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omplications of Central Venous Catheterization
oberto E Kusminsky, MD, MPH, FACS
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t is estimated that millions of central venous cathetersCVCs) are inserted yearly in US hospitals.1 The pro-ound impact of the complications associated with CVCse is so important that efforts to minimize and preventheir occurrence should be a routine element of qualitymprovement programs. This review aims at centralizinghe evidence currently available and presenting it as aeady reference that could assist in estimating the mag-itude of the problem and formulating prevention ini-iatives. Additionally, emphasis is placed on the grow-ng body of information that supports the use ofltrasonography-assisted insertion (UAI) as a superiorechnique to decrease adverse events from CVC inser-ion. From a clinical and practical point of view, whichetter correlates with usage issues, CVC complicationsre best classified as secondary to insertion, indwelling,nd extraction practices.

ISK FACTORShe incidence of mechanical complications is modifiedy a variety of factors:

. Inexperience, variably defined but with a consistentrelationship between less experience and the rate ofcomplications.2,3

. Number of needle passes, with the incidence of com-plications rising with two venopunctures2-5 to a six-fold increase with three or more.6

. Body mass index � 30 or � 20,4,7 previous catheter-izations, and severe dehydration or hypovolemia arefactors that increase risk.

. Coagulopathies do not appear to increase the risk ofpercutaneous insertion8-11 if appropriate precautionsare taken,12 such as transfusing thrombocytopenicpatients with platelets until a count of 50,000 or

ompeting Interests Declared: None.

eceived October 24, 2006; Revised January 16, 2007; Accepted January 17,007.rom the Department of Surgery, West Virginia University, Robert C Byrdealth Sciences Center, Charleston Division and Charleston Area Medicalenter, Charleston, WV.orrespondence address: Roberto E Kusminsky, MD, MPH, FACS, West

firginia University, 3110 MacCorkle Ave, Charleston, WV 25304.

6812007 by the American College of Surgeons

ublished by Elsevier Inc.

higher is reached, and fresh-frozen plasma in patientswith elevated prothrombin and partial thromboplas-tin times. Administration of antihemophilic globulinbefore subclavian vein (SCV) catheterization has ledto reports with similar conclusions in patients withhemophilia.13 Even heparinization does not appear toincrease the risk of bleeding or hematoma duringinternal jugular vein (IJV) insertion.14 Although co-agulopathies are not a clear contraindication,15 theIJV or femoral vein (FV) appears to be the compress-ible access site chosen by many authors for patientswith coagulation disorders.16,17

. Large catheter size, such as those used for dialysis,appears to influence the risk of vascular complica-tions of insertion.18

. Failure to catheterize is influenced by factors such asexperience,2,3,19 previous catheterizations, previouscatheterization attempts, and previous operation orradiotherapy in the anatomic region of interest.4,6

. Unsuccessful insertion attempts are the strongest pre-dictor of insertion complications.6 Overall rates ofunsuccessful insertion attempts for IJV access havebeen reported at 12%20 and 12% to 20% for SCVand IJV in adults19 and infants weighing � 10 kg.21

Among patients who fail attempts at catheterization,complications develop in 28%.6

verall incidenceomplications associated with CVC insertion fluctuate

ccording to their definition and the correlation with theultiple factors that influence their occurrence, ranging

etween 5% and 19%.19,22 Femoral catheterization has aigher incidence of mechanical complications than SCVr IJV access,22 and can be associated with severe injuryf an inadvertent femoral artery puncture is too high ands followed by anticoagulation.23 IJV and SCV catheter-zation carry similar risks of mechanical complications,1

lthough IJV insertion has been reported to have aigher incidence of mechanical complications than SCV

n elective24 and emergency situations.25 A prospective,omparative study suggests that during cardiac arrest theatheterization success rate can be higher for SCV than
or FV access.26
ISSN 1072-7515/07/$32.00doi:10.1016/j.jamcollsurg.2007.01.039

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682 Kusminsky Complications of Central Venous Catheterization J Am Coll Surg

Because the complication rate decreases with train-ng,27,28 designing a standardized method of CVC inser-ion29 is a logical process to promote prevention andecrease the incidence of adverse events.1,30,31 Standard-

zation can also establish management guidelines forome complications that commonly follow CVC inser-ion, such as pneumothorax.32 Standardization can es-ablish a best-practice approach based on evidence, andt can provide an answer to the questions sometimesaised about the competence of house officers.

