Nall L, et al. Fatal outcome of
and surface landmark techniques compared by using trans- jugular vein cannulation. South Med J 1995;88:1159–1160.
esophageal echocardiography. Anesth Analg 2004;98:910– 101. Williams A, Little M, Gibbs J, et al. Spinal cord infarction
914. following central-line insertion. Ren Fail 2003;25:327–329.
80. Nazarian GK, Bjarnason H, Dietz CA, et al. Changes in tun- 102. Eckhardt WF, Iaconetti J, Kwon JS, et al. Casa 1⫺1996. Inad-
neled catheter tip position when a patient is upright. J Vasc vertent carotid artery cannulation during pulmonary artery
Interv Radiol 1997;8:437–441. catheter insertion. J Cardiovasc Vasc Anesth 1996;10:283–
81. Kidney DD, Nguyen DT, Deutsch LS. Radiologic evaluation 290.
and management of malfunctioning long-term central vein 103. Golden LR. Incidence and management of Large-Bore intro-
catheters. AJR Am J Roentgenol 1998;171:1251–1257. ducer sheath puncture of the carotid artery. J Cardiovasc Vasc
82. Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of Anesth 1995;9:425–428.
the guidewire, in Seldinger technique, is a significant factor in 104. Augoustides JG, Diaz D, Weiner J, et al. Current practice of
misplacement of subclavian vein catheter: a randomized, con- internal jugular venous cannulation in a university anesthesia
trolled study. Anesth Analg 2005;100:21–24. department: influence of operator experience on success of
83. Langston CS. The aberrant central venous catheter and its cannulation and arterial injury. J Cardiothorac Vasc Anesth
complications. Radiology 1971;100:55–59. 2002;16:567–571.
84. Ambesh SP, Dubey PK, Tripathi M, et al. Manual occlusion of 105. Robinson JF, Robinson WA, Cohn A, et al. Perforation of the
the internal jugular vein during subclavian vein catheteriza- great vessels during central line placement. Arch Int Med 1995;
tion: a maneuver to prevent misplacement of catheter into 155:1225–1228.
internal jugular vein. Anesthesiology 2002;97:528–529. 106. Shah PM, Babu SC, Goyal A, et al. Arterial misplacement of
85. Gann M, Sardi A. Improved results using ultrasound guidance large caliber cannulas during jugular vein catheterization: case
for central venous access. Am Surg 2003;69:1104–1107. for surgical management. J Am Coll Surg 2004;198:939–944.
692 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

107. Schwartz AJ, Jobes DR, Greenhow DE, et al. Carotid artery clavian artery puncture. Cathet Cardiovasc Interv 2003;59:
puncture with internal jugular cannulation using the Seldinger 369–371.
technique: incidence, recognition, treatment and prevention. 126. Burbridge B, Stoneham G, Szkup P. Percutaneous subclavian
Anesthesiology 1979;51:S160. artery stent-graft placement following failed ultrasound guided
108. Kron IL, Joob AW, Lake CL, et al. Arch vessel injury during subclavian venous access. BMC Med Imaging 2006;6:1–5.
pulmonary artery catheter placement. Ann Thorac Surg 1985; 127. Carr M, Jagannath A. Hemopericardium resulting from at-
39:223–224. tempted internal jugular vein catheterization: a case report and
109. Jain U, Shah KB, Belusko RJ, et al. Subclavian artery laceration review of complications of central vein catheterization. Cardio-
and acute hemothorax on attempted internal jugular vein can- vasc Interv Radiol 1986;9:214–218.
nulation. J Cardiothor Vasc Anesth 1991;5:608–610. 128. Losert H, Prokesch R, Grabenwoger M, et al. Inadvertent
110. Mainland PA, Tam WH, Law B, et al. Stroke following central transpericardial insertion of a central venous line with cardiac
venous cannulation. Lancet 1997;349:921. tamponade failure of preventive practices. Intensive Care Med
111. Garcia E, Wijdicks EFM, Younge BR. Neurologic complica- 2000;26:1147–1150.
tions associated with internal jugular vein cannulation in crit- 129. Hamilton DL, Jackson RM. Haemopericardium: a rare fatal
ically ill patients: a prospective study. Neurology 1994;44: complication of attempted subclavian vein cannulation. A re-
951–952. port of two cases. Eur J Anesth 1998;15:501–504.
