1, 2, 3, 4, 5Ībdelkefi et al 3 reported that the catheter tip is often positioned so that it is in direct contact with the lateral wall of the SVC where the innominate vein is at a right angle to the SVC. Among delayed vascular complications, delayed vascular perforation is a rare but life‐threatening complication, especially when placed on the patient's left side. Futhermore, the delayed complications include infection, venous thrombosis, and catheter migration. The common immediate complications include arterial puncture, hematoma, pneumothorax, and hemothorax. ![]() The patient's postoperative course was uneventful, and she was transferred to a rehabilitation hospital on 20 day after surgery.Ĭentral venous catheters (CVCs) are frequently associated with complications. The catheter was removed, and the site of perforation was sutured. During the procedure, we determined that the infusion port of the catheter had penetrated one wall of SVC both drainage and return ports remained inside vessel (Figure 4). On day 7, transcatheter angiography revealed extravasation of the contrast media from the proximal lumen, confirming with vascular injury (Figure 3) therefore, an emergency thoracotomy was performed. Since those inflammatory indices were gradually worsening, CT was performed on day 6, which suggested vascular injury (Figure 2). With respect to fever, laboratory data, and CT findings, we misdiagnosed them as mediastinitis associated with the first puncture. ![]() CRRT could be continued without difficulty (blood flow in the circuit: 80 ml/min, drainage pressure: 70–80 mmHg, and infusion pressure: 100–120 mmHg). After initiation of CRRT with administration of Nafamostat mesylate, a chest radiograph taken on day 3 revealed an enlarged mediastinum, which was consistent with mediastinitis at that time, vital signs remained stable except for low‐grade fever, and laboratory data showed an elevated white blood cell count (90 × 10 3/µL) and C‐reactive protein value (10.7 mg/dl). ![]() The position of the tip of catheter was confirmed by X‐ray, and smooth functioning of the catheter was confirmed by blood withdrawal and saline flush through all three of the catheter lumens. Therefore, we placed the catheter at the innominate vein without touching the superior vena cava (SVC) wall. But a longer blood access catheter was not available in our institute. Although the catheter advanced easily into the central vein, it was too short (16 cm) to reach the right atrium. On day 2, we inserted a triple‐lumen catheter (Gentle Cath™® COVIDIEN) via the left internal jugular vein under fluoroscopic guidance by emergency physician who is a nonvascular expert (Figure 1). An initial effort was made to obtain central access via ultrasound‐guided insertion of a triple‐lumen catheter into the right internal jugular vein this effort failed due to accidental arterial puncture. Given her clinical condition, we were concerned that conventional HD would be associated with a high risk of disequilibrium syndrome as such, CRRT was recommended. Upon admission, she was diagnosed with cerebral infarction by computed tomography (CT) and magnetic resonance image (MRI) that was treated via a thrombectomy. ![]() Her medical history was notable for chronic renal failure due to diabetic nephropathy that required regular hemodialysis (HD). An 87‐year‐old woman was transported to our institute for evaluation and treatment of an acute disturbance of consciousness and right hemiplegia.
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