Vascular complications of central venous access and their management in adults

INTRODUCTION — Central venous access is necessary for an increasing number of medical interventions. In United States intensive care units, over 5 million central venous catheters are inserted annually for rapid intravenous access and resuscitation [1,2]. Over 200,000 patients annually are identified who require permanent pacemaker placement, and increasing numbers of cardiac ablations have been performed over time [3,4]. In addition, over 80 percent of new hemodialysis patients are initiated with hemodialysis catheters, despite guidelines recommending early planning for arteriovenous access to minimize catheter use [5,6].

Central venous access complications significantly increase length of stay and health care costs and negatively impact quality-of-life. Many complications are preventable with improved training and meticulous technique, and growing awareness of these issues has led to even greater emphasis on addressing these deficiencies.

Central venous access may be achieved from several access sites. The most frequently accessed sites are the internal jugular, subclavian, and femoral veins. For many years, these veins were accessed using familiarity with nearby anatomic structures (ie, landmark techniques) (table 1). However, this approach fails to account for body habitus, anatomic variations, or pathology in patients, possibly leading to higher complication rates even in well-versed hands [7]. As an example, the internal jugular veins are typically 1 to 2 cm from the skin but may be markedly deeper in obese patients, increasing the risk of complications; these vessels may also be thrombosed (eg, oncology patients), making cannulation impossible and subjecting the patient to a needless and unsuccessful procedure.

Ultrasound-guided access has become the standard for venous access in most situations because of these shortcomings. Even a quick, single view can be useful; real-time ultrasound-guided access in either the transverse or longitudinal plane provides information that can reduce access-related complications [8]. However, the utility of ultrasound depends on the skill of the operator and inherent properties of ultrasound waves. As an example, compared with experienced users, novices are not likely sufficiently proficient to fully benefit from ultrasound-guided access [9,10]. Nevertheless, various studies suggest an approximately 50 percent reduction in complications for ultrasound-guided access compared with landmark techniques [11,12]. (See "Basic principles of ultrasound-guided venous access".)

Vascular complications related to central venous access are reviewed. Other complications (eg, pneumothorax, air embolism) related to central venous access are reviewed separately. (See "Central venous catheters: Overview of complications and prevention in adults".)

ARTERIAL COMPLICATIONS

Inadvertent arterial puncture — A potential complication associated with central venous access is inadvertent needle puncture of an associated artery (eg, common femoral artery, carotid artery, innominate artery, subclavian artery, vertebral artery) instead of the targeted vein (image 1). Arterial puncture is noted to occur in about 5 percent of all central venous access procedures, with reported incidences ranging from 1 to 11 percent [13-17]. It remains uncertain when and if coagulation defects should be corrected prior to elective central venous catheter placement [18]. However, the consistent use of ultrasound during central venous access decreases the incidence of vascular complications. Inadvertent arterial puncture is typically reported to occur in less than 1 percent of access cases when ultrasound-guided access is used. (See "Basic principles of ultrasound-guided venous access".)

Initial management — Immediate recognition and management of arterial puncture usually prevents subsequent complications. Late recognition of arterial catheterization increases the risk of hemorrhagic or thrombotic complications that may require surgical intervention.

The most immediate sign of an inadvertent arterial puncture is pulsatile bleeding from the access needle (algorithm 1), though this may not always be apparent in patients who are critically ill or those without pulsatile flow (eg, left ventricular assist device, hypotensive). Venous blood is darker than arterial blood, which may serve as another subjective indication that an arterial puncture has occurred. More objectively, the access site can be connected to an arterial line setup to assess the waveform (waveform 1) or pressure or sent as an arterial blood gas [14,19]. Ultrasound can also be used to assess the location of the needle or catheter in real-time at bedside. With increasing operator experience, the needle location within the vein can be confirmed by ultrasound before a wire is even passed. If arterial access is not recognized before the sheath or catheter has been placed, several radiographic modalities, including plain films or computed tomography (CT) scans, can be used to identify the insertion site and location of a catheter.

Once an arterial puncture is suspected, the needle can be immediately withdrawn and direct but nonocclusive pressure applied to the site continuously for 15 minutes to prevent hematoma formation (algorithm 1). Bleeding usually resolves within 10 to 15 minutes with direct compression, which is more easily performed at the femoral and jugular sites compared with the subclavian site.