The advantages of UAI of CVCs have been reporteds far back as 1978,33 and the body of literature support-ng its adoption continues to expand. There is nowbundant evidence to establish UAI as the safest methodo prevent or decrease overall and specific complicationsf insertion. Reports of the advantages of ultrasonogra-hy over the anatomic landmark method support theindings of risk reduction20,34 and improved cannulationuccess20,34-36 for all access sites—FV37, SCV, IJV36—indults and children36,38 and in different settings.39 Inddition, the gap between experienced and inexperi-nced operators has been reported to disappear whenAI is used.40 Conversely, UAI can be of help to a skillfulperator who is otherwise unable to cannulate.41 Therere reports disputing these results,42 although some ofhe discrepancies have been reported in studies in whichltrasonography was not used in real-time mode.6

nsertion complicationsneumothorax is one of the most common complica-ions of CVC insertion, reportedly representing up to0% of all mechanical adverse events.43,44 Its incidencearies between 0%7,24 and 6.6%,45,46 with higher inci-ences when the number of needle passes increases,4 inmergency situations,47-49 and when the catheters in-erted are large, such as those used for dialysis.45 A 1% to.5% incidence is more consistently reported.6,32,50 Mostf the evidence points toward a higher incidence ofneumothorax when the SCV is cannulated, as com-

Abbreviations and Acronyms

CVC � central venous catheterFV � femoral veinIJV � internal jugular veinSCV � subclavian veinUAI � ultrasonography-assisted insertion

ared with the IJV.5,24 SCV catheterization has occasion- s

lly been linked to a lower incidence of pneumothoraxhan IJV access.51

Delayed pneumothorax has been reported to occur in.5%44,52 to 4% of the insertions,45 but the incidence isuite a bit lower in some studies.53 Symptoms com-only appear within 6 hours but not in all patients,53

hich calls for the need to exercise caution and increasedwareness in those cases where the insertion was diffi-ult,54 despite the ostensible early lack of complications.

A standardized treatment algorithm of CVC-inducedneumothorax can lead to good results with safety, im-rovements in patients’ comfort, and decreases in lengthf stay in adults32,55-57 and children.58 Such an algorithmhould include elements of awareness and treatment ofeexpansion pulmonary edema,59,60 particularly if pa-ients are treated on outpatient basis.57 Re-expansionulmonary edema is estimated to occur in 1% to 14% ofatients with pneumothorax.59,61

Clinician-performed bedside ultrasonography allowshe diagnosis of pneumothorax to be made immediately,ith a high degree of sensitivity and with better accuracy

han supine chest films and equal to that of CT scan.62-64

his approach has not yet gained widespread accep-ance, is operator-dependent, and patient selection andquipment can influence the results.65

Malpositioning of a CVC has been associated forears with problems of local toxicity, perforation, andenous thrombosis and its sequelae. In the past, a con-iderable percentage of catheters were left within theight atrium,66 but today the consensus in the literaturepposes this practice67 because of the increased risk oferforation. The debate about the validity of this recom-endation continues to surface68,69 and many believe

hat the purported advantages of a CVC tip in thetrium are associated with minimal risks.69-71 These dis-greements produce difficulties with the interpretationf the true incidence of malposition, particularly if thenalysis includes information derived from older series,hen the definition of malposition, catheter length, and

ngle of incidence was not a common element of discus-ion, and when repositioning was not a major concern.72

oday, malposition includes the recognition that an an-le of incidence of the CVC tip against the wall of theessel � 40 degrees carries an increased risk of perfora-ion.73 To avoid the tip from abutting against the wall ofhe vein at an inappropriate angle, it is best to approacheft-sided insertions with a 20-cm catheter and the right-
ided ones with a 16-cm catheter74,75 in adult patients.

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683Vol. 204, No. 4, April 2007 Kusminsky Complications of Central Venous Catheterization

ust as catheter length bears a direct relationship to tiposition,76 such might be the case as well with catheteriameter and tip malposition in children � 10 kg.77

When a CVC is inserted without image-guided assis-ance, as it regularly happens, the initial estimate of in-ertion depth must be made in the clinical setting fol-owing unreliable anatomic landmarks. One suchpproximation is made by premeasuring to a central des-ination point located just above one-third of the dis-ance between the manubrium and the xyphoid, wherehe caval-atrial junction can be expected to be. It is com-on practice, then, to assess the final position of the

atheter’s tip radiologically, accepting that the pericar-ial reflection is below the carina.74 A more precise mea-urement emerges from the study by Aslamy and col-eagues,78 which establishes convincingly that the rightracheobronchial angle is the most reliable landmark tossure that a catheter’s tip is at least 2.9 cm above theericardial reflection, even if it appears to lie within theardiac silhouette. Similarly, 20% of catheter tips con-irmed to be in the atrial-caval junction by transesopha-eal echocardiography are still visualized in the midpor-ion of the right atrium on supine chest films.79 From aractical point of view, it is prudent to judge the finalosition of the catheter in light of the fact that the tipractically always migrates, peripherally, as demon-trated by changes between supine and upright postpro-edure imaging.71,80