112. Shah P, Leong B, Babu SC, et al. Cerebrovascular events asso- 130. Baumgartner FJ, Rayhanabad J, Bongard FS, et al. Central
ciated with infusion through arterially malpositioned triple- venous injuries of the subclavian-jugular and innominate-caval
lumen catheter. Report of three cases and review of the litera- confluences. Tex Heart Inst J 1999;26:177–181.
ture. Cardiol Rev 2005;13:304–308. 131. Greenall MJ, Blewitt RW, McMahon MJ. Cardiac tamponade
113. Riebau DA, Selph JF, Jarquin-Valdivia AA. Acute ischemic and central venous catheters. BMJ 1975;2:595–597.
strokes after central line placement. The Internet J Emerg In- 132. Collier PE, Goodman GB. Cardiac tamponade caused by cen-
tens Care Med 2005;8:1–6. tral venous catheter perforation of the heart: a preventable
114. Oropello JM, Leibowitz AB, Manasia A, et al. Dilator- complication. J Am Coll Surg 1995;181:459–463.
associated complications of central vein catheter insertion: pos- 133. Fangio P, Mourgeon E, Romelaer A, et al. Aortic injury and
sible mechanisms of injury and suggestions for prevention. cardiac tamponade as a complication of subclavian venous
J Cardiothorac Vasc Anesth 1996;10:634–637. catheterization. Anethesiology 2002;96:1520–1522.
115. Lobato EB, Gravenstein N, Paige GB. Dilator-associated com-
134. Barton BR, Hermann G, Weil R III. Cardiothoracic emergen-
plications of central vein catheter insertion: possible mecha-
cies associated with subclavian hemodialysis catheters. JAMA
nisms of injury and suggestions for prevention [letter]. J Car-
diothorac Vasc Anesth 1997;11:539–540.
135. Castelli P. Cardiac tamponade resulting from attempted inter-
116. Dorje P, LaGorio J, Mullin V. Dilator-associated complications
nal jugular vein catheterization. J Cardiothor Vasc Anesth
of central vein catheter insertion: possible mechanisms of in-
jury and suggestions for prevention [letter]. J Cardiothorac
136. Todd MR, Barone JE. Recognition of accidental arterial can-
Vasc Anesth 1997;11:540.
117. Oropello JM, Leibowitz AB, Benjamin E. Dilator-associated nulation after attempted central venipuncture. Crit Care Med
complications of central vein catheter insertion: possible mech- 1991;19:1081–1083.
anisms of injury and suggestions for prevention [letter]. J Car- 137. Patel SJ, Venn GE, Redwood SR. Percutaneous closure of an
diothorac Vasc Anesth 1997;11:541. iatrogenic puncture of the aortic arch. Cardiovasc Intervent
118. Porter JM, Page R, Wood AE, et al. Ventricular perforation Radiol 2003;26:407–409.
associated with central venous introducer-dilator systems. Can 138. Walser EM, Crow WN, Zwischenberger JB, et al. Percutane-
J Anaesth 1997;44:317–320. ous tamponade of inadvertent transthoracic catheterization of
119. Angelotti T, Amador ER. Right subclavian artery injury [let- the aorta. Ann Thor Surg 1996;62:895–896.
ter]. Anesth Analg 2003;96:1237. 139. Sirivella S, Gielchinsky I, Parsonnet V. Management of
120. Schummer W, Schummer C, Frober R. Internal jugular vein catheter-induced pulmonary artery perforation: a rare compli-
and anatomic relationship at the root of the neck [letter]. cation in cardiovascular operations. Ann Thor Surg 2001;72:
Anesth Analg 2003;96:1540. 2056–2059.
121. Kulvatunyou N, Heard SO, Bankey PE. A subclavian artery 140. Boyd KD, Thomas SJ, Gold J, et al. A prospective study of
injury, secondary to internal jugular vein cannulation, is a pre- pulmonary artery catheterizations in 500 consecutive patients.
dictable right-sided phenomenon. Anesth Analg 2002;95: Chest 1983;84:245–249.
564–566. 141. Shah KB, Rao TLK, Laughlin S, et al. A review of pulmonary
122. Yerdel MA, Karayalcin K, Aras N, et al. Mechanical complica- artery catheterization in 6,245 patients. Anesthesiology 1984;
tions of subclavian vein catheterization. A prospective study. 61:271–275.