Vascular referral — Unrecognized arterial puncture with subsequent dilation of the arteriotomy and catheter placement, particularly of large-bore catheters (≥7 French), can lead to life-threatening bleeding into the neck, chest, retroperitoneum, or thigh depending on the access site [20]. Accidental catheterization of the carotid, subclavian, or vertebral artery by a large-bore catheter can cause arterial thrombosis, hemorrhage, stroke, pseudoaneurysm, airway compression, or death. (See 'Bleeding' below and 'Internal bleeding' below.)

Simple catheter removal (catheter <7 French), also known as the "pull-and-pressure" approach, may be considered for inadvertent cannulation of the common femoral artery (ie, below the inguinal ligament) [14]. However, removal of the catheter from other access sites without further imaging is not recommended, as it can lead to uncontrollable bleeding [15,21,22].

If the vessel is cannulated by a large-bore catheter (>7 French), clinicians should consult urgently with a vascular surgeon for catheter removal and repair of the injured artery (algorithm 2) [15,23]. Because tunneled hemodialysis catheters are 12 French or larger in diameter, arterial placement of a tunneled hemodialysis catheter at any site mandates emergency consultation with a vascular surgeon. Removal of the catheter should not be attempted without surgical oversight. When the catheter is in place, arterial tamponade by the catheter may prevent hemorrhage, but removal of such a large-bore device risks serious hemorrhage and almost always requires repair, using either an endovascular or open surgical approach. (See 'Surgical and endovascular management' below.)

Bleeding — Bleeding related to central venous access can be external at the access puncture sites, through a catheter tunnel, or internal. Bleeding can be related to an unrecognized inadvertent arterial puncture or other access placement-associated cardiac or vascular injury (arterial or venous). Bleeding is often related to coagulation defects, the correction of which may resolve the problem.

External bleeding — External bleeding is typically immediately evident and can be due to arterial or venous injury. This can happen during initial access, vessel dilation, or device insertion [7]. External bleeding is first and foremost treated with direct pressure at the access site or on the tunnel. The next step is to check and treat any coagulopathy. The same principles can be applied to local hematomas. In selected scenarios, external bleeding around the venous catheter or the tunnel may be controlled with external reinforcement of the exit site (eg, suture placement) to tamponade low-pressure bleeding, but surgical referral is typically recommended at this point.

Internal bleeding — Internal bleeding is frequently more insidious and may not be recognized immediately. This can present as a local hematoma, a retroperitoneal hematoma in cases of femoral access, or a hemothorax in cases of jugular or subclavian accesses. While serious blood loss associated with central venous catheter placement is uncommon, hematomas that form after inadvertent arterial puncture can compress associated structures. In the case of inadvertent carotid puncture, hematoma can obstruct the airway and be life-threatening [24]. (See 'Initial management' above.)

Local hematoma formation is estimated to occur in less than 5 percent of cases in the literature, with retroperitoneal hematomas and hemothoraces rarer still [25]. Frequently, internal bleeding is suspected based on hemodynamic instability and/or laboratory changes and confirmed with radiographic studies like plain radiographs or CT.

Hemothorax — Hemothoraces can occur as complications of subclavian or jugular venous access. Chest cavity drainage using a 32 or 36 Fr tube thoracostomy in adults is the standard therapy for these patients [26,27]. Surgical intervention is rarely needed but may be necessary with large hemothoraces exceeding 1500 mL at time of insertion or persistent bleeding greater than 200 mL/hour over four hours indicative of injury to significant structures. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children" and 'Surgical and endovascular management' below.)

Retroperitoneal hematoma — Retroperitoneal hematomas from complicated femoral access are traditionally managed nonoperatively. Serial laboratory studies are obtained to identify continued bleeding, which can be confirmed on radiographic studies (most frequently CT) [28,29]. If feasible, anticoagulation should be discontinued and any coagulopathy reversed. Most cases are self-limiting, and surgical intervention is rarely needed [30]. In instances of persistent hemodynamic instability, continued bleeding, and/or compressive symptoms, angiography and coil embolization may be considered [31]. (See 'Surgical and endovascular management' below.)

Cardiac injury and pericardial effusion — Injuries to the heart are rare and usually poorly tolerated. A number of early and late pericardial effusions associated with central venous catheter insertion have been reported in the literature [32-34]. Symptom presentation can be related to insertion of guidewires, dilators, or catheters or related to chronic erosion from an indwelling device [35,36]. Clinical manifestations include pericardial effusion with bradycardia, hypotension, low oxygen saturation, and elevated venous pressures. As examples, a tunneled hemodialysis catheter perforating the right atrium can result in severe bleeding and hypotension, whereas placement of a hemodialysis catheter perforating through the myocardium may not be associated with any bleeding but may cause acute pericardial tamponade if hemodialysis is started with catheter tip in the pericardial space.