In general, there appears to be less opportunity foralposition with jugular than with subclavian access.50

ubclavian entry is followed by misplacement of theVC into the ipsilateral jugular vein in up to 15% of the

atheterizations.81 This can be avoided in a major frac-ion of patients by simply assuring that the J tip of theuidewire is pointing caudad during insertion.82 Addi-ionally, turning the head toward the insertion side nar-ows the os of the IJV,83 and manual compression of theugular can avoid misdirection as well while the guide-ire is threaded.84 UAI has been reported to be effective

n detecting anatomic variants85 and in steering the suc-essful placement of the tip to avoid catheter misplace-ent in adults86 and children.87

Postprocedure films are useful to check for complica-ions and misplacement.81 Congenital anatomic varia-ions can confound the radiologic interpretation of theip’s location. Of these, the most common clinically sig-ificant anomaly of the great systemic veins is the per-
istence of a left superior vena cava, which is seen in c
.3% of patients; the incidence is higher when cardiacongenital abnormalities are present.88 In children cath-terized through a FV, unusual but serious complica-ions secondary to misplacement might be preventabley postprocedure films and contrast injections.89 Pediat-ic peripherally-inserted central catheters inserted with-ut image guidance require repositioning of the tip in asany as 85% of the patients.90

Vascular injuries during CVC insertion encompass aide spectrum of complications, with arterial puncture

he most common. It occurs more frequently with IJVnd FV22,91 access than with SCV,50 and even though thisomplication is usually self-limiting, it should not beismissed as inconsequential because it can lead to sub-tantial morbidity92 or death,93,94 even if the puncturingeedle is of a relatively small gauge95 or the catheter isorrectly placed in its intended venous location.96

Puncture of the carotid artery during IJV catheteriza-ions attempts averages 6% in prospective studies,97 al-hough higher rates have been reported with the land-ark method20,91 and as high as 18% to 25% in

nfants.21,91 Of greater clinical significance is the fact thatp to 40% of carotid punctures are associated with aematoma; 10 of 25 in one study.20 This, in conjunctionith manual pressure, has been interpreted as the mech-

nism responsible for the appearance of cerebrovasculareurologic deficits97-99 and death.100 Puncture of the sub-lavian artery during SCV catheterization attempts oc-urs in 0.5% to 4% of the patients.6,22,50 Hemothoraxfter CVC insertion is mostly an expression of an inad-ertent arterial injury, which has been reported to occurpproximately in 1% of central catheterizations,50 some-imes leading to uncommonly severe consequences, suchs quadriplegia.101

It stands to reason that the best way to care for arterialerforations during CVC insertion is to avoid them, andhe first preventive step to be taken is to recognize thathe needle entering the vessel is actually in a vein. Moreften than not, the operator can rapidly determine thathe vessel is an artery because of pulsatile back flow, buthat is not always the case. A variety of methods, andheir pros and cons, have been described to facilitateecognition of an inadvertent arterial puncture,102,103 butone is foolproof. UAI remains the best prevention prac-ice currently available,1,20,35,40 although these advantagesre not universally reproduced.104

Large-bore arterial perforation or cannulation of the
arotid or subclavian occurs in approximately 0.1% to

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% of cases.18,91,105-108 Uncommon as it is, this compli-ation is associated with potentially devastating conse-uences: approximately 30% of these patients can bexpected to become symptomatic—bleeding,109 neuro-ogic findings or other sequelae106,108—and if so, the

ortality rate reaches 20% to 40%.18,105,107 Stroke oreurologic deficits associated with large-bore arterial in-

ury can be estimated to occur in 27% of the patients106

nd is reported often,97,100,110,111 particularly in associa-ion with infusions through the cannulated artery.112,113

Most arterial large-bore perforations can be attributedo the unsafe manipulation of the dilators,105,114-117

hich should only be used to widen the skin and SCissues but frequently are inserted unnecessarily far,ometimes even causing ventricular perforation.118

ther possible mechanisms of injury include kinking ofhe guidewire resulting in misdirection of the dilator anderhaps insertion of the wire outside the vessel.119,120

