Inadvertent catheterization of the carotid artery is a known complication during placement of central venous catheters. There are no standard guidelines for management; potential treatment options include manual compression, surgical repair, and endovascular therapy. In this case, we demonstrate successful removal of a central venous catheter inadvertently placed in the carotid artery with an Angio-Seal closure device without complication. Of note, an embolic protection device was also utilized to prevent potential embolic stroke during placement of the closure device.
Key Words: Closure device, carotid catheterization, central venous catheter
An 87-year-old male with a past medical history significant for hypertension and atrial fibrillation presented to the emergency department after experiencing the sudden onset of shortness of breath and chest congestion; he was subsequently diagnosed to have a pulmonary embolism. The patient was immediately started on anticoagulation with heparin. A couple of days after admission, the patient developed atrial fibrillation with rapid ventricular response. He coded and was transferred immediately to the intensive care unit intubated, where a right neck central venous catheter was placed bedside and the patient was placed on a diltiazem drip. Two days later, the patient presented with left-sided sensory and motor weakness, and magnetic resonance imaging (MRI) revealed multiple right-sided lesions compatible with ischemic stroke of embolic origin (Figure 1).
A CT scan of the neck subsequently revealed that the central venous catheter was inadvertently placed into the right common carotid artery (Figure 2) with the tip of the catheter in the innominate artery (Figure 3). Incidentally noted is plaque at the origin of the right internal carotid artery.
After evaluation by vascular surgery, cardiothoracic surgery, and vascular/interventional radiology services, a decision was made to close the arterial puncture site with a closure device. Due to the potential for hemorrhage, anticoagulation was stopped and an inferior vena cava (IVC) filter was placed. There was concern that there could be further cerebral embolic events during the procedure. As a result, carotid angiography (Figure 4) was performed and a SpiderFX (Medtronic) embolic protection device was placed into the right common carotid artery above the central venous catheter access site via a right common femoral artery access (Figure 5). An Angio-Seal device (St. Jude Medical) was then used to close the carotid puncture.
The embolic protection device was removed and no particulate matter was captured. A subsequent angiogram was performed which demonstrated successful closure of the carotid puncture site without evidence of extravasation or other abnormality (Figure 7). Final cerebral angiogram demonstrated no evidence of new emboli.
There were no procedural complications. Of note, there were no further neurologic events. The patient was discharged on antiplatelet medication and his neurologic deficit was improving.
In central venous catheterization, no definitive guidelines are available within the literature to guide patient management after accidental carotid artery cannulation with a relatively large-bore catheter (≥7 French).1 Given the advent of ultrasound-guided placement of such catheters, there are fewer complications and an increased probability of successful catheter placement during such procedures.2 Despite the decrease in risk associated with ultrasound usage, blind catheter placement based on anatomical landmarks still occurs. Mechanical, thrombotic, and infectious complications can follow, with arterial puncture being among the most common mechanical complication during internal jugular venous catheterization.3 Current management options include direct manual compression, open surgical repair, and endovascular intervention.
Manual compression has been regarded as the standard method of achieving hemostasis after percutaneous procedures for nearly five decades.4 However, in accidental carotid arterial puncture, removal of a large-bore catheter followed by direct manual compression has been demonstrated to be associated with a significantly higher morbidity relative to surgical and endovascular approaches.1 Potential complications include stroke5, hematoma6, pseudoaneurysm7, arteriovenous fistula8, and death9. Reasons for poor outcomes include the overlying bony structure preventing full application of pressure in the region of the proximal common carotid and arterial puncture location further from an access site than anticipated.10 Guilbert et al reported a 47% (n=17) complication rate among patients treated with external compression following inadvertent carotid catheterization. They further reported at three large institutions in Montreal that all patients (n=5) treated with direct manual pressure were affected by major complications. Immediate stroke risk of 5.6% as well as pseudoaneurysm and arteriovenous fistula up to 2 weeks later have been reported with this technique.1 Shah et al additionally reported complications in 30% of patients (n=20) treated with external compression, including 2 deaths, after review of 4 studies.10 Collectively, the evidence strongly advises against the use of external manual compression in the management of inadvertent carotid arterial puncture with large-bore catheters, especially for low puncture sites that are not easily compressible.
In comparison, evidence suggests surgical and endovascular interventions are associated with fewer complications and minimal morbidity. Bechara et al reported no complications or neurologic deficits in patients (n=12) treated with either open or endovascular repair in a retrospective medical review.11 Similarly, Guilbert et al reported no complications in patients treated with endovascular intervention (n=12) and one complication with surgical repair (n=14); this was thought to be secondary to delayed surgical intervention. They further reported the complication incidence in carotid injury repair to have a relative risk of 17.86, favoring surgical or endovascular repair over direct manual compression.1 In comparing open surgical versus endovascular procedures, evidence suggests noninvasive endovascular repair may be more advantageous. Both mean procedural time and delay of intended operation were shorter with endovascular therapy.11 Moreover, neither carotid clamping nor surgical cut down are required. Location of carotid injury may further dictate choice of therapy; carotid punctures below or behind the clavicle are more ideally treated with endovascular therapy due to difficult surgical accessibility.1 Attempts have been made to delineate when surgical versus endovascular repair would be most appropriate in inadvertent carotid cannulation1, yet no standard guidelines are currently agreed upon to date.