Depending on the injury, evacuation of the pericardial effusion alone may be enough, but most frequently, surgical repair via either thoracotomy or sternotomy is required [36,37]. (See 'Surgical and endovascular management' below.)

Delayed complications

Arteriovenous fistula — Arteriovenous fistulas are abnormal connections between arteries and veins that can occur with inadvertent arterial puncture during catheter insertion (image 2) or, less frequently, chronic erosion from indwelling devices. A number of case reports exist in the literature describing carotid-jugular [13,38], subclavian-subclavian [39-41], and femoral-femoral [42-44] arteriovenous fistulas, but their exact incidence is likely underreported, as a number of these patients can be largely asymptomatic. Depending on their location, arteriovenous fistulas can present with limb edema, pain, palpable masses, heart failure, or cerebrovascular accidents. Thrill sometimes can be felt on examination, and bruit can be heard on auscultation. If suspected, a contrasted CT scan or angiography is preferred to establish the diagnosis; these patients will have asymmetric, early contrast filling of the adjacent venous system.

For symptomatic patients, options include open surgical repair or endovascular treatment. Open surgical repair is standard for accessible lesions and can involve direct surgical repair, patch angioplasty, or interposition grafting depending on the location and extent of the fistula. Select patients may be candidates for endovascular therapy with covered stent placement depending on comorbid conditions and surrounding anatomy. (See "Acquired arteriovenous fistula of the lower extremity", section on 'Surgery'.)

Manual compression, frequently used to treat other pathologies, is unlikely to be effective in this situation due to the high flow and short connection between adjacent vessels. (See "Acquired arteriovenous fistula of the lower extremity", section on 'Ultrasound-guided compression'.)

Pseudoaneurysm — Pseudoaneurysm can also occur following inadvertent arterial puncture during central venous access. (See 'Inadvertent arterial puncture' above and "Femoral artery pseudoaneurysm following percutaneous intervention".)

VENOUS COMPLICATIONS

Deep venous thrombosis — Catheter-related thrombosis is a subacute or chronic issue that can occur with indwelling central venous catheters. These are estimated to contribute to 10 percent of all deep venous thrombosis in adults but approximately 50 percent of those in children [45-47]; the majority involve the upper extremities. Risk factors for thrombosis include malignancy, previous venous thrombosis, intensive care unit admission, hypercoagulability, and infection [48,49]. (See "Clinical features, diagnosis, and classification of thoracic central venous obstruction" and "Catheter-related upper extremity venous thrombosis in adults", section on 'Epidemiology and risk factors'.)

Symptoms vary depending on the timing, extent, and location of thrombus. Many patients are asymptomatic, but routine screening for catheter-associated thrombosis is not recommended [50,51]. Symptomatic patients complain of pain and swelling near or distal to the access site, and emboli are frequently observed in these patients, though many are not clinically apparent. In patients with symptomatic disease, duplex ultrasound is the diagnostic test of choice, as it is noninvasive and radiation-free, with a sensitivity and specificity of 97 and 96 percent, respectively [52]. Computed tomographic (CT) venography and magnetic resonance (MR) venography are alternatives when operator dependency or anatomy may limit the utility of ultrasound studies. MR venography is preferred over CT if there are no contraindications. Catheter-based venography and intravascular ultrasound may be appropriate when additional intervention is anticipated but is rarely performed as a diagnostic study when noninvasive options are available [53].

Anticoagulation is first-line therapy for deep vein thrombosis [54-56]. The American College of Chest Physicians guidelines recommend against removal of a functional indwelling catheter if there is an ongoing need for the catheter and recommend continued anticoagulation as long as the catheter is in place [57]. If the catheter is removed, anticoagulation should continue for at least three months or longer in cancer patients. Novel oral anticoagulants like apixaban and rivaroxaban are recommended over low-molecular-weight heparin and vitamin K antagonist in noncancer patients, whereas low-molecular-weight heparin remains the drug of choice for cancer patients [55]. Catheter-directed thrombolysis decreases the overall clot burden but has not demonstrated consistent long-term results, and guidelines recommend against general use [58-60]. Similarly, percutaneous or open thrombectomy is not appropriate, except for select cases. Prophylactic anticoagulation to prevent catheter-associated vessel thrombosis is also not generally recommended, even among patients with a prior history of thrombosis. (See "Catheter-related upper extremity venous thrombosis in adults", section on 'Treatment' and "Overview of thoracic central venous obstruction", section on 'Management'.)

