Accidental Carotid Artery Catheterization
During Attempted Central Venous Catheter
Placement: A Case Report
Pauline Marie Maietta, CRNA, MS
More than 2.1 million central venous catheters are
placed annually. While carotid artery cannulation is
rare, its effects can be devastating. Anesthesia providers frequently work with central venous catheters in
the perioperative setting. Therefore, it is imperative
that they be able to identify and react appropriately to
carotid artery injury both in preexisting central lines
and those that they have placed.
This case report details a case of accidental carotid
artery catheterization during attempted right internal
jugular vein catheterization and the steps taken to
treat the patient following its recognition. A discus-
A
nesthesia professionals commonly work
with and place central venous catheters
(CVCs). Although carotid artery cannulation is a rare complication associated with
central line placement, its occurrence can
be devastating to the patient. It is therefore important for
anesthesia providers to appropriately identify and manage
complications associated with an improperly placed catheter and to be knowledgeable of tools and techniques that
can help prevent future carotid artery catheterizations.
CVCs are commonly placed for: central venous pressure
monitoring; infusion of fluids, medication, and nutrition;
aspiration of air emboli; insertion of transcutaneous pacing leads; insertion of pulmonary artery catheters; and
temporary hemodialysis (Table 1).
The right internal jugular (RIJ) vein has been the preferred site for central venous access1,2 since the central
landmark technique was first described in 1969.3 This
site is often chosen over other central line insertion
sites because of its readily identifiable landmarks, short
direct route to the junction of the superior vena cava
and right atrium, distance from the thoracic duct, and
its ease of access for the anesthesia provider.1 Although
CVCs placed in the internal jugular vein are associated
with a high success rate, catheterization of the internal
jugular vein is also associated with various techniquerelated complications.4 Complications of internal jugular
cannulation include infection, embolism, dysrhythmia,
hematoma, pneumothorax, cardiac perforation, cardiac
tamponade, trauma to nearby nerves or arteries, thrombosis, and fistula formation (Table 2).5,6 According to
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sion of technique for central venous catheterization,
indications for suspicion of arterial puncture, methods
for confirming venous or arterial placement, appropriate methods for management of carotid artery
cannulation, and the benefit of ultrasound in central
venous cannulation follow. Through the appropriate
use of equipment, early detection and management
of carotid artery injury, and proper training, patient
outcomes may be improved.
Keywords: Carotid artery catheterization, central
venous catheter, complication, ultrasound.
Tom Richardson, Northeast regional district representative of CVC manufacturer, Arrow International, Boston,
Massachusetts, via a phone conversation, more than 2.1
million CVCs are placed annually. While carotid artery
complications are 1 of the 3 most common complications
associated with central venous catheterization,7 cannulation of the carotid artery by a large bore catheter is less
frequent, occurring in 0.1% to 0.5% of cases.8
Case Summary
A 77-year-old male presented to the emergency department (ED) following progressive shortness of breath for
several days and chest pain upon exertion. His medical
history included diabetes mellitus, coronary artery
disease, atrial fibrillation, chronic obstructive pulmonary
disease, and chronic bronchitis. He had an 80 pack year
smoking history and had been receiving 2.5 L of oxygen
via nasal cannula at home for 6 months before presentaVenous access in patients with poor or no previous access
Rapid fluid resuscitation (as in hypovolemia or shock)
Monitoring of central venous pressure and or pulmonary artery
catheterization for comprehensive cardiac monitoring
Infusion of caustic drugs, vasoactive drugs, or total parenteral
nutrition
Temporary hemodialysis access
Aspiration of air emboli in the event of venous air embolism
Insertion of transcutaneous pacing leads
Table 1. Indications for Central Venous
Catheterization1,4-6,8
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tion to the ED. The patient’s presenting data included the
following: height, 172.7 cm; weight, 68.2 kg; temperature, 98.2°F; heart rate, 102/min; blood pressure, 214/98
mm Hg; and peripheral oxygen saturation (SpO2), 93%
following the administration of non-rebreather mask.
