| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Interventional Radiology |
1 All authors: Department of Radiology, St. Mary's Medical Center, 3801 Spring St., Racine, WI 53405.
Received October 29, 2003; accepted after revision January 30, 2004.
Address correspondence to M. K. Hatfield.
Case Report
An 87-year-old woman was admitted from a nursing home with a chief complaint of shortness of breath. The family requested minimal palliative care. The portable chest radiograph (Fig. 1A) obtained at admission showed an atelectatic left lower lobe with a moderate left effusion, hyperinflation of the right lung, and cardiomegaly. CT was not ordered before the procedure, and the patient had no further preprocedural workup. The patient was referred to the radiology department for placement of a percutaneous chest tube for decompression of the left effusion and reexpansion of the left lung.
|
Sonographic guidance without color-flow Doppler sonography was used. Conscious sedation was provided. With the patient in the right decubitus position, a COOK 4-French coaxial micropuncture set (Cook) was placed in what was thought to be the small effusion via a left posterolateral puncture. Care was taken to avoid the enlarged left ventricle. The tract was serially dilated, and a 12-French Cook multipurpose drainage catheter (Cook) was placed to function as a chest tube. Its tip was positioned overlying the posterior left chest cavity. A specimen was not obtained because diagnostic fluid was not requested.
The chest tube was connected to an Ocean water seal chest drain (Atrium Medical). Rapid filling of the collection chamber with sanguineous or serosanguineous material was noted, and the patient became tachycardic and hypotensive. The chest tube was immediately clamped, and IV fluids were administered aggressively. A hand injection of contrast material into the chest catheter showed the chest tube to be within the thoracic arch of the aorta. (Fig. 1B). The vital signs quickly stabilized. A total of approximately 800 mL of blood was drained. The patient's blood was typed and cross-matched, and she was subsequently transfused with 2 U. The thoracic surgery service, the patient's family, and her primary physician were consulted. After discussing various treatment options and recognizing the patient's poor surgical risk, we decided that the best treatment was to attempt placement of one or two 8-French Angio-Seal Vascular Closure Devices at the aortic puncture site. This off-label use and other treatment options were discussed with the patient's family.
|
A sheath was placed via a right common femoral arterial puncture with its tip in the descending aorta. A deflated 27-mm occlusion balloon was positioned just above the thoracic puncture site to control any future potential arterial hemorrhage and for additional angiographic injections of contrast material. The drainage catheter was removed and replaced with a 9-French 25-cm long Pinnacle vascular sheath (Boston Scientific) with its tip in the thoracic arch. A 9-French sheath was selected because its outer diameter is roughly 11 to 12 French. Two guidewires were then placed, and the sheath was removed. First, a single 8-French Angio-Seal Vascular Closure Device was deployed in the standard fashion. Trace amounts of hemorrhage were noted on follow-up angiography performed by injecting contrast material through the balloon occlusion catheter (Fig. 1C). A second 8-French Angio-Seal Vascular Closure Device was deployed. Again, minimal continued hemorrhage was observed on aortography (Fig. 1D). Gentle percutaneous traction on the two device strings was applied for 10 min. Follow-up angiography showed no evidence of hemorrhage (Fig. 1E). The sutures were then taped taut to the skin with skin closure strips (Proxi-Strip, Ethicon). The following day, the sutures were cut flush with the skin.
|
|
|
After we were confident that the hemorrhage had been controlled, a second 12-French catheter was then placed with its tip in the mid chest cavity using a lateral approach and sonographic guidance. Approximately 140 mL of clear yellow fluid was removed from the left pleural space, and no significant hemorrhage was identified. The patient recovered completely. Over the next few days, the chest tube drained a small amount of yellow fluid and no blood. Chest CT performed 5 days later showed no sign of hemorrhage (Fig. 1F). Unfortunately, the chest tube was unsuccessful in reexpanding the left lung, which progressively collapsed. The patient died 10 days later. The underlying cause of the atelectatic left lung was unknown.
|
Discussion
When catheters are inadvertently placed in arteries, the risks include arterial occlusion, embolism, pseudoaneurysm, dissection, and fatal exsanguination. Misplaced catheters may be removed with direct compression; however, some puncture sites are noncompressible because of their anatomic location. Surgical exploration and closure have obvious risks.
There are various references in the medical literature regarding the efficacy of vascular closure devices [1–8]. Severe complications can and do occur when central venous catheters are inadvertently placed into subclavian arteries. Several strategies for achieving hemostasis after inadvertent subclavian arterial puncture have been reported in the literature. One case report [9] describes how these inadvertent arterial punctures can be closed using the Perclose device (Abbott Laboratories), but at the time, we did not have access to this device.
Three articles [10–12] describe internal balloon tamponades that were placed in the subclavian arteries in several patients for successful and safe removal of catheters without significant blood loss. In our patient, we placed a large occlusion balloon for potential internal balloon tamponade, although we did not use it. This technique is effective; however, it requires one or two additional arterial punctures to allow balloon placement and simultaneous angiography. There is also prolonged arterial occlusion for 10–15 min, with the concomitant risk of inadequate hemostasis, thromboembolism, or thrombosis. Collagen plugs have also been described for percutaneous closure [13]. The use of collagen plugs requires direct access to the arterial puncture site, which was not possible in our patient.
Although we could not be certain that the intended target, the pleural space, was never entered, we assumed that the puncture site was extrapleural. Therefore, we believed that the Angio-Seal device was our best option, with the balloon occlusion as our backup device. The Angio-Seal device was secured without incident by the internal button on the luminal side and by the collagen plug sandwiched on the outer wall of the vessel. The device was placed under tension by the retaining string, which was brought out through the patient's skin, as is standard practice. We maintained tension on the retaining string for about 10 min after deployment. The Angio-Seal system, unlike a collagen plug, does not require a large extravascular tract to be effective. The difference is due to the intravascular button. We used the Angio-Seal device because of its mechanically favorable properties and availability, but other devices may have worked. Thoracic aorta stent grafts have been used for treatment of both dissecting aneurysms and traumatic ruptures [14, 15]; however, their use has not been described for inadvertent catheter placement.
This case includes two unique features that, to our knowledge, have not been described. First, the descending aorta was punctured during placement of a chest drainage catheter. The direct chest approach to achieve hemostasis posed additional difficulty, with more intervening tissue between the arterial wall and puncture site versus a common femoral artery or brachial artery puncture. The second unique feature is that two Angio-Seal Vascular Closure Devices were deployed because one did not seem to be enough.
In summary, we present a case of inadvertent placement of a 12-French drainage catheter in the descending thoracic aorta. This drain was successfully removed, and Angio-Seal Vascular Closure Devices were used to achieve hemostasis. To our knowledge, the use of an Angio-Seal Vascular Closure Device in the descending aorta has not been described. We found the off-label use of this vascular closure device to be extremely useful in treating a life-threatening complication. It may be an option for patients with noncompressible or inaccessible arterial punctures who are not good surgical candidates.
References
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