Central venous obstruction — Central venous stenosis is a chronic complication of indwelling central venous devices, particularly among hemodialysis patients. (See "Overview of thoracic central venous obstruction" and "Overview of iliocaval venous obstruction" and "Central vein obstruction associated with upper extremity hemodialysis access".)

Intimal trauma, inflammation, and chronic endothelial injury have all been implicated in its pathogenesis [61-63]. The incidence varies between 20 and 40 percent of patients with chronic catheters but is likely under-reported, as many are asymptomatic [61]. Patients can otherwise present with ipsilateral edema or pain. When the superior vena cava (SVC) is involved, patients may experience headaches, facial edema, dyspnea, and hoarseness consistent with SVC syndrome [64]. CT or MR venography is noninvasive and can aid in the diagnosis [65]. Catheter-based venography remains the gold standard, but a number of different techniques have been explored to improve the accuracy of noninvasive techniques. One review noted significant improvement using MR venography to detect venous occlusions with the addition of time-resolved images [66]. The authors' clinical experience also indicates much promise using protocolized dynamic MR venography to characterize central venous lesions and guide therapy.

Intervention is not recommended for asymptomatic disease. For symptomatic patients, endovascular revascularization is first-line therapy due to its minimally invasive nature [5] and can be performed concurrently with diagnostic catheter-based venography or after the diagnosis has been established by a less invasive test, depending on the institutional resources. The authors' preference is to use diagnostic catheter-based venography in symptomatic patients to expedite intervention.

Recanalization of obstructive lesions is facilitated by using hydrophilic guidewires and support catheters to cross occlusive lesions. Successful traversal rates vary in the literature, ranging from 50 to 93 percent depending on technique, chronicity of the lesion, and degree of sclerosis [67,68]. Open surgical bypass around the occlusion or directly to the right atrium has been reported but is typically reserved for symptomatic patients who have failed endovascular therapy [69,70]. (See "Endovenous intervention for thoracic central venous obstruction" and "Central vein obstruction associated with upper extremity hemodialysis access", section on 'Endovascular outcomes'.)

Migration/embolization of catheter components — Migration and embolization of catheter components are most commonly associated with totally implantable venous access devices (TIVAD) but also can be seen with other types of catheters (eg, transhepatic dialysis catheters) [22,71]. Migration and embolization of the catheter or parts of the catheter is reported to be 0.2 to 0.8 percent. The causes of disconnect and subsequent migration are faulty assembly, pressurized flushing (eg, using small caliber needles), and degeneration of the catheter from mechanical stress at the thoracic outlet (ie, pinched off syndrome) accompanied by pulsatility of the heart [72].

The most common and earliest sign of disconnection is catheter malfunction that can be associated with local infiltration and swelling. The nature and severity of local symptoms relate to the type of fluid that extravasates. (See "Extravasation injury from cytotoxic and other noncytotoxic vesicants in adults".)

Cardiac complication rates are estimated at 7 percent, including arrythmia and pulmonary artery thrombosis. Migration of the catheter to the right atrium, right ventricle, pulmonary artery, and coronary sinus has been reported. Some of these complications can be fatal, with overall reported mortality of 1.8 percent. Entrapment of catheter fragments in the heart can lead to arrhythmias or perforation [35,36]. Pulmonary fragments can present as symptomatic pulmonary embolism or remain asymptomatic [37]. Plain radiographic films are the first step to assess the position and integrity of the catheter. If fracture or migration is suspected, CT may provide further anatomic detail for retrieval.

SURGICAL AND ENDOVASCULAR MANAGEMENT

●Closure devices — The utility of percutaneous closure devices in managing inadvertent arterial injury varies depending upon the nature of the arterial injury and other patient factors. A number of percutaneous closure devices have been used to provide closure during percutaneous arterial access for endovascular intervention and are commonplace in catheterization lab, interventional radiology, and the operating room settings [73]. Off-label use of these devices has been applied on a case-by-case basis successfully in proximal common carotid, subclavian artery, and brachiocephalic arteries. The devices have been used when the puncture site is below the clavicle or sternoclavicular joint in patients who are at high risk for open surgical repair to avoid extensive surgical exploration or sternotomy [22].