Int Surg 1991;76:18–22. 142. Hirsch NP, Robinson PN. Pulmonary artery puncture follow-
123. Nicholson T, Ettles D, Robinson G. Managing inadvertent ing subclavian venous cannulation. Anaesthesia 1984;39:727–
arterial catheterization during central venous access proce- 728.
dures. Cardiovasc Intervent Radiol 2004;27:21–25. 143. Brzowski BK, Mills JL, Beckett WC. Iatrogenic subclavian
124. Holder R, Hilton D, Martin J, et al. Percutaneous thrombin artery pseudoaneurysms: case reports. J Trauma 1990;30:616–
injection of carotid artery pseudoaneurysm. J Endovasc Ther 618.
2002;9:25–28. 144. Sato O, Tada Y, Sudo K, et al. Arteriovenous fistula following
125. Fraizer MC, Chu WW, Gudjonsson T, et al. Use of a percuta- central venous catheterization. Arch Surg 1986;121:729–731.
neous vascular suture device for closure of an inadvertent sub- 145. Yu NR, Eberhardt RT, Menzoian JO, et al. Vertebral artery
Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization 693

dissection following intravascular catheter placement: a case secondary to internal jugular catheterization. Clin Nephrol
report and review of the literature. Vasc Med 2004;9:199–203. 2001;56:78–80.
146. Asteri T, Tsagaropoulo I, Vasiliadis K, et al. Beware Swan-Ganz 167. Davis P, Watson D. Horner’s syndrome and vocal cord paral-
complications. Perioperative management. J Cardiovasc Surg ysis as a complication of percutaneous internal jugular vein
2002;43:467–470. catheterization in adults. Anaesthesia 1982;37:587–588.
147. Chloroyiannis Y, Reul GR. Iatrogenic left subclavian artery-to- 168. Ruggiero RP, Caruso G. Chylothorax—a complication of sub-
left brachiocephalic vein fistula. Tex Heart Inst J 2004;31:172– clavian vein catheterization. JPEN J Parenter Enteral Nutr
174. 1985;9:750–753.
148. Inamasu J, Guiot BH. Iatrogenic vertebral artery injury. Acta 169. Kurecki E, Kaye R, Koehler M. Chylothorax and chylopericar-
Neurol Scand 2005;112:349–357. dium: a complication of a central venous catheter. J Pediatr
149. Bernik TR, Friedman SG, Scher LA, et al. Pseudoaneurysm of 1998;132:1064.
the subclavian-vertebral artery junction. Case report and re- 170. Van Veldhuizen PJ, Yaylor S. Chylothorax: a complication of a
view of the literature. Vasc Endovasc Surg 2002;36:461–464. left subclavian vein thrombosis. Am J Clin Oncol 1996;19:99–
150. Holder R, Hilton D, Martin J, et al. Percutaneous thrombin 101.
injection of carotid artery pseudoaneurysm. J Endovasc Ther 171. Scharff RP, Recto MR, Austin EH III, et al. Lymphocutaneous
2002;9:25–28. fistula as a long-term complication of multiple central venous
151. Schonlolz C, Krajcer Z, Parodi C, et al. Stent-graft treatment of catheter placement. Tex Heart Inst J 2000;27:57–60.
pseudoaneurysms and arteriovenous fistulae in the carotid ar- 172. Beljaars GH, Van Schil P, De Weerdt A, et al. Chylothorax, an
tery. Vascular 2006;14:123–129. unusual mechanical complication after central venous cannu-
152. Damen J, Bolton D. A prospective analysis of 1400 pulmonary lation in children. Eur J Pediatr 2006;165:646–647.
artery catheterizations in patients undergoing cardiac surgery. 173. Khalil KG, Parker FB, Mukherjee N, et al. Thoracic duct in-
Acta Anaesthesiol Scand 1986;30:386–392. jury. A complication of jugular vein catheterization. JAMA
153. Lee TY, Sung CS, Chu YC, et al. Incidence and risk factors of 1972;221:908–909.
guidewire-induced arrhythmia during internal jugular venous 174. Kwon SS, Falk A, Mitty HA. Thoracic duct injury associated
catheterization: comparison of marked and plain J-wires. with left internal jugular vein catheterization: anatomic con-
J Clin Anesth 1996;8:348–351. siderations. J Vasc Interv Radiol 2002;13:337–339.
