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.
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.