INADVERTED PLACEMENT OF CENTRAL VENOUS CATHETER FOR DIALYSIS IN THE SUBCLÁVIA ARTERY: STENTGRAFT, A THERAPEUTIC ALTERNATIVE
Introduction: The inadvertent arterial puncture in the placement of dialysis catheters is uncommon, occurring in 4.2% - 9.3% of the cases, and it may be difficult to recognize immediately in previously unstable and in shock patients. It is a serious situation that occurs more frequently in the femoral region in relation to the subclavian and there is no recommended standard treatment. The purpose of this study is to present the treatment method used in a case of inadvertent placement of a dialysis catheter in the subclavian artery.
Clinical Case: A 58-year-old woman with a history of hypertension and CRF on hemodialysis, admitted in the infecciology service in septic shock clinic with a starting point in a central venous dialysis catheter (CVCd) placed in the left femoral vein and associated with endocarditis. After the beginning of empirical antibiotic therapy with vancomycin and gentamicin, the CVCd of the left femoral vein was removed and an attempt was made to place a new catheter in the left subclavian vein. On suspicion of intra-arterial localization of the catheter, the patient performed an angio-CT that confirmed the presence of CVCd in the left subclavian artery without contrast extravasation or thrombosis. On observation, the patient was intubated and ventilated, with normal humeral, radial and ulnar pulses, with no evidence of hematoma, false aneurysm or thrum at the puncture site. The patient underwent surgical treatment and a Viabahn® 8 x 50 mm self-expandable covered stent was deployed in the left subclavian artery, distal to the emergence of the vertebral and internal mammary arteries (excluding the site of the CVCd puncture). The covered stent was placed in the correct location and deployed immediately after the removal of the CVCd by the anesthesiologist, with control and resolution of the hemorrhage. Intraoperatively, a new CVCd was placed in the right femoral vein. There were no vascular intercurrences and an Enterobacter Cloacae sensitive to ertapnem was later isolated in the blood cultures. The patient was discharged on the 24th day with pulses kept in the left upper limb and without complications of the access.
Conclusion: Removal and immediate compression of CVCd when introduced into the arterial sector may result in uncontrollable hemorrhage, pseudoaneurysm or AV fistula, especially if the entrance site is in a zone of difficult access to compression, as it is the case of the subclavian artery. The endovascular positioning of a covered stent at the entrance site of the CVCd and its opening immediately after the removal of the CVCd constitutes an interesting, innovative technical aspect whose disclosure may be useful in similar cases.
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