A 67-yo male with severe three-vessel coronary artery disease, type 2 diabetes, and COPD, was scheduled for nonemergent CABG. Transthoracic echo showed normal ejection fraction, mild left ventricular hypertrophy, and dilated atria.

An introducer sheath and pulmonary artery catheter were placed under ultrasound guidance by the surgery resident. Waveforms were identical for the arterial catheter, central venous, and pulmonary artery catheter. The CABG was cancelled, and the patient was instead taken for catheter removal and carotid artery repair.

During surgical exploration, the introducer sheath was found transecting the right internal jugular vein before terminating in the innominate artery via the right carotid. The pulmonary artery catheter terminated in the left subclavian artery. The patient recovered and returned to the OR four days later for CABG, with access obtained via the left internal jugular vein.

Despite routine ultrasound guidance, inadvertent carotid cannulation during internal jugular vein catheterization occurs in 1%-2.7% of cases (J Clin Neurosci 2014;21:1973-5). Given the risk of embolic stroke, urgent catheter removal is indicated. Other complications include hemothorax, arterial dissection, and puncture of nerves, pleura, and esophagus. Traditionally, extracting the catheter and holding pressure was standard of care, but that carried a significant risk for stroke (J Vasc Surg 2010;52:1682-96; J Vasc Surg 2008;48:918-25). Surgical approaches for repair are preferred due to high success rate with low complications, but alternative methods include microsurgery and endovascular approaches (Anal Vasc Surg 2022;2:100044; J Vasc Interv Radiol 2019;30:1785-94). Regardless of which repair technique is utilized, it should be performed as soon as possible.

The incidence of accidental carotid puncture (not cannulation) is 7%-8.4%, with manual compression to achieve hemostasis (Ann Card Anaesth 2016;19:594-8). One should consider delaying the case if heparinization is planned, due to potential hematoma formation (Ann Card Anaesth 2016;19:594-8). If arterial puncture is recognized after the dilator is placed, surgical consultation is indicated (Anesthesiology 2020;132:8-43).

Placing a pulmonary artery catheter (PAC) creates a new set of risks and challenges. Despite its unique advantages, PAC use is declining (JAMA Cardiol 2017;2:908-13). Ikuta et al. found an overall decrease of almost 68% between 1999-2013, but a variable trend in heart failure patients. Koo et al. found a 50% reduction in use between 2002 and 2006 (Crit Care Med 2011;39:1613-8). While a good tool, pulmonary artery catheterization is being replaced by echocardiography, which has a lower morbidity and provides almost as much information (Pulmonary Artery Catheterization. 2024). Several trials have shown the efficacy of PACs in decreasing morbidity and mortality, but due to several factors (patients with PACs are often sicker) it is difficult to have a true random double-blinded study. Other studies show PACs do not make a difference (Br J Anaesth 2022;129:3-7). An advantage of a PAC is it can be used throughout postoperative care without increasing risk. Transesophageal echocardiography (TEE) requires a large machine and can only be used intermittently due to probe heating. TEE has several risks, including dental, oropharyngeal and laryngeal trauma, esophageal tears/perforations, and other issues (Indian J Anaesth 2009;53:567-74). Though TEE and PAC are both useful, they provide different information. While PACs can provide information about cardiac output, systemic vascular resistance, pulmonary artery, and wedge pressures, it cannot show true volume status or wall motion abnormalities, areas where the TEE excels.

When placing a central venous catheter, ultrasound is used to confirm wire placement in the internal jugular vein (Figure 1). Another sign indicating correct location is dysrhythmia caused by the wire touching the right atrium. Because ultrasound only sees an image slice, scanning cephalad and caudad with the probe helps create a 3D picture of the anatomy and facilitates accuracy. Depending on anatomy and neck rotation, the carotid artery can be just underneath the internal jugular, making through-and-through puncture a higher risk. An alternative is to use a modified Seldinger technique with a long angiocath. If one is not certain which vessel is cannulated, they can attach a long tubing piece, let blood enter it, and raise it up. Since the average central venous pressure is 0-10 mmHg, and higher in the Trendelenburg position, raising up the tubing vertically should demonstrate blood lowering. Intra-arterial cannulation will result in blood briskly exiting out the end of the tubing. Though venous blood is typically darker than arterial blood, hyperoxygenation can minimize color difference. If needed, one can utilize a TEE to confirm wire placement in the RA and guide PAC placement.

Figure 1: Confirming wire placement in the internal jugular vein.

Figure 1: Confirming wire placement in the internal jugular vein.

For PACs, different wave forms (Figure 2, A-D) are seen while traversing from RA to RV to PA. The RA should be reached at approximately 20 cm insertion depth, the RV at 30-35 cm, the PA at 40-45 cm, and the wedge position at 50 cm (Figure 2, D) (Br J Anaesth 2006;97:147-9). In heart failure with RV dilatation, or in tall patients, an insertion length of greater than 50 cm may be necessary (J Clin Monit Comput 2022;36:5-15).

Figure 2: The contemporary pulmonary artery catheter. Part 1: placement and waveform analysis (J Clin Monit Comput 2022;36:5-15).

Figure 2: The contemporary pulmonary artery catheter. Part 1: placement and waveform analysis (J Clin Monit Comput 2022;36:5-15).

After advancing the PAC with an inflated balloon past the RA through the tricuspid valve, an RV pressure waveform will appear (Figure 2B), showing an increase in systolic pressure with a steep, rapid systolic slope. The RV blood pressure of a healthy individual is roughly 15-28 over 0 mmHg (Figure 2) (J Clin Monit Comput 2022;36:5-15).

With an inflated balloon, advancing the PA catheter across the pulmonary valve into the PA, a pulmonary artery pressure waveform will appear (Figure 2C). There should be a diastolic pressure step-up in the PA compared to the diastolic pressure in the normal RV (J Clin Monit Comput 2022;36:5-15). This can be minimal in the setting of right heart failure. Normal pulmonary artery pressure ranges between 14 and 28 mmHg over 5 and 16 mmHg (mean 10 and 22 mmHg) (Figure 2C). Advancing further will reach the PAC’s wedge position, with the inflated balloon stopping all distal blood flow, thus creating a static fluid column between the tip of the catheter to where the pulmonary veins meet the left atrium. The PA wedge pressure reflects the pulmonary veins and left atrium pressures.

Ideally, all pressures should be measured at the end of expiration, although the influence of pleural pressures on measurements is minimal (J Clin Monit Comput 2022;36:5-15).

During central venous catheter placement, accidental arterial puncture and cannulation can lead to potentially serious consequences. If arterial trauma with a large-caliber catheter occurs, prompt surgical treatment is the safest approach with subsequent neurological evaluation, even if requiring postponing surgery, such as in the case presented above. Though this patient suffered a procedural complication that ended up prolonging his hospital stay, the vigilance of the anesthesia team and rapid mitigation of the initial event likely prevented a far worse outcome of stroke or central vessel hemorrhage.