154. Stuart RK, Shikora SA, Akerman P, et al. Incidence of arrhyth- 175. Teichgraber UKM, Nibbe L, Gebauer B, et al. Inadvertent
puncture of the thoracic duct during attempted central venous
mia with central venous catheter insertion and exchange. J
catheter placement. Cardiovasc Interv Radiol 2003;26:569–
Parenter Enteral Nutr 1990;14:152–155.
155. Flaccadori E, Gonzi G, Zambrelli P, et al. Cardiac arrhythmias
176. Arditis J, Giala M, Anagnostidou A. Accidental puncture of the
during central venous catheter procedures in acute renal fail-
right lymphatic duct during pulmonary artery catheterization.
ure: a prospective study. J Am Soc Nephrol 1996;7:1079–
Acta Anaesthesiol Scand 1988;32:67–68.
177. Walters G, Kahn A, Jescovitch A Jr, et al. Efficacy of a central
156. Unnikrishnan S, Idris N, Varshneya N. Complete heart block
venous access service. South Med J 1997;90:37–39.
during central venous catheter placement in a patient with 178. Muhm M. Supraclavicular approach to the subclavian/
pre-existing left bundle branch block. Br J Anesth 2003;91: innominate vein for large-bore central venous catheters. Am J
747–749. Kidney Dis 1997;30:802–808.
157. Quiney NF. Sudden death after central venous cannulation. 179. Haapaniemi L, Slatis P. Supraclavicular catheterization of the
Can J Anaesth 1994;41:513–515. superior vena cava. Acta Anaesth Scand 1974;18:12–22.
158. Brothers TE, Von Moll LK, Niederhuber JE, et al. Experience 180. Barnacle AM, Kleidon TM. Lymphatic leak complicating cen-
with subcutaneous infusion ports in three hundred patients. tral venous catheter insertion. Cardiovasc Interv Radiol 2005;
Surg Gynecol Obstet 1988;166:295–301. 28:839–840.
159. Dohering M. An unexpected complication of central line 181. Berkenbosch JW, Withington DE. Management of postoper-
placement [letter]. Acad Emerg Med 2001;8:854. ative chylothorax with nitric oxide: a case report. Crit Care
160. Starr DS, Conicelli S. EKG guided placement of subclavian Med 1999;27:1022–1024.
CVP catheters using J-wire. Ann Surg 1986;204:673–676. 182. Inderbitzi RG, Krebs T, Stirneman T, et al. Treatment of post-
161. Sylvestre DL, Sandson TA, Nachmanoff DB. Transient bra- operative chylothorax by fibrin glue application under thora-
chial plexopathy as a complication of internal jugular vein coscopic view with use of local anesthesia. J Thorac Cardiovasc
cannulation. Neurology 1991;41:760. Surg 1992;104:209–210.
162. Trentman TL, Rome JD, Messick JM. Brachial plexus neurop- 183. Binkert CA, Yucel EK, Davison BD, et al. Percutaneous treat-
athy following attempt at subclavian vein catheterization. Case ment of high-output chylothorax with embolization or needle
report. Reg Anesth 1996;21:163–165. disruption technique. J Vasc Interv Radiol 2005;16:1257–
163. Karakaya D, Baris S, Guldogus F, et al. Brachial plexus injury 1262.
during subclavian vein catheterization for hemodialysis. J Clin 184. Cope C, Salem R, Kaiser LR. Management of chylothorax by
Anesth 2000;12:220–223. percutaneous catheterization and embolization of the thoracic
164. Ramdial P, Singh B, Moodley J, et al. Brachial plexopathy after duct: a prospective trial. J Vasc Interv Radiol 1999;10:1248–
subclavian vein catheterization. J Trauma 2003;54:786–787. 1254.
165. Porzionato A, Montisci M, Manani G. Brachial plexus injury 185. Cope C, Kaiser LR. Management of unremitting chylothorax
following subclavian vein catheterization: a case report. J Clin by percutaneous embolization and blockage of retroperitoneal
Anesth 2003;15:582–586. lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002;13:
166. Takaspan H, Oymak O, Dogukan A, et al. Horner’s syndrome 1139–1148.
694 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

186. Bessoud B, de Baere T, Kuoch V, et al. Experience at a single 207. Crnich JC, Maki DG. Are antimicrobial-impregnated cathe-
institution with endovascular treatment of mechanical compli- ters effective? When does repetition reach the point of exhaus-
cations caused by implanted central venous access devices in tion? Clin Infect Dis 2005;41:681–685.
pediatric and adult patients. AJR Am J Roentgenol 2003;180: 208. Deshpande KS, Hatem C, Ulrich HL, et al. The incidence of
527–532. infectious complications of central venous catheters at the sub-
187. Wang HE, Sweeney TA. Subclavian central venous catheteriza- clavian, internal jugular, and femoral sites in an intensive care
tion complicated by guidewire looping and entrapment. unit population. Crit Care Med 2005;33:13–20.