Arterial puncture and perforation during CVC inser-ion appears to be mostly a right sided phenome-on,91,121,122 which coincides with the anatomic differ-nces of the vascular system at either side of the midline.n the right, the subclavian-jugular venous junction

verlies the subclavian artery, making this vessel morerone to injury than it is on the left. The right SCVnters the innominate at a sharper angle than its coun-erpart on the left, which would make it then more vul-erable to perforation if a firm dilator is inserted tooeeply.105,121

Whatever management choices are made to treathese arterial complications, it is prudent to leave theffending catheter in place until the next step isaken.103,106,116,123 Individual patient circumstancesight dictate the selection of surgical procedure,106

hrombin injection,124 percutaneous suture devices,125

tent graft placement,126 or balloon tamponade123 as theest way to handle these emergencies.Perforation of the aorta during CVC insertion ap-

ears in the literature more often than would have beenxpected,127-130 suggesting some degree of underreport-ng. It sometimes presents with a simultaneous perfora-ion of the superior vena cava.130 If the perforation oc-urs within the pericardial reflection there will be anssociated cardiac tamponade, in which case the mortal-ty rate reaches 90%.131,132 Aortic injuries, as with arterialerforations in general, are also attributable to the im-roper use of the dilator, although they can also occur
ith a needle133 or a large catheter.134 Most reports of v
ortic perforation describe multiple insertion attemptsnd have been right-sided,133,135 although a left-sided en-ry does cause this injury as well. The diagnosis of anortic injury and the estimation of its extent requiresareful assessment, as is the case with any arterial injuryfter attempted venous catheterization; it is not uncom-on for a chest x-ray to be misleading,106,136 and often

he artery is entered after the vein is perforated.106,109,121

ltrasonography and CT scanning have been used withuccess, but the more central the injury the best way totudy the damage is a contrast study, if there is time.oth percutaneous closure137 and balloon tamponade138

ave been described as a treatment approach to aorticnjuries.

Injuries to the pulmonary artery result more com-only from the use of pulmonary artery catheters,139-141

lthough occasionally the vessel is punctured directlyuring CVC insertion attempts.142 The estimated inci-ence of pulmonary artery catheter-associated injury—emorrhage and infarct—is 0.1% to 0.2%, with a mor-ality rate of 42%.139,141

Pseudoaneurysms143, AV fistulas144 and vertebral ar-ery injuries145 are rare complications of inadvertent ar-erial perforation or cannulation. AV fistulas can develophortly or years after catheterization attempts.144 Theyave been estimated to occur in 0.2% of IJV146 and 0.6%f SCV catheterization attempts.147 Vertebral artery in-uries are sometimes associated with acute neurologicnjury, but more frequently they have a delayed presen-ation as a fistula after SCV or IJV attempts, or as aseudoaneurysm.148

The treatment of most pseudoaneurysms of centralrteries has evolved into progressively less invasive andffective approaches.148,149 Ultrasonography-guided per-utaneous thrombin injection has been used in the ca-otid artery,150 but this technique is viewed with uneaseecause of its potential for embolization into the cerebralirculation.149 Similarly, the use of stents to treatseudoaneurysms and AV fistulas is a reasonable ap-roach if the grafts do not obstruct the takeoff of theertebral or carotid arteries,148 although stenting the ca-otids directly to treat these problems has beenuccessful.151

Dysrhythmias accompany CVC insertion fairly oftennd more so when pulmonary artery catheters are used.ven palpation and pressure on the carotid artery during

nsertion of a pulmonary artery catheter has resulted in
entricular fibrillation and cardiac arrest.152

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The incidence of cardiac ectopy during catheteriza-ion is clearly related to the guidewire insertion depth,eaching 75% as the wire is advanced between 25 cmnd 32 cm from an IJV entry site, the usual findingeing the occurrence of premature atrial contractions.153

entricular ectopy can be triggered in up to 25% ofatients, suggesting the possibility that a malignant ar-hythmia could arise.154 Only a small percentage of allrrhythmias are symptomatic155 and almost invariablyhese difficulties cease after the guidewire is withdrawn.ccasionally, serious problems arise during guidewire

nsertion in patients at risk, such as a complete heartlock,156 and even sudden death.157

Indwelling catheters have been reported to cause ar-hythmias in 0.9% of patients, with some necessitatingherapeutic intervention in addition to removal.158

arely, inserting a guidewire in a patient with an im-lanted cardioverter device can lead to the most unusualituation of inducing an arrhythmia while delivering ahock to the operator.159

