D&C Case Presentation
January 26, 2012
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Malpositioned central venous catheter
 Right subclavian vein laceration
 Right subclavian artery laceration
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Procedure:
 Central venous catheter insertion
 Deceased donor liver transplant
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63yo woman
Cirrhosis due to Hepatitis C
Moderate/Severe decompensation:
 MELD 24 – Cr 1.76 ; Bilirubin 5.2; INR 1.4; Na 138
 Weekly paracentesis for refractory ascities
 Encephalopathy
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Presented for Liver transplant on Jan 14
Donor – 34yo man – DCD donor
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Taken to the operating room for deceased
donor liver transplant
Central venous catheter
 MAC (9.0 Fr)
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Swan-Ganz catheter
Chest X-Ray
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Arterial puncture
Pneumothorax
Arrythmia
Thoracic Duct Injury
Guidewire Loss
Cardiac Perforation
Evens SRT. Surgical Pitfalls: Prevention and Management. Philadelphia: Saunders. 2009.
1. Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal
jugular vein. A prospective comparison to the external landmark-guided
technique. Circulation. 1993;87:1557-1562.
2. Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Subclavian venous
catheterization: greater success rate for less experienced operators using
ultrasound guidance. Crit Care Med. 1995;23:692-697.
3. Mallory DL, McGee WT, Shawker TH, Brenner M, Bailey KR, Evans RG, et al.
Ultrasound guidance improves the success rate of internal jugular vein
cannulation. A prospective, randomized trial. Chest. 1990;98:157-160.
4. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal
jugular vein. A prospective, randomized study. Anesth Analg. 1991;72:823-826.
5. Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral
vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med.
1997;29:331-336.
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BG Denys et al from Pitt, 1993
Prospective study, 1230 patients
Landmark versus Ultrasound guided:
 Longer access times (44 sec versus 10 sec)
 More attempts (2.5 versus 1.2)
 Decreased successful cannulation on first attempt
(38.4 versus 82%)
 More carotid punctures (25 versus 8)
French JLH, Raine-Fenning NJ, Hardman JG, Bedforth NM. Pitfalls of ultrasound guided
Vascular access: the user of three/four-dimensional ultrasound. Anaesthesia, 2008:63; 806-813.
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Liver transplant proceeds
Pause prior to bile duct to check for bleeding
 Abdomen dry
 Chest tube with minimal output
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~30 minutes later – hypotension
 Chest now has high output
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Thoracic consulted – Sternotomy
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Subclavian ligation is well tolerated
Thoracic EndoVascular Aortic Repair (TEVAR)
 Left subclavian may be occluded with or without
bypass from left carotid
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WWII – ligation resulted in 25% gangrene
Vietnam registry:
 Mortality 5 to 10% (earlier series up to 30%)
▪ All due to hemorrhage
 5-10%: distal ischemia, gangrene,
pseudoaneurysm formation, AV fistula, limb loss
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Graham et al – 1980
 93 patients from 1955 to 1978
 Mortality 4.7%; Neurological deficit accounted for
major early and late morbidity
Intimal flap found at reoperation
Left subclavian
Right subclavian