In this case, patient management was extensively discussed among vascular surgery, cardiothoracic surgery, and vascular/interventional radiology services. An endovascular approach was ultimately decided upon due to the less invasive nature of the procedure given the patient’s age and medical comorbidities. Further discussion revolved around the appropriate closure device to be used. Previous literature provides little in the way of guidance as to the appropriate arterial closure device to be used in inadvertent carotid injury. Several options are available for such procedures. Suture-mediated closure devices, such as the Perclose device (Abbott Vascular), deploy sutures that are tied to form a knot at the arterial access site. Collagen-based devices, such as the Angio-Seal (St. Jude Medical), deploy collagen plugs external to the artery to induce clot formation while also expanding upon contact with blood to occlude the arteriotomy site. The Angio-Seal device, in particular, contains an intraluminal T-shaped anchor connected to the external collagen plug via an absorbable traction suture. Additionally, metal clip or disc-based devices, such as the StarClose device (Abbott Vascular), close arterial puncture sites with metal clips or staples that do not undergo resorption.4 Finally, there are other extravascular closure devices which do not leave any device within the artery, including the MynxGrip and Exoseal (Cardinal Health).
Here, the Angio-Seal was utilized as a closure device for the carotid artery. Concern about this device arises from the intraluminal anchor, which creates the hypothetical possibility of dislodgement and embolization into the intracranial circulation.12 In contrast, the hemostatic nitinol clip of the StarClose device is entirely extraluminal and the Perclose device leaves only an intraluminal suture loop.13 The MynxGrip and Exoseal are also entirely extravascular, but these devices were not available at the institution at the time of the procedure. Evidence suggests, though, that the Angio-Seal can be utilized in carotid arterial puncture safely. Cuellar et al12 utilized the Angio-Seal in direct carotid artery puncture in 8 patients undergoing aneurysm embolization or carotid artery stenting without complication in all but 1 patient; this patient developed a hematoma that may have been due to inadvertent internal jugular injury. They further demonstrated no flow abnormalities or stenosis in 6 of the patients at 6-month follow-up. Successful use of the Angio-Seal has also been noted without complication in 4 cases of inadvertent subclavian cannulation.14 As we had the most experience with this closure device, it was our device of choice. Given the relative rarity of this condition, there are no studies comparing different closure devices for carotid closure. Furthermore, it is important to note that utilization of all closure devices for this indication is off label.
Of note, a SpiderFX (Medtronic) embolic protection device was deployed cranial to the carotid catheterization site in order to protect against further possible cerebral embolic events. Upon removal, no particulate debris was seen within the device. While the Angio-Seal device appears promising as an arterial closure device in accidental carotid arterial cannulation, further studies are needed to more fully assess the benefits and risks of its use for this indication.
- Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg. 2008; 48(4): 918-925.
- Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med. 1996; 24(12): 2053-2058.
- Mcgee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003; 348(12): 1123-1133.
- Bechara CF, Annambhotla S, Lin PH. Access site management with vascular closure devices for percutaneous transarterial procedures. J Vasc Surg. 2010; 52(6): 1682-1696.
- Mainland PA, Tam WH, Law B, Kee, WN. Stroke following central venous catheterization. Lancet. 1997; 349: 921.
- Eckhardt WF, Laconetti J, Kwon JS, et al. Inadvertent carotid artery cannulation during pulmonary artery catheter insertion. J Cardiothorac Vasc Anesth. 1996; 10: 283-290.
- Nayeem SA, Tada Y, Takagi A, et al. Carotid artery pseudoaneurysm following internal jugular vein cannulation. J Cardiovasc Surg (Torino). 1990; 31: 182-183.
- Ezri T, Szmuk P, Cohen Y, et al. Carotid artery-internal jugular vein fistula: a complication of internal jugular vein catheterization. J Cardiothorac Vasc Anesth. 2001; 15: 231-232.
- Benter T, Teichgraber UK, Kluhs L, Dorken B. Percutaneous central venous catheterization with a lethal complication. Intensive Care Med. 1999; 25: 1180-1182.
- Shah PM, Babu SC, Goyal A, Mateo RB, Madden RE. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: case for surgical management. J Am Coll Surg. 2004; 198(6): 939-944.
- Bechara CF, Barshes NR, Pisimisis G, Kougias P, Lin PH. Management of inadvertent carotid artery sheath insertion during central venous catheter placement. JAMA Surg. 2013; 148(11): 1063-1066.
- Cuellar H, Guimaraens L, Ambekar S, Vivas E, Theron J. Angioseal™ as a hemostatic device for direct carotid puncture during endovascular procedures. Interv Neuroradiol. 2015; 21(2): 273-276.
- Pua U, Tan GW, Punamiya S. Use of StarClose device under ultrasound guidance in inadvertent carotid artery puncture. J Vasc Interv Radiol. 2015; 26(9): 1410-1412.
- Nicholson T, Ettles D, Robinson G. Managing inadvertent arterial catheterization during central venous access procedures. Cardiovasc Intervent Radiol. 2004; 27(1): 21-25.
Disclosure: Dr. Ripal Gandhi reports he is a consultant to Medtronic. Christopher Tournade, BS, reports no conflicts of interest regarding the content herein.
Dr. Ripal Gandhi can be contacted at email@example.com.