The rarity of serious sequelae and the usually transientature of the arrhythmias induced by CVC insertionommonly permeate institutional cultures with feelingshat these consequences are negligible. In the past, theedical literature reported seeking out ectopy during

uidewire insertion as a marker of correct positioning.160

onsidering the possibility of inducing ventricular ec-opy,154 efforts to avoid overinsertion of the guidewireould be a prudent strategy.In contrast with CVCs, pulmonary artery catheters

nduce dysrhythmias in 72% of the patients,141 with ven-ricular ectopy in 65% to 68% of them.141,152 Three per-ent of all pulmonary artery catheters have persistentVCs requiring therapy141 and ventricular tachycardiaevelops in 1.5%, with one-fourth of these patients re-uiring cardioversion.140

The neurologic complications of CVC insertionore commonly reported—excluding cerebrovascular

ccidents—include brachial plexus injury and Horneryndrome. Brachial plexopathies can follow IJV161 orCV162 catheterization, and are mostly transient, partic-larly if the local anesthetic is the cause of the symp-oms.161 Multiple punctures or hematoma163 can lead torogressively worsening symptoms resulting sometimesn permanent damage.99,164,165 Typically, IJV insertionsre associated with injury to the upper trunk161 and SCV
ccess with the lower trunk163 of the brachial plexus. The f
ncidence of brachial plexus punctures is approximately.7% and can be decreased substantially by UAI.20

Horner syndrome has been reported to occur in 2%f IJV cannulations,111 but this appears to be somewhatigh an incidence, inconsistent with the realities of cur-ent clinical practice. Other reports describe the syn-rome in 2 of 1,000 patients undergoing pulmonaryrtery catheterization152 and CVC insertions,16 whichppears to be a more reliable estimate.This complications occasionally permanent152 and perhaps likelier to oc-ur with larger-sized catheters,166 and is sometimes cou-led with other neurologic manifestations, such as vocalord paralysis.167

Incidence of lymphatic injuries during CVC insertions difficult to assess, because most of the available litera-ure is limited to isolated reports, although it is estimatedhat 25% of overall cases of chylothorax are a result ofurgical injury.168 Chylothorax and chylopericardiuman occur as a complication of venous thrombosis in-uced by a CVC169-171 or by direct damage to the lym-hatic ducts.168,172,173 Traditional thinking suggests that

ymphatic injuries are associated with left IJV or SCVnsertions and represent thoracic duct damage.168,174,175

nterestingly, a right-sided approach can lead to lym-hatic duct harm in adults176 and children.172 Right su-raclavicular access has been associated with a 0.5%

ncidence of lymphocutaneous fistula.177 The supracla-icular approach appears to be associated with a higherhan expected rate of lymphatic injury, in the range of%.178,179 Notably, UAI does not appear to prevent thisomplication.174,177,180

Over the past several years, innovative and well–hought-out methods of treating these complicationsave emerged. Proposed and successfully tried therapies

nclude the use of nitric oxide,181 thoracoscopic fibrinlue application,182 and percutaneous embolization withlatinum microcoils.183-185

Guidewire loss during insertion of a CVC is a rarevent, occurring approximately twice in several thou-and catheterizations.186 Guidewires can loop and be-ome entrapped,187 stick inside the inserted catheter,188

not and fracture,189 and embolize producing acute ar-erial insufficiency190 or paradoxically through a patentoramen ovale.191 Straight-tipped guidewires can causeardiac perforation.192 Occasionally, a lost wire presentsn a most bizarre manner: protruding through thekin.193 Entrapment of a guidewire within a vena cava
ilter is a serious complication of vascular access that can

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ead to displacement or fracture of the intravascular de-ice, but clinician awareness and careful technique couldake this a largely preventable problem.194

The cornerstone of safe guidewire insertion is to avoidinking105,188 and potentially lethal injury,117-120 simulta-eously assuring that resistance during insertion or re-oval is met with cautious response.187 Under these cir-

umstances, the needle-guidewire ensemble must beemoved and the procedure reinitiated. To do otherwiseubstantially increases the risks of wire fracture and itserious sequelae.190,191

