This case is being reported after obtaining written consent from the patient.\nA 38-year-old woman was admitted with per rectal bleeding and abdominal pain. She had a history of Crohn's disease. She had undergone four previous bowel resections during the last 15 years. Total parenteral nutrition was planned through a CV catheter, and a referral was made to the on-call anesthesia resident for gaining CV access. Preprocedural examination showed normal vital signs. The patient's coagulation profile was normal. Patient had been receiving azathioprine, zopiclone, tramadol, and amitriptyline. She had history of the previous catheterization of both the right and left internal jugular veins during the last 5 years.\nWith noninvasive monitoring of blood pressure and pulse oximetry established, right IJV catheterization was attempted in the High Dependency Unit (HDU) using a triple lumen catheter (16 cm 7.5 Fr Multicath 3 L Expert/VYGON GmbH and Co., Germany). Due to technical reasons, ultrasound (US) could not be used, and the right IJV was accessed by the standard landmark approach at the apex of two heads of sternomastoids using the Seldinger's technique. The right IJV was first accessed with a 22G finder needle. The vein was then cannulated with the 70 mm larger needle and nonpulsatile dark blood was aspirated freely. The J-tip guide-wire was then passed successfully through the needle, and the dilator was advanced without any resistance over the guide-wire and was then removed. The catheter was threaded over the guide-wire up to the 7 cm mark, when some resistance was encountered. Further attempts to thread the catheter were abandoned as aspiration revealed bright red and pulsating blood giving rise to suspicions of an arterial placement. Immediately, the catheter along with the guide-wire was removed, and firm pressure applied over the site. 4 h later, IJV cannulation was performed on the same side by identifying the IJV with a finder needle and then successfully inserting the catheter without any resistance. Dark venous blood was aspirated freely from all the three ports of the catheter. A chest X-ray was taken, and satisfactory position of the catheter tip was confirmed. 2 h later, the patient woke up from sleep complaining of pain from the right shoulder to the elbow and also a dead feeling in the right arm. Physical examination revealed a cold and tender right arm, with a delayed capillary refill and absent radial, brachial and axillary pulses on the right side. Doppler signals were also negative for axillary, brachial and radial pulsations on this side. The radial and brachial pulsations on the other side were normal. A partial or complete arterial occlusion due to spasm or thrombosis was suspected, and the patient was transferred to the regional vascular center for further management. At the regional center, the IJV catheter was removed and anticoagulation by low molecular weight heparin was commenced. Ascending aortography with selective catheterization of the brachiocephalic trunk was performed subsequently, which confirmed an intraluminal thrombus in the proximal right SCA []. The patient was started on a heparin infusion. Thrombolysis was not thought to be appropriate in view of the risk of bleeding at the CV access site, active rectal bleeding and Crohn's disease. Subsequently, right SCA thrombectomy with graft was performed under general anesthesia. A Fogarty catheter was passed easily, and a large volume of clot extracted. Postoperatively positive Doppler signals for arterial flow were obtained. She was transferred to the ward after 3 days of monitoring in the intensive care unit and was discharged home a week after surgery.
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.