J Emerg Med 1991;7:721–724. 209. Shapiro C. Central venous access catheters. Surg Oncol Clin
188. Tewari P, Agarwal A. Spring guidewire sticks in the indwelling North Am 1995;4:443–451.
catheter during internal jugular vein catheterization. Anaesthe- 210. McConnell SA, Gubbins PO, Anaissie EJ. Are antimicrobial-
sia 2000;55:832. impregnated catheters effective? Replace the water and grab
189. Schwartz AJ, Horrow C, Jobes DR, et al. Guide wires—a cau- your washcloth, because we have a baby to wash. Clin Infect
tion. Crit Care Med 1981;9:347–348. Dis 2004;39:1829–1833.
190. Breznick DA, Ness WC. Acute arterial insufficiency of the upper 211. Mughal MM. Complications of intravenous feeding catheters.
extremity after central venous cannulation. Anesthesiology 1993; Br J Surg 1989;76:15–21.
78:594–596. 212. Fontes ML, Barash PG. “AAA” to the rescue? Crit Care Med
191. Casserly IP, Goldstein JA, Rogers JH, et al. Paradoxical embo- 1999;27:2827–2829.
lization of a fractured guidewire: successful retrieval from left 213. Santilli J. Fibrin sheaths and central venous catheter occlu-
atrium using a snare device. Catheter Cardiovasc Interv 2002; sions: diagnosis and management. Tech Vasc Interv Radiol
57:34–38. 2002;5:89–94.
192. Blake PG, Uldall R. Cardiac perforation by a guide wire during 214. Trottier SJ, Veremakis C, O’Brien J, et al. Femoral deep vein
subclavian catheter insertion. Int J Artif Organs 1989;12:111– thrombosis associated with central venous catheterization: re-
113. sults from a prospective, randomized trial. Crit Care Med
193. Guo H, Lee JD, Guo M. Images in cardiology. Guidewire loss: 1995;23:52–59.
mishap or blunder? Heart 2006;92:602. 215. Cadman A, Lawrance JAL, Fitzsimmons L, et al. To clot or not
194. Streib EW, Wagner JW. Complications of vascular access pro- to clot? That is the question in central venous catheters. Clin
cedures in patients with vena cava filters. J Trauma 2000;49: Radiol 2004;59:349–355.
553–558. 216. Cohn DE, Mutch DG, Rader JS, et al. Factors predicting sub-
195. Schummer W, Schummer C, Gaser E, et al. Loss of the guide cutaneous implanted central venous port function: the rela-
wire: mishap or blunder? Br J Anaesth 2002;88:144–146. tionship between catheter tip location and port failure in pa-
196. Barker P. Guide wire embolism [letter]. Anaesthesia 1991;46: tients with gynecologic malignancies. Gynecol Oncol 2001;
595. 83:533–536.
197. Lum TE, Fairbanks RJ, Pennington EC, et al. Profiles in pa- 217. Bolad I, Karanam S, Mathew D, et al. Percutaneous treatment
tient safety: misplaced femoral line guidewire and multiple of superior vena cava obstruction following transvenous device
failures to detect the foreign body on chest radiography. Acad implantation. Cathet Cardiovasc Interv 2005;65:54–59.
Emerg Med 2005;12:658–662. 218. Sticherling C, Chough SP, Baker RL, et al. Prevalence of central
198. Auweiler M, Kampe S, Zahringer M, et al. The human error: venous occlusion in patients with chronic defibrillator leads.
delayed diagnosis of intravascular loss of guidewire for central Am Heart J 2001;141:813–816.
venous catheterization. J Clin Anesth 2005;17:562–564. 219. Taal MW, Chesterton LJ, McIntyre CW. Venography at inser-
199. Suzuki T, Nishiyama J, Hasegawa K, et al. Development of a tion of tunneled internal jugular vein catheters reveals signifi-
safe guidewire. J Anesth 2006;20:64–67. cant stenosis. Nephrol Dial Transplant 2004;19:1542–1545.