Despite admonitions that guidewire loss is a totallyreventable situation if the operator makes sure to holdnto the wire during insertion and to inspect it afteremoval,189,195 these and other precautions are notnough to avoid the problem entirely. An easily inserteduidewire, normally shaped after removal, can still bessociated with fracture and embolism196 and multipleilms might not demonstrate the complication,197 so theiagnosis of a retained foreign body is commonly de-

ayed.198 Attempts to design a safer guidewire have beeneported, with good results.199

ndwelling complicationsnfection is the main complication of indwelling cathe-ers, with an incidence of approximately 5.3 per 1,000atheter days and an attributed mortality of 18% (0% to5%).200 Most infections arise from the skin insertionite or the catheter hub, depending on the indwellingime, and are then perpetuated by biofilm, a bacterial-erived community embedded in a matrix of extracellu-

ar polymeric substances that they produce.201 This de-erminant factor could explain the favorable results seenith the injection of hydrochloric acid to treat CVC

nfections.202

FV catheters have a higher risk of infection than SCVr IJV catheters,1 as do noncuffed catheters comparedith cuffed ones.200 Because the risk of infection iseightened by thrombosis,203,204 efforts to render theatheters less thrombogenic have included heparin-oating, but the risk of activating heparin inducedhrombocytopenia makes their use imprudent.205

atheter-related bloodstream infections can be pre-ented: in an elegantly designed study, Berenholtz andolleagues206 instituted sequential measures in an ICUopulation, bringing the incidence of infection down toirtually zero. Currently, this “bundle” of standard ac-
ions includes educating caregivers in hand hygiene, clo- t
hexidine preparation, use of full sterile garb precau-ions, and CVC removal as soon as possible. Thisducational module includes a checklist to ensure adher-nce to evidence-based guidelines.206,207 Other preven-ive measures found to be effective additions to the pre-iously mentioned bundle include voiding routineatheter exchanges and the use of antibiotic ointmentsn the entry site, plus the use of clorhexidine impreg-ated sponges to dress the insertion area.200 Some studiesuggest that adhering to these measures eliminates theifference in infection rates seen in all three insertionites.208 Gram-positive infections and those involvingmplanted reservoirs practically always require removalf the catheter.209

The use of antimicrobial impregnated catheters is stillebated by some authors,210 and the Center for Diseaseontrol and Prevention guidelines recommends the usef antimicrobial-impregnated CVCs in selected clinicalituations,200 but a strong body of evidence justifies theirse.207 In a persuasively written viewpoint, Crnich andaki207 provide an excellent summary of the numerous

ound studies demonstrating that a substantial numberf blood stream infections can be prevented—40%t least—with the use of short-term antimicrobial-mpregnated CVCs.

Thrombosis induced by CVCs is a frequent occur-ence, ranging between 33%1 and 59% of indwellingatheters, although clinical symptoms develop in just amall percentage of patients.211 The pathogenesis is mul-ifactorial, but endothelial injury, turbulence of the ve-ous flow and catheter thrombogenicity211 play a role, asoes the composition of the infusate212 and the charac-eristics of the disease process. A fibrin sheath developsithin 24 hours of catheter insertion, and although this

heath contributes to catheter occlusion, it does not pre-ict subsequent deep vein thrombosis of the vessel,203

ut all CVCs are subjected to malfunction as a result ofhis fibrin casing.213

The rate of CVC-induced thrombosis is lower forCV than for IJV and FV access.1 The rate of thrombosiss reported at 1.9% for SCV access22 and 22% to 29%fter 4 to 14 days of indwelling time214 for a femoralVC.22,204 Location of the CVC tip within an inlet vein

ncreases the likelihood of catheter-associated thrombo-is 16 times,215 but malfunction is lessened when theatheter lies in a high-flow central vein.216 Superior venaava obstruction can be a substantial problem, estimated
o occur in 1/1,000 indwelling devices.217

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Varying degrees of occlusion induced by CVCs aressociated with varying degrees of stenoses,218 althoughs many as 30% of the patients without previous cath-terizations might have clinically significant venous an-tomic abnormalities—greater than 50% stenoses andngulations—that could increase the risks of catheteriza-ion.219 Twice as many patients—60%—will have de-ects if they have been catheterized previously,219 partic-larly through a subclavian approach.204 Longer catheterwell times increase development of central vein abnor-alities,220 as expected. Stenoses induced by large-bore

atheters are reported in the range of 40% to 50%, andigher if the CVC has been infected.221 Narrowing de-elops mostly behind the clavicle, an area difficult toisualize with ultrasonography.222