Laboratory test results revealed: bicarbonate, 37 mmol/L;
blood urea nitrogen, 28 mg/dL; blood glucose, 199
mg/dL; white blood cell count, 23.7 K/µL; and troponin
levels, 0.09 ng/mL (> 0.03 ng/mL considered significant
by hospital laboratory). The patient’s electrocardiogram
was consistent with his history of atrial fibrillation and
did not show changes in the ST waveform. In the ED, the
patient’s arterial blood gas revealed: pH, 7.23; PaCO2, 111
mm Hg; PaO2, 77 mm Hg; HCO3-, 47 mEq/L; and SaO2,
93%. Bilateral crackles were noted upon auscultation of
the patient’s lungs. He was diagnosed with acute respiratory failure secondary to chronic obstructive bronchitis
with acute exacerbation and Pseudomonas pneumonia
along with subendocardial infarction.
One hour after admission to the ED, the patient was
intubated for respiratory distress and administered continuous fentanyl and midazolam infusions for sedation.
A large-bore5,6 7-French triple lumen catheter insertion
was then attempted aseptically by the ED team via the RIJ
under ultrasound guidance per the hospital sepsis protocol. Vital signs just prior to catheter placement were:
heart rate, 98/min; blood pressure, 83/52 mm Hg, SpCO2,
100%. Difficulty with fluid infusion 1 hour after placement of the CVC prompted the ED team to transduce the
central line. A pulsatile arterial waveform was noted, and
arterial placement confirmed via PaCO2 of 429 mm Hg. At
this time, a chest x-ray was also obtained and suggestive
of catheter entrance into the innominate artery. Consults
were obtained from the vascular and anesthesia services.
The catheter was not removed manually because there
was a high risk of adverse side effects associated with
catheter removal, and surgical intervention was planned.
Preoperatively the patient was assigned ASA class 4E.
A plan including risks, benefits, and alternatives was
discussed with the patient’s son who understood and
consented to anesthesia for the procedure.
The patient arrived in the operating room intubated
and receiving 100% oxygen via manual ventilation. His
sedative infusions were continued throughout the case.
He was transferred safely to the operating room table
where he was placed in the supine position by anesthesia
for surgery on his RIJ and carotid artery. Standard monitors were applied with the addition of a cerebral oximeter. Initial cerebral oximetry values were obtained and
maintained within normal limits throughout the procedure. Correct endotracheal tube position was confirmed
via auscultation and end-tidal CO2. Sevoflurane was administered and ventilation was controlled via mechanical
ventilation. An arterial line was placed and transduced
before induction, which allowed for baseline activated
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Infection
Air or thrombus embolism
Dysrhythmia
Hematomaa
Pneumothorax, hemothorax, hydrothorax
Cardiac perforation
Cardiac tamponade
Trauma to nearby nerves or arteriesa
Thrombosis
Fistula formation (possibly arteriovenous)a
Table 2. Complications Associated with Central Line
Placement in the Internal Jugular Vein5,6
a Concerns that were considered for this case.
clotting time of 146 seconds and arterial blood gas
values: pH, 7.38; PaCO2, 65 mm Hg; PaO2, 208 mm Hg to
be established. No heparin was used during the case and
no further blood specimens were necessary during the
procedure. Vital signs were maintained within normal
limits throughout the case with no additional pharmaceutical interventions necessary. Over the course of the
surgery, the vascular team found that the catheter had
entered the lateral wall of the RIJ, punctured the medial
wall of the RIJ where it exited the vein, entered the right
common carotid artery, and catheterized the carotid
artery in a caudad direction (Figures 1 and 2). Both the
RIJ and right common carotid artery were repaired by
the vascular team, and the surgery was completed in
less than 1 hour. Postoperatively the patient remained
intubated because of his underlying respiratory status.
He was transferred to the intensive care unit where he
was extubated on postoperative day 1 and discharged on
postoperative day 9 with no further complications.
Discussion
Anesthesia providers are frequently responsible for the
insertion and use of CVCs in the operating room setting.