200. O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for 220. Gonsalves CF, Eschelman DJ, Sullivan KL, et al. Incidence of
the prevention of intravascular catheter-related infections. central vein stenosis and occlusion following upper extremity
Centers for Disease Control and Prevention. MMWR PICC and port placement. Cardiovasc Intervent Radiol 2003;
Recomm Rep 2002;51(RR-10):1–29. 26:123–127.
201. Costerton JW, Montanaro L, Arciola CR. Biofilm in implant 221. Mickley V. Central venous catheters: many questions, few an-
infections: its production and regulation. Int J Artif Organs swers. Nephrol Dial Transplant 2002;17:1368–1373.
2005;28:1062–1068. 222. Surratt RS, Picus D, Hicks ME, et al. The importance of pre-
202. Barbaric D, Curtin J, Pearson L, et al. Role of hydrochloric acid operative evaluation of the subclavian vein in dialysis access
in the treatment of central venous catheter infections in chil- planning. AJR Am J Roentgenol 1991;156:623–625.
dren with cancer. Cancer 2004;101:1866–1872. 223. Ascher E, Salles-Cunha S, Hingorani A. Morbidity and mor-
203. Kutter DJ. Thrombotic complications of central venous cath- tality associated with internal jugular vein thromboses. Vasc
eters in cancer patients. Oncologist 2004;9:207–216. Endovasc Surg 2005;39:335–339.
204. Mickley V. Central vein obstruction in vascular access. Eur J 224. Sprouse LR, Lesar CJ, Meier GH III, et al. Percutaneous treat-
Vasc Endovasc Surg 2006;32:439–444. ment of symptomatic central venous stenosis. J Vasc Surg
205. Laster JL, Nichols WK, Silver D. Thrombocytopenia associ- 2004;39:578–582.
ated with heparin-coated catheters in patients with heparin- 225. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous
associated antiplatelet antibodies. Arch Int Med 1989;149: thromboembolism: the Seventh ACCP Conference on Anti-
2285–2287. thrombotic and Thrombolytic Therapy. Chest 2004;
206. Berenholtz S, Pronovost PJ, Lipsett PA, et al. Eliminating 126[suppl]:338S–400S.
catheter-related bloodstream infections in the intensive care 226. Gray RJ, Levitin A, Buck D, et al. Percuateneous fibrin sheath
unit. Crit Care Med 2004;32:2014–2020. stripping versus transcatheter urokinase infusion for malfunc-
Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization 695

tioning well-positioned tunneled central venous dialysis 246. Scott WL. Complications associated with central venous cath-
catheters: a propective, randomized trial. J Vasc Interv Radiol eters. A review. Chest 1988;94:1221–1225.
2000;11:1121–1129. 247. Hinke DH, Zandt-Stasthy DA, Goodman LR, et al. Pinch-off
227. Hardy G, Ball P. Clogbusting: time for a concerted approach to syndrome: a complication of implantable subclavian venous
catheter occlusions? Curr Opin Clin Nutr Metab Care 2005; access devices. Radiology 1990;177:235–236.
8:277–283. 248. Andris DA, Krzywda EA, Schulte W, et al. Pinch-off syn-
228. Duntley P, Siever J, Korwes ML, et al. Vascular erosion by drome: a rare etiology for central venous catheter occlusion. J
central venous catheters. Clinical features and outcome. Chest Parenter Enteral Nutr 1994;18:531–533.
1992;101:1633–1638. 249. Mirza B, Vanek VW, Kupennsky DT. Pinch-off syndrome: case
229. Ellis LM, Vogel SB, Copeland EM III. Central venous catheter report and collective review of the literature. Am Surg 2004;
vascular erosions. Diagnosis and clinical course. Ann Surg 70:635–644.
1989;209:475–478. 250. Monsuez JJ, Dourd MC, Martin-Bouyer Y. Catheter frag-
230. Jiha JG, Weinberg GL, Laurito CE. Intraoperative cardiac tam- ments embolization. Angiology 1997;48:117–120.
ponade after central venous cannulation. Anesth Analg 1996; 251. Vesely TM. Air embolism during insertion of central venous
82:664–665. catheters. J Vasc Interv Radiol 2001;12:1291–1295.