In cancer patients, CVCs cause vessel thrombosis in1% of the patients, with postphlebitic syndrome devel-ping in 15% to 30% of them and pulmonary embolismeveloping in 11%.203 Morbidity and mortality of jugu-

ar and subclavian thrombosis appears to be similar.223

lthough treatable, longterm relief for central venouscclusive disease is rarely achieved.224 Despite this, theonsensus in the medical literature indicates that routinentithrombotic therapy for oncologic patients withVCs is not warranted,225 a conclusion that is likely

pplicable to patients without cancer.Fibrin sheath stripping and urokinase infusion work

qually well to salvage catheter patency,226 and appropri-te differentiation between a fibrin sheath and thrombo-is is necessary before the initiation of therapeutic ma-euvers.213 There is increasing interest in endoluminalrushing as a method to regain patency of occludedatheters.227

Vascular erosion and perforation of an indwellingVC can be associated with cardiac tamponade, de-ending on whether the perforation occurs below orutside the pericardial reflection. Perforation withoutamponade occurs in 0.4% to 1% of catheterizations,ith a resulting mortality rate of 12%.228,229 Erosion fol-

owed by tamponade is estimated to take place in 0.2%f patients,230 with an associated mortality under theseircumstances of nearly 90%.131,132 Use of peripherallylaced catheters in neonates carries an overall reportedortality rate of 0.7%,231 because of the disproportion-

te higher risk of cardiac tamponade with these type ofines.232 Although perforation without tamponade can
resent as a hemothorax,233 it manifests most commonly d
s a hydrothorax,228,229,234 which is bilateral in up to one-hird of patients.235

A useful predictor of impending perforation is theadiographic confirmation of a curled-up catheter tip,hich occurs in approximately 4% of placements,236 and

ometimes requires a lateral chest film for visualiza-ion.237 Myriad reports discuss the likelihood of perfora-ion by indwelling catheters as a function of the entryide, because most of the cases reported have been asso-iated with left-sided CVC insertions,228 which results inmore horizontal position of the catheter shaft and

butting of its tip against the vein wall when the catheters of insufficient length. The pathogenesis of this com-lication must be attributed to the steady pressure andriction exerted on the vessel wall by the catheter tipventually leading to erosion, the same way a decubituslcer forms. So, abutting the vein wall or curling of aatheter tip that does not normally have a curvature, isasically a signal that the CVC tip is compressing theein and should be repositioned to lie parallel to theessel wall by whatever maneuvers are required. Unfor-unately, this cannot always be accomplished by stayingbove the pericardial reflection.

This information then leads to the simple question ofhy is it that pigtailed venous catheters are not beingsed more often? In an intelligently conceived study,ravenstein and Blackshear238 demonstrated that a pig-

ail catheter is 100 times less likely to perforate thantraight-tipped catheters. There is also additional com-elling evidence to support the use of pigtail catheters:tudies in a porcine model have shown that central accessith looped catheters can eliminate the vein wall injuryrocess for substantial periods as compared with straightatheters.239 This also suggests that a thrombus at the tipf the catheter—a common cause of dysfunction—ight be less likely to develop if the tip does not lie in

irect contact with the vein wall. So far, clinical experi-nce with catheters contoured in this manner is limitedut favorable.240,241

Catheter fracture and embolization is reported to oc-ur in 0.5%186 to 3% of patients203 with indwellingVCs. Embolization can lead to arrhythmia242 with car-iac arrest,243 pulmonary embolism with hemoptysis,244

erforation, thrombosis, and infection, for an overallorbidity rate of 71%245 and a mortality of 30% to

8%.245,246 Compression of the central catheter betweenhe clavicle and the first rib causes the pinch-off syn-
rome,247 clinically manifest by a functional occlusion

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inked to postural changes. The mechanical shearingorces on the catheter can, over time, lead to fracture andmbolization. This syndrome is estimated to occur in% of patients,248 and it is important to differentiate itrom other causes of catheter obstruction, which can beone by detecting telling radiographic findings. Becauseaising the arms or shrugging opens the costo-clavicularngle, the films should be taken with the patient uprightnd with arms by the side.248,249 Catheter fracture canlso occur by shearing from the insertion needle or dur-ng extraction.250 This information suggests that a saferay to remove a SCV catheter should include elevationf the patient’s arm as traction is applied.

xtraction complicationslthough air embolism can occur during insertion of aVC,251 it is perhaps more commonly seen as a compli-

ation of catheter extraction.252 It is reported to occur in.13%251 to 0.5%3,253 of CVC insertions, with tunneledatheters inserted through a peel-away sheath a likelierource of this complication.251 The associated mortalitys substantial, ranging between 23%252 and 50%,254 of-en if not always connected to neurologic deficits ofarying degree.255

