A 57-year-old Caucasian woman was recently diagnosed with advanced stage ovarian cancer. Otherwise healthy, she had initially consulted her general practitioner simply for abdominal distension. Further investigations [abdominal computed tomography (CT), serum CA125determination and laparoscopy] revealed a peritoneal carcinomatosis. The diagnosis of stage III (FIGO classification) ovarian cancer was established and the patient received a carboplatin-paclitaxel based chemotherapy regimen in a neoadjuvant setting. The indication of a debulking surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) was retained by our institutional tumor board. A CVL was inserted via the right jugular vein into the superior vena cava in prevision of surgery and the appropriate positioning of the catheter was verified by chest x-ray. An implantable central venous catheter (Port-a-Cath) was already in place (Fig. ).\nThe first 48 postoperative hours were marked by difficult pain management, hypotension, and transient hyperlactatemia responding to fluid replacement and norepinephrine. On postoperative day 3, she presented acute onset dyspnea when transferred from the bed to a chair, and a major drop in pulse oxygen saturation (from SpO2 96% to 83%) justified the administration of oxygen (5 L/min) via a nasal cannula. On physical examination, her body temperature was 37.4 °C, blood pressure 135/81 mmHg, heart rate 122 beats/min, respiratory rate 20/min. No chest pain was reported. Pulmonary examination revealed a bilateral reduction of basal breath sounds with dullness at percussion. Chest x-ray examination (Fig. ) showed bilateral pleural effusions that could largely explain patient’s dyspnea and oxygen desaturation. After switching from a nasal cannula to a nonrebreather mask (FiO2 0.40), the patient’s condition seemed to stabilize in supine position. A measurement of the arteriovenous oxygen difference was obtained via sampling through the arterial and central venous line after the patient was again lying in supine position (Table ).\nA sampling error or a wrong positioning of the recent CVL was suspected, but a sample taken from the Port-a-Cath confirmed the venous value. A transthoracic echocardiography (TTE) with bubble test failed to show a right-to-left shunt, atrial septum was intact. No pulmonary hypertension was detected and right ventricle was not dilated. A CT pulmonary angiography (Fig. ) showed large bilateral pleural effusions with atelectasis of both lower lobes, acute pulmonary embolism in the right middle and upper lobe pulmonary arteries, and ultimately an anatomical variant of the left upper pulmonary vein draining into the left innominate vein. Following bilateral chest drainage, the patient was treated with low molecular weight heparin twice daily. There was no evidence for deep venous thrombosis. This was followed by a significant clinical improvement, a disappearance of the platypnea–orthodeoxia complaints and a reduction of oxygen requirement over the following days.\nAt 1-year follow-up, TTE showed no right ventricular dilation and absence of pulmonary hypertension. From an oncological perspective, stability was also observed during her niraparib maintenance therapy, with absence of new lesions at a 1-year follow-up abdominal CT.
A 65-yr-old woman with an underlying chronic kidney disease was presented to the emergency room (ER) with uremia because of sepsis accompanied by oliguria and severe metabolic acidosis on August 29, 2008. To begin emergency HD, we attempted to insert a 7.5 French (Fr) catheter into the right IJV under ultrasound guidance. The initial puncture with an 18-gauge needle into the right IJV using real-time US guidance by the short-axis method was successful with no pulsatile arterial back flow. Thereafter, the rest of the procedure with removal of the ultrasound transducer was performed without any resistance to advancing the guide wire and HD catheter by the Seldinger technique. No immediate complications such as rapidly expanding hematoma, pain, dyspnea, shock, or signs of neurologic deficits were noticed during insertion of the THC. However, a routine post-cannulation chest X-ray suggested that the catheter tip had been misplaced into the right subclavian artery (SCA) (), and subsequent computed tomographic (CT) angiography with contrast enhancement revealed that the catheter had indeed passed through the right IJV and been misplaced into the right SCA (). We assumed that the puncture needle had initially been inserted into the right IJV, but had been unintentionally advanced into the right SCA after the absence of arterial back flow had been established and before inserting the guide wire.\nThe HD catheter into the right SCA was left in place without an immediate catheter removal and direct external compression, because of the uncontrollable arterial bleeding that might result from application of the pull/pressure technique. Following consultation with a vascular surgeon, the surgical exploration in the operating room revealed that the HD catheter had transected the right IJV and the right SCA. The catheter was removed and the SCA injury was surgically repaired without complications. An angiogram under real-time fluoroscopy revealed no further bleeding or fistula between right IJV and right SCA (). Also, subsequent evaluation of neurological status following open surgical repair and angiography for any intra-arterial catheter-related thrombi or emboli, revealed no neurologic deficit. The patient underwent an uneventful hospital course with antibiotic therapy and intermittent hemodialysis through the THC into the right femoral vein, as required. HD was stopped on the 12th hospital day.