●Angioplasty and stenting — For occlusive lesions in the venous circulation, balloon angioplasty and stenting can relieve obstruction and is technically successful in 70 to 90 percent of lesions, but recurrent lesions are common and may require stenting. (See "Endovenous intervention for thoracic central venous obstruction" and "Central vein obstruction associated with upper extremity hemodialysis access".)

●Surgical repair of vascular injury — Surgical repair of iatrogenic vascular injuries follows the principles of trauma management. Repair of specific injuries are discussed separately.

•Major thoracic vascular injury (see "Overview of blunt and penetrating thoracic vascular injury in adults", section on 'Management of specific vascular injuries')

•Iliofemoral injury (see "Abdominal vascular injury", section on 'Iliac arteries')

•Major venous injury (see "Abdominal vascular injury", section on 'Abdominal venous injury' and "Abdominal vascular injury", section on 'Inferior vena cava')

•Cardiac injury (see "Management of cardiac injury in severely injured patients", section on 'Definitive repair of cardiac injuries')

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Venous access".)

SUMMARY AND RECOMENDATIONS

●Central venous access is necessary for an increasing number of medical interventions. Frequent access sites include the internal jugular, subclavian, and femoral veins. Complications related to central venous access can significantly increase length of stay and health care costs and negatively impact quality of life. Vascular complications can occur immediately during attempts at catheter insertion as well as longer term (>1 week). Many complications are preventable with improved training and meticulous technique, and in particular, the use of ultrasound to guide access. (See 'Introduction' above.)

●Inadvertent arterial puncture is common, but immediate recognition and management usually prevents subsequent complications (eg, hemorrhage, arterial thrombosis, arterial embolism). The consistent use of real-time ultrasound guidance decreases the incidence of inadvertent arterial puncture. The most immediate sign of an arterial source is pulsatile bleeding from the access needle, though this may not always be apparent. When inadvertent needle puncture is suspected (algorithm 1), the needle can be removed and direct pressure applied. Unrecognized arterial puncture with subsequent dilation of the arteriotomy and dilator, sheath, or catheter placement, particularly of large-bore catheters (≥7 French), can lead to life-threatening bleeding into the chest, retroperitoneum, or thigh, depending on the access site. Large-bore catheters should not be removed from the arterial circulation without vascular surgical oversight. (See 'Inadvertent arterial puncture' above.)

●Bleeding related to central venous access can be external at the access puncture sites or through a catheter tunnel or internal. Bleeding can be related to an unrecognized inadvertent arterial puncture or other access placement-associated cardiac injury causing pericardial effusion or tamponade, or vascular injury (arterial or venous) resulting in hemopneumothorax or retroperitoneal hematoma. For otherwise complication-free catheter placement, bleeding is often related to coagulation defects, the correction of which typically resolves the problem. Internal bleeding can be insidious and may not be recognized immediately and can present as a localized hematoma, a retroperitoneal hematoma in cases of femoral access, or a hemothorax with jugular or subclavian accesses. Internal bleeding is suspected based on hemodynamic instability and/or laboratory changes and confirmed with radiographic studies like plain radiographs or computed tomography (CT). (See 'Bleeding' above and 'Internal bleeding' above.)

●Arteriovenous fistulas are abnormal connections between arteries and veins that can occur with inadvertent arterial puncture during catheter insertion or, less frequently, chronic erosion from indwelling devices. If suspected, contrast-enhanced CT scan or CT angiography is preferred to establish the diagnosis and will demonstrate asymmetric, early contrast filling of the adjacent venous system. Surgery is typically required for repair. (See 'Arteriovenous fistula' above.)

●Venous complications of central venous catheters include deep venous thrombosis and central venous stenosis related to chronic endothelial injury. Most catheter-related venous thrombosis or stenosis occurs in the upper extremities. Risk factors for thrombosis include malignancy, previous venous thrombosis, intensive care unit admission, hypercoagulability, and infection. (See 'Venous complications' above.)

●Migration and embolization of catheter components is uncommon, and most are associated with totally implantable venous access devices but can also be seen with other types of catheters. Migration of components into the heart can be fatal. The causes of disconnect and subsequent migration are faulty assembly, pressurized flushing, and degeneration from mechanical stress at the thoracic outlet. The most common and earliest sign of disconnection is catheter malfunction, which can be associated with local infiltration and swelling. In addition to the consequences of potential embolization, the nature and severity of local symptoms relates to the type of fluid that extravasates. (See 'Migration/embolization of catheter components' above.)