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 64-year-old man, weighing 47 kg and having a height of 154 cm, was scheduled for a pericardiectomy for treatment of constrictive pericarditis. When he was hospitalized with a two-week history of aggravating dyspnea, he had been placed on outpatient follow-up for pulmonary tuberculosis, previously diagnosed with dyspnea on exertion and pleural effusion. His past medical history included diabetes mellitus diagnosed 20 years ago and stent insertion in the left anterior descending (LAD) coronary artery eight years ago. Preoperative ECG revealed left atrial enlargement, and ST depression and flat T-wave on lead II, III and V4-6. Chest radiograph showed pulmonary edema and bilateral pleural effusion. Coronary computerized tomography demonstrated that the LAD stent was intact, but there was >50% narrowing of the left circumflex coronary artery, and pericardial thickening with adhesion to the right atrial and left ventricular lateral walls. Echocardiography showed a left ventricular ejection fraction of 73%, and mild pulmonary hypertension with a systolic right ventricular pressure of 38 mmHg.\nAn hour before surgery, premedication was done with IM morphine 3 mg. On arrival, continuous monitoring of ECG lead II and V5 was initiated, and the radial artery cannulation was done under local anesthesia for pressure monitoring. Vital signs before induction of anesthesia were HR 85/min, ABP 108/68 mmHg, and SpO2 98%. Anesthesia was induced with IV midazolam 3 mg and ketamine 20 mg. Rocuronium 50 mg was administered to facilitate endobronchial intubation with a 35 Fr left-sided double-lumen tube. After intubation, lungs were ventilated with a tidal volume of 8-10 ml/kg, adjusted to maintain end-tidal CO2 within 33-38 mmHg. Anesthesia was maintained with 1.0-1.5% sevoflurane in 60% oxygen in air and continuous infusion of remifentanil at 0.1-0.3µg/kg/min.\nAfter induction of anesthesia, the patient was turned to the head-down position with the head rotated leftward by approximately 60° to facilitate internal jugular catheterization. An 18-G puncture needle was inserted at the conjoined site of both bellies of the SCM, and was advanced toward the ipsilateral nipple until free regurgitation of venous, non-pulsatile blood flow was observed. During the first attempt, the puncture needle had to be withdrawn, as the J-tipped guide wire could be advanced <10 cm. After 5 min of manual compression, jugular venous puncture was retried in the same manner, and non-pulsatile, free-regurgitant blood flow was again obtained. In the second attempt, the J-tipped guide wire was inserted into the vessel without significant resistance, even though it was initially difficult to advance the wire and the puncture needle had to be withdrawn a few millimeters to obtain free regurgitant blood flow. Then, a 7-Fr double-lumen central venous catheter (Arrow Gard Blue, Arrow International, Inc., USA) was inserted using the Seldinger method and was suture-fixed at 16 cm in the skin after confirming free inflow of fluid. At the end of procedure, the guide wire withdrawn showed no deformations. Central venous pressure (CVP) was measured to be 20 mmHg with the patient in a supine position and thereafter was maintained within 30-40 mmHg in the right semi-lateral decubitus position at approximately 30° during one-lung ventilation for surgery. Such a high CVP was considered to be related to the constrictive pericarditis, as the pressure measurement was less than the mean arterial pressure of the radial artery (80-85 mmHg) and the waveform was flat without pulsations, being affected by right-side one-ling ventilation and surgical manipulation of the heart. During the catheterization, vital signs were stable with HR 83/min, BP 90-100/65-68 mmHg, and SpO2 99-100%. Arterial blood gas analysis was done after induction of anesthesia and revealed pH 7.486, PaO2 331 mmHg, and PaCO2 36.2 mmHg with FiO2 0.6.\nApproximately 50 minutes after the surgery began, the pressure waveform from the central venous catheter changed abruptly into what was seemingly an arterial waveform, with a mean pressure of 61 mmHg, almost same to the mean arterial pressure of 62 mmHg (). Simultaneously, blood regurgitated through the fluid line connected to the central venous catheter. Even though about 300 ml of fluid had already been administered, no hematoma or edema was shown in the puncture site. Arterial blood gas measurement was done on blood withdrawn from the central venous catheter, indicating a PaO2 of 438.7 mmHg with a FiO2 of 0.6, confirming that it was arterial blood. Furthermore, the catheter was apparent in the aortic arch on TEE (). Fluid infusion was immediately stopped, and the catheter was removed when the surgery was completed. After confirming that there was no bleeding or developing hematoma in the puncture site with >15 min of compression, the double-lumen tube was replaced with a single-lumen endotracheal tube. Thereafter, the patient was transferred to the intensive care unit with the endotracheal tube in situ. Extubation was done after seven days of mechanical ventilatory care for tachypnea and CO2 retention, and the patient was transferred to the general ward without central venous catheter-related complications on the 10th postoperative day.