231. Nadroo AM, Lin J, Green RS, et al. Death as a complication of 252. Heckmann JG, Lang CJG, Kindler K, et al. Neurologic man-
peripherally inserted central catheters in neonates. J Pediatr ifestations of cerebral air embolism as a complication of central
2001;138:599–601. venous catheterization. Crit Care Med 2000;28:1621–1625.
232. Yoder D. Cardiac perforation and tamponade: the deadly duo 253. Caridi JG, West JH, Stavropoulos SW, et al. Internal jugular
of central venous catheters. Int J Trauma Nurs 2001;7:108– and upper extremity central venous access in interventional
112. radiology: is a postprocedure chest radiograph necessary? AJR
233. Carbone K, Gimenez LF, Rogers WH, et al. Hemothorax due Am J Roentgenol 2000;174:363–366.
to vena caval erosion by a subclavian dual-lumen catheter. 254. Kashuk JL, Penn I. Air embolism after central venous catheter-
South Med J 1987;80:756–795. ization. Surg Gynecol Obstet 1984;159:249–252.
234. Kapadia CB, Heard SO, Yeston NS. Delayed recognition of 255. Kim DK, Gottesman MH, Forero A, et al. The CVC removal
vascular complications caused by central venous catheters. distress syndrome: an unappreciated complication of central
J Clin Monit 1988;4:267–271. venous catheter removal. Am Surg 1998;64:344–347.
256. Boer WH, Hene RJ. Lethal air embolism following removal of
235. Li PK, Taylor CW III, Chung RS. Delayed hydrothorax: a
a double lumen jugular vein catheter. Nephrol Dial Transplant
complication of central venous catheterization. Surg Rounds
257. Zafronte RD, Hammond FD, Rahimi R. Air embolism in the
236. Conces DJ, Holden RW. Aberrant locations and complications
agitated traumatic brain injury patient: an unusual complica-
in initial placement of subclavian vein catheters. Arch Surg
tion. Brain Inj 1996;10:759–761.
258. Phifer TJ, Bridges M, Conrad SA. The residual central venous
237. Tocino IM, Watanabe A. Impending catheter perforation of
catheter track—an occult source of lethal air embolism: case
superior vena cava: Radiographic recognition. AJR Am J report. J Trauma 1991;31:1158–1160.
Roentgenol 1986;146:487–490. 259. Laskey AL, Dyer C, Tobias JD. Venous air embolism during
238. Gravenstein N, Blackshear R. Relative perforating potential of home infusion therapy. Pediatrics 2002;109:e15.
7-Fr triple-lumen catheters. Abstr Crit Care Med 1988;16: 260. Vignaux O, Borrego P, Macron L, et al. Cardiac gas embolism
435. after central venous catheter removal. Undersea Hyperb Med
239. Kohler TR, Kirkman BS. Central venous catheter failure is 2005;32:325–326.
induced by injury and can be prevented by stabilizing the cath- 261. Yu AS, Levy E. Paradoxical cerebral air embolism from a he-
eter tip. J Vasc Surg 1998;28:59–66. modialysis catheter. Am J Kidney Dis 1997;29:453–455.
240. Belani KG, Wilder RT, Campbell LM, et al. The new “pig-tail” 262. Blanc P, Boussuges A, Henriette K, et al. Iatrogenic cerebral air
tipped central venous catheter—a design to eliminate vascular embolism: importance of an early hyperbaric oxygenation. In-
perforation. Anesth Analg 1989;68:S20. tensive Care Med 2002;28:559–563.
241. Merry AF, Webster CS, Van Cotthem IC, et al. A prospective 263. Kolbeck KJ, Stavropoulos SW, Trerotola SO. Aerostasis during
randomized clinical assessment of a new pigtail central venous central venous access: updates in protective sheaths. J Vasc
catheter in comparison with standard alternatives. Anaesth In- Interv Radiol 2006;17:1155–1163.
tensive Care 1999;27:639–645. 264. Peter DA, Saxman C. Preventing air embolism when removing
242. Gowda MR, Gowda RM, Khan IA, et al. Positional ventricular CVCs: an evidence-based approach to changing practice. Med-
tachycardia from a fractured mediport catheter with right ven- surg Nurs 2003;12:223–228.
tricular migration—a case report. Angiology 2004;55:557– 265. Aroesty JM, Cohen SI. Traction-induced fracture of a central
560. venous pressure catheter. Chest 1971;60:515–516.