One-hundred milliliters of air can pass through a 14-auge needle in 1 second,255 so it is imperative to beware of this possibility during cannulation of any vesselnd during catheter exchanges and removal.256 Air em-olism has occurred during accidental hub disconnec-ion,257 through a residual catheter track,258 as a worri-ome factor during home infusion therapy,259 and haseen reported to lodge in the coronary circulation.260 Its occasionally a result of inadvertent arterial cannula-ion, in which case, neurologic sequelae are frequent.uring venous catheterization, the path leading the air

mbolus to produce a cerebrovascular accident appearso be mostly by pulmonary shunting or through a patentoramen ovale.252,261 When air embolism is recognized, ifhe usual therapeutic maneuvers—left lateral Trendelen-urg, air aspiration, 100% oxygen—are not effective,yperbaric oxygen treatment could be of help.262 Im-roved designs of protective insertion sheaths appearapable of decreasing the incidence of this grave compli-ation.263 Technique standardization should include ed-cation about prevention of air embolism during CVC

nsertion30 and removal.255,264

Other extraction complications include breakage,265

eparation from the hub,246 and knotting of the cathe- a

er266,267 or guidewire.268 Breakage is frequently a result ofxcessive traction force,246 although the catheter materialan sometimes be faulty and ruptures or dilates.269 Acci-ental CVC removal is a serious problem because of thessociated risks of hemorrhage and air embolism, and itccurs between � 1% and 7.5% in ICU popula-ions270,271 and in children.269 Rarely, extraction of aVC placed in the ipsilateral side of a patient with an AV

istula for dialysis can lead to hemothorax.272 Centralatheters attached to the vein are more commonly aonsequence of dwell time273 and the constellation ofistologic changes associated with fibrin formation.274

ccasionally, a stuck catheter might be a result of frac-ures in the material.275 This complication has been re-orted in adults,276 children,277 and with peripherallynserted lines.278

echnical considerations and discussionver the years, a plethora of reports and adjunct com-entary have highlighted the myriad complications that

an befall patients receiving a CVC, in an effort to em-hasize effective prevention opportunities. In this con-ext, UAI can help the operator decide the relationshipetween artery and vein,41,279 how often the venous anat-my is abnormal,280 which vessel is best to use,281 howuch the head should be turned,282 and the effect of

atient position on the diameter of the vein.283

UAI is not infallible, and certain complications andrecautions require constant operator alertness. Arterialuncture, for example, can still occur with UAI,20 andhe methods described to ascertain if a catheter is insiden artery are not foolproof, but they are reasonable andffective. Routinely measuring blood gases or attachinghe catheter to a transducer is not always practical, noran physicians realistically be expected to use these tech-iques on every patient. A simple method to detect ar-erial placement might be to return to the standard ofunning saline solution through the line before using aolumetric pump,112 a practice that perhaps can be re-uscitated as part of a standardized method of insertion.

Final position of the CVC tip is particularly impor-ant in relationship to the complications seen with antrial location, or when the tip is curled on itself 236,237

nd exerts pressure against the vessel’s wall. Regardless ofow rational some arguments in favor of an atrial loca-ion might be, the sine qua non of any procedure isatient’s safety, and the mortality of an atrial perforation
nd tamponade makes any such debate a rather gratu-

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tous point. Instead, the scientific world needs the con-ribution of a method that avoids this lethal complica-ion, and such could be the possibility that emerges withhe use of venous pigtailed catheters.239

The site of insertion remains an issue of discussionnd varied preferences, but in terms of infection preven-ion the consensus points toward the SCV as the betteroute of access.1 The agreement is not as clear in terms ofrevention of mechanical complications, particularly inhe areas of malposition and pneumothorax.50

Side of insertion also remains a contested theme.any believe that left-sided insertions are burdenedith a higher probability of superior vena cava perfora-

ion68 than access through the right side, although themportant element of catheter length and its relationshipo this problem is not always emphasized. Othersresent good evidence that right-sided SCV and IJVnsertions are likelier to induce arterial injury,114,122 al-hough the left side offers a smoother and more obtusengle of subclavian approach.284 A left-sided approach iseported to be associated with less technical difficulty285

nd complications122,236 in a statistically significant num-er of patients.286

Ultimately, physicians should be cognizant of theany complications associated with CVCs, recognizing

hat the sheer volume of lines used is substantial enougho convert a rare problem into one they will be likely toxperience. With this in mind, prevention of even theost unusual complication becomes a worthwhile ini-

iative. The weight of evidence in favor of UAI to de-rease the incidence of mechanical complications sug-ests that this kind of image-guided approach to CVCnsertion should be made available routinely.

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