Iatrogenic Innominate Vein Injury by Hemodialysis Catheter, Successful Endovascular Repair

Central venous catheters procedure related complications occur in about 7%: specific complications such as pneumothorax, hemothorax, or air embolism are set at 2% (1). Especially, the iatrogenic innominate vein injury by the catheter insertion is rare through the central vein. Not rapidly managed, it can be life-threatening. A 90-year-old woman was admitted due to obstruction of left elbow arteriovenous fistula (AVF). She underwent a cuffed tunneled central venous catheter placement. The catheter was placed under Doppler ultrasonogram and fluoroscopic guidance, alert consciousness, and local anesthesia. The right internal jugular vein was entered with the 18-gauge introducer needle. The guidewire was passed smoothly through the needle. Next, the 12F dilator passed over the guidewire. When the dilator passed over the guidewire to its full extent, the patient presented abrupt, sudden severe chest pain, tightness, dyspnea, and sweating. We stopped all procedures and proceeded to wait. As the patient was stable, the catheter insertion was completed. Through fluoroscopy, we recognized that the catheter tip was placed in SVC (Superior vena cava). Within minutes after the procedure, the patient became hemodynamically unstable. The chest x-ray showed large amount of right hemothorax associated with compressive atelectasis in right lung. The right tube thorachostomy catheter was performed. The patient was transferred to an angio-procedure room. The 10F vascular sheath was inserted through the right common femoral vein. Then, the catheter was changed to 5F head-hunter catheter, and the diagnostic venogram was performed. In right innominate venogram, the contrast extravasation was noted at the medial side of the right innominate vein (Fig. 1). A 14 mm x 40 mm (Taewoong Niti-S stent 9F; Taewoongmedical, Korea) stent graft was positioned at the perforation area. The hemodialysis catheter was removed before the stent graft was deployed at the same time. There is no leakage at post-deployment venogram (Fig. 2). The next day, the patient was conscious and recovered. On the 14th day after deployment, the chest tube was removed. The patient recovered uneventfully. We do not know why it happens, but it is usually attributed to perforation of vessel by the puncture needle, the catheter, or rarely vessel dilator. Oropello et al (2) described the mechanisms of injury and suggestions for prevention. They said the dilators could penetrate a vessel wall if it is forced in too deeply, and they may have an even greater propensity for causing perforation than the catheter, which is softer. The authors thought that the rupture was caused by the vessel dilator. There are two methods of providing treatment: surgical repair and endovascular repair. Surgical repair requires a median sternotomy. Endovascular repair (balloon angioplasty and stent placement) has been described for treatment of superior vena cava syndrome (3-5). In our cases, the patient needed a vascular access for hemodialysis; during placement of catheter, the rupture occurred. Our patient was a poor candidate for surgery because she was hemodynamically instable. For such patients, endovascular intervention provides a viable option. We report a case in which emergency endovascular stent-graft repair was successful in treating the iatrogenic patient with an innominate vein injury.