243. Raymond-Carrier S, Dube M, Nolin L, et al. Hemodialysis 266. Georghiou GP, Vidne BA, Raanani E. Knotting of a pulmo-
catheter tip embolization in the right pulmonary vasculature: nary artery catheter in the superior vena cava: surgical removal
report of a cardiac arrest. ASAIO J 2003;49:751–754. and a word of caution. Heart 2004;90:e28.
244. Sagar V, Lederer E. Pulmonary embolism due to catheter frac- 267. Agarwal NN, Giesswein P, Leverett L, et al. An unusual case of
ture from a tunneled dialysis catheter. Am J Kidney Dis 2004; pulmonary artery catheter knotting during withdrawal. Crit
43:e13–14. Care Med 1989;17:1081–1082.
245. Reynen K. 14-year follow-up of central embolization by a 268. Nguyen D, Omari B, Chung C, et al. Guidewire knotting after
guide wire [letter]. N Engl J Med 1993;329:970–971. carotid perforation. Tex Heart Inst J 1996;23:313.
696 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

269. Fratino G, Mazzola C, Buffa P, et al. Mechanical complications central catheters in children with cystic fibrosis. Eight cases of
related to indwelling central venous catheter in pediatric difficult removal. J Infus Nurs 2001;24:297–300.
hematogy/oncology patients. Pediatr Hematol Oncol 2001; 279. Troianos CA, Kuwik RJ, Pasqual JR, et al. Internal jugular vein
18:317–324. and carotid artery anatomic relation as determined by ultra-
270. Carrion MI, Ayuso D, Marcos M, et al. Accidental removal of sonography. Anesthesiology 1996;85:43–48.
endotracheal and nasogastric tubes and intravascular catheters. 280. Caridi JG, Hawkins IF, Wiechmann BN, et al. Sonographic
Crit Care Med 2000;28:63–66. guidance when using the right internal jugular vein for central
271. Lorente L, Huidobro MS, Martin MM, et al. Accidental cath- vein access. AJR Am J Roentgenol 1998;171:1259–1263.
eter removal in critically ill patients: a prospective and obser- 281. Lichtenstein D, Saifi R, Augarde R, et al. The internal jugular
vational study. Crit Care 2004;8:R229–R233. veins are asymmetric. Usefulness of ultrasound before catheter-
272. Collini A, Nepi S, Ruggieri G, et al. Massive hemothorax after ization. Intensive Care Med 2001;27:301–305.
removal of subclavian vein catheter: a very unusual complica- 282. Lieberman JA, Williams KA, Rosenberg AL. Optimal head
rotation for internal jugular vein cannulation when relying
tion. Crit Care Med 2002;30:697–698.
on external landmarks. Anesth Analg 2004;99:982–988.
273. Thein H, Ratanjee SK. Tethered hemodialysis catheter with
283. Fortune JB, Feustel P. Effect of patient position on size and
retained portions in central vein and right atrium on attempted
location of the subclavian vein for percutaneous puncture.
removal. Am J Kidney Dis 2005;46(3):e35–e39. Arch Surg 2003;138:996–1000.
274. Forauer AR, Theoharis C. Histologic changes in the human 284. Cockburn JF, Eynon CA, Virji N, et al. Insertion of Hickman
vein wall adjacent to indwelling central venous catheters. J Vasc central venous catheters by using angiographic techniques in
Interv Radiol 2003;14:1163–1168. patients with hematologic disorders. AJR Am J Roentgenol
275. Mahadeva S, Cohen A, Bellamy M. The stuck central venous 1992;159:121–124.
catheter: beware of potential hazards. Br J Anaesth 2002;89: 285. Matthews NT, Worthley LIG. Immediate problems associated
650–652. with infraclavicular subclavian catheterisation; a comparison
276. Ng PK, Ault MJ, Fishbein MC. The stuck catheter: a case between left and right sides. Anaesth Intensive Care 1982;10:
report. Mt Sinai J Med 1997;64:350–352. 113–115.
277. Filan PM, Woodward M, Ekert PG. Stuck Long line syn- 286. Onders RP, Shenk RR, Stellato TA. Long-term central venous
drome. Arch Dis Child 2005;90:558. catheters: size and location do matter. Am J Surg 2006;191:
278. Miall LS, Das A, Brownlee KG, et al. Peripherally inserted 396–399.