Approach to intervention for large bore inadvertent catheterization

CT: computed tomography; ALI: acute limb ischemia; TIA: transient ischemic attack.
* Insertion of a large bore central venous catheter confirmed clinically as inadvertently placed into an artery. Refer to UpToDate algorithm for the management of suspected arterial puncture during central venous access.
¶ A handheld Doppler can be used to determine the quality of distal pulses and to obtain an ankle-brachial or wrist-brachial index. Comparison with preprocedure values is useful following intervention. Duplex ultrasound can be used before, during, or after intervention to assess the patency and flow characteristics of the vessel.
Δ Ultrasound confirms the location of the puncture and identifies associated injury (eg, intimal flap) or hematoma and can help determine the best approach to intervention.
◊ For selected patients with common carotid artery puncture, a percutaneous approach has been used, although would require a thorough discussion of potential risks (ie, stroke) versus benefits (ie, avoiding surgery).
§ The use of closure devices in this manner is considered "off label."
¥ For subclavian artery catheterization, access the right or left common femoral artery. For external iliac artery catheterization, access the contralateral femoral artery.
‡ To expose the carotid artery, an incision along the sternocleidomastoid muscle provides flexible exposure. To expose the common femoral artery, use a vertical groin incision. To expose the external iliac artery, a transverse retroperitoneal incision exposes the vessel avoiding the need to divide the inguinal ligament. To expose the subclavian artery, use a supraclavicular or infraclavicular incision; however, a median sternotomy may be necessary to expose a proximal injury.