Identification and management of complications associated with central line placement are an essential
component of safe anesthesia practice. A brief discussion
addressing the risk of carotid artery cannulation during
CVC insertion in the RIJ, detection and management of
carotid artery cannulation, and the use of ultrasound in
the prevention of carotid artery cannulation follows.
• Risk for Arterial Cannulation. The RIJ is typically
the preferred site for central venous catheterization via
the central landmark technique. However, this technique
may not identify the middle 80% of the RIJ’s venous
lumen in up to 34% of patients even with correct positioning of the patient and needle at the insertion site.9
When this occurs, the risk of carotid artery catheterization or injury is increased because of the proximity of
the artery and vein. The central landmark technique is
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Figure 2. Surgical Dissection of Neck
Figure 1. Surgical Dissection of Suspected Carotid
Artery Catheterization
also more likely to intersect the carotid artery in obese
patients.9 In addition, excessive rotation or extension
of the head greater than 40° may increase the likelihood
of carotid artery puncture by altering cervical vascular
anatomy causing the RIJ to overlie the carotid artery.10
• Detecting Cannulation. If pulsatile or high-pressure
backflow occurs from the needle or catheter placed
during attempted RIJ cannulation, carotid artery puncture should be suspected. Methods for confirming carotid
artery puncture include comparison of blood color with
an arterial sample, comparison of PaO2 from the suspected catheter with an arterial sample, transduction of the
catheter and assessment for a pulsatile waveform, use of
manometry, chest x-ray, use of transesophageal echocardiogram, and visualization (as with surgery) (Table 3).
However, certain criteria used for determining whether
carotid injury has occurred are not always accurate.
Techniques such as blood color comparison and catheter
transduction may produce incorrect results depending on
the patient’s oxygenation status, fluid volume status, and
blood pressure.8
• Management of Arterial Cannulation. Two techniques are commonly employed for the management
of carotid artery cannulation with a large bore catheter
(ie, 7 French or greater).5,6 These techniques consist
of removal of the catheter and application of direct
pressure, or surgical exploration, repair, and catheter
removal. Results of large bore catheter removal and
external pressure application are varied.6 Guilbert et al
reported serious complications in up to 47% of patients
treated by removal of the catheter and application of
direct pressure, which included death in several cases.
No complications from surgery or catheter misplacement were reported in those patients treated via surgical
repair in the same study.5 Negative patient outcomes associated with carotid artery cannulation include stroke,
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Image displays central venous catheter exiting the medial wall of
the right internal jugular and entering the common carotid artery.
Abbreviations: CVC, central venous catheter; IJV, internal jugular vein.
airway obstruction, hematoma, additional surgery for
arterial repair, hemothorax, pseudoaneurysm, arteriovenous fistula, and death.5,7 Therefore, it is prudent to treat
suspected carotid artery catheterization with immediate
examination of neurological function where applicable,
followed by surgical exploration, and repair of the artery
to prevent negative patient outcomes.
Prevention of Arterial Cannulation
Several factors mitigate carotid artery injury. Insertion of
a catheter by a practitioner who has placed 50 or more
central lines is 50% less likely to cause a mechanical
complication than an insertion by a practitioner who
has not.4 Thus, practitioner experience inversely correlates with the likelihood of carotid injury. In addition,
literature supports the use of real time/dynamic ultrasound guidance over the central landmark technique
for cannulation of the RIJ to decrease the risk of injury
(Table 4).2,11 In this method, the needle and catheter are
observed at all points from insertion through placement.
Ultrasound guided central venous cannulation has
been endorsed by several major healthcare agencies12,13
because it can lead to improved outcomes when used appropriately. It allows providers to differentiate between
venous and arterial anatomy through its ability to display
arterial pulsatility, venous compressibility, and venous
engorgement (as with Trendelenburg positioning). Realtime ultrasound views decrease thrombotic, infectious,
and mechanical complications (eg, carotid artery trauma)
associated with central venous cannulation.2 However,
formal training on a standardized method of real time
ultrasound use for central venous catheterization is
lacking in medical education,11 as is research on the best
methods for approaching central venous catheterization
with ultrasound (eg, short axis vs long axis approach).14
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Reliability
Method
Compare blood color from suspected catheter/needle with an arterial sample.a
Low
Transduce the catheter and check for a pulsatile waveform congruent with arterial placementb
Use of manometryc
Moderate
Chest x-ray confirmation
Compare PaO2 from suspected catheter/needle with an arterial sample.
