Arterial Placement of Central Venous Catheter

(CVC)

General Considerations

• Percutaneous cannulation of a central venous structure is a common procedure, most often for fluid replacement, administration of medication, for parenteral alimentation
• Arterial puncture has been reported in 5.2% of attempted central venous catheter (CVC) insertions
• Pneumothorax is the most common complication of central venous catheter insertion attempts
• Puncture of the artery (carotid) is more likely to occur in an attempted internal jugular approach than a subclavian vein approach for the subclavian artery
• Frequency of a mechanical complication increases six-fold when three or more attempts are made
• Arterial cannulation may occur if the subclavian puncture is too lateral or too deep

Clinical Findings

• Bright red pulsatile back flow instead of steady venous backflow
• Occurs more often with right-sided insertions

Imaging Findings

• Ultrasound-guided subclavian vein cannulation has reduced complications
• Chest radiography following attempted insertion of a CVC is the standard of care
• The normally-positioned CVC descends around the medial end of the clavicle
• The normal position of the tip of a CVC is to the right of midline at the first intercostal space
• Arterial placement is to be suspected if the catheter fails to descend to the right of the spine and/or…
• If the catheter follows the expected course of the aortic arch

Differential Diagnosis

• Persistent left superior vena cava
  • Drains into right atrium
• Inadvertent arterial puncture and a right-sided aortic arch

Treatment

• Most can be managed percutaneously
• For subclavian arterial punctures, patients need to be monitored for hemodynamic instability and hemothorax development

Complications

• Neurologic complications