Original Investigation | Association of VA Surgeons

Management of Inadvertent Carotid Artery Sheath Insertion During Central Venous Catheter Placement

Carlos F. Bechara, MD, MS1,2; Neal R. Barshes, MD, MPH1,2; George Pisimisis, MD1,2; Panos Kougias, MD1,2; Peter H. Lin, MD1,2
[+] Author Affiliations
1Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2Michael E. DeBakey VA Medical Center, Houston, Texas
JAMA Surg. 2013;148(11):1063-1066. doi:10.1001/jamasurg.2013.3770.
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Importance  Inadvertent carotid sheath insertion during central venous catheter placement could lead to serious complications.

Objective  To describe management of inadvertent carotid artery sheath insertion placed intraoperatively during attempted jugular venous cannulation for pulmonary artery catheter placement.

Design, Setting, and Participants  In a retrospective medical record review of patients from hospitals affiliated with Baylor College of Medicine, Houston, Texas, a total of 12 patients over 11 years who sustained intraoperative carotid artery introducer sheath placement during attempted jugular vein cannulation were identified. Six patients underwent immediate carotid artery exploration with sheath removal and primary repair. The remaining 6 patients underwent percutaneous closure using a suture-mediated closure device. Treatment outcomes of these 2 groups were analyzed.

Main Outcomes and Measures  Technical success, duration of treatment, stroke, return to the operating room, and long-term outcomes.

Results  Technical success was achieved in all patients in both groups. The intended operations were aborted in all patients following catheter removal and carotid artery closure. The mean (SD) durations of treatment for the operative and endovascular groups were 32 (12) minutes and 6 (3) minutes, respectively (P = .03). No neurological deficit occurred in either group. The intended operations were all subsequently performed, and the mean delays of operation in the operative and endovascular groups were 5 and 3 days, respectively (P = .20). Follow-up carotid duplex showed no injury of the repaired artery in either group. During a mean follow-up of 42 months, no complications or neurological deficits were noted in either patient cohort.

Conclusions and Relevance  Inadvertent carotid artery sheath placement during attempted central venous cannulation for pulmonary artery catheter insertion mandates catheter removal and repair of the carotid artery puncture site. The closure device permits percutaneous repair of the carotid artery expeditiously. Our experience showed this treatment modality to be as safe and effective as operative repair.

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Figure 1.

A, Carotid angiogram showing a large sheath misplaced in the common carotid artery during jugular vein cannulation. No filling defect is seen, suggestive of thrombus. B, Computed tomographic angiogram performed 2 days later showing successful closure.

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Figure 2.
Handling Iatrogenic Carotid Artery Injuries

Our Baylor College of Medicine algorithm on handling iatrogenic carotid artery injuries.

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