High
Use of transesophageal echocardiogram
Surgical visualizationd
Table 3. Methods for Confirming Suspected Carotid Artery Catheterization and/or Puncture4,6,8
a Venous blood should be darker than arterial blood.
b Blood pressure dependent.
c Procedure in which a piece of extension tubing is attached to the angiocatheter before wire placement to determine artery puncture
by ascension/descension of blood in the tubing.
d As depicted in Figure 2.
The use of ultrasound guidance in CVC placement may
also be limited despite promotion of its use by literature
and government agencies; 67% of those surveyed by
the Society of Cardiovascular Anesthesiologists report
that they do not use, or rarely use, ultrasound guidance
when placing CVCs.15 Increased education of nursing
and medical students on the use of ultrasound for central
venous cannulation could potentially increase ultrasound
use by anesthesia providers and lead to improved patient
outcomes.
1969
English describes the central landmark technique for
internal jugular catheterization.
1978
Ullman and Stoelting describe the use of Doppler technology for detecting the internal jugular vein.
1984
Legler describes the use of Doppler ultrasound for cannulation of the internal jugular vein.
1993
Denys shows use of ultrasound may reduce risk of
carotid artery puncture 1.7% (ultrasound) vs 8.3%
(landmark technique).
1998
Voluntary verification process made available to surgical fellows in a statement by the American College
of Surgeons to ensure they are qualified to use ultrasound and maintain quality standards.
2001
Agency for Healthcare Research and Quality (US
Department of Health and Human Services) endorses
the use of real-time (dynamic) ultrasound in central
venous catheterization.
2007
Survey by the Society of Cardiovascular Anesthesiologists reports that despite recommendation and literature supporting the use of ultrasound in central venous
pressure placement, it remains limited (with 67% of
respondents reporting that they never, or almost never,
use ultrasound).
Conclusion
Although carotid artery cannulation is a rare complication of central venous catheterization, its effects can be
devastating. Therefore, it is important for anesthesia
providers to be familiar with the risks involved with
central venous catheterization; to have had formal
training and in-servicing on tools available to prevent
said risks; to be readily able to identify complications
associated with CVCs; and to be prepared to manage
such complications. Evidence-based policies enacted by
hospitals can also help practitioners follow best practice
methods for central line placement and management of
complications resulting from central line placement. In
addition, simple measures such as transducing CVCs
and manometry may aid in the early detection of improperly placed central lines. Combining these measures with advances in central venous catheterization
through the use of ultrasound technology decreases the
incidence of complications associated with CVCs.1,7,15
When hospitals merge these measures to create a cohesive protocol for CVC insertion, confirmation of
placement, identification of error, rapid neurological
assessments, and appropriate treatment via surgical intervention, time to treatment may be decreased limiting
complications associated with carotid artery injury and
improving patient outcomes.
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Table 4. Chronology of Ultrasound Use2,11,12,15-19
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AUTHOR
Pauline Marie Maietta, CRNA, MS, is a staff nurse anesthetist at New York
Presbyterian/Weill Cornell Medical Center, New York, New York. She was
a student at Columbia University, School of Nursing Program in Nurse
Anesthesia, New York, New York, and completing clinical rotations at
Englewood Hospital, Englewood, New Jersey, during the writing of this
article. Email: pmm2127@columbia.edu.
ACKNOWLEDGMENTS
I thank the administration of Columbia University, School of Nursing Program in Nurse Anesthesia, and I especially thank William Enlow, CRNA,
DNP, for his support and guidance in the preparation of this article. I
also thank Seth Perelman, MD, of Englewood Hospital, for allowing me
to participate in this case and encouraging me to research its implications; Eleanor Dunn, RN, Englewood Hospital, for taking the beautiful
photographs associated with this case; and my family and friends for their
support throughout my education and writing of this article.
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