Central venous access is now commonly used peri-operatively as it not only provides a means of administering fluids and drugs, but also allows invasive monitoring of cardiac parameters. On a long-term basis its use is well recognized for long-term chemotherapy and parenteral feeding. However, complications rate of up to 14% [1] have been reported when central venous access is acquired.
Failure to cannulate the vein may be partly due to an aberrant anatomy of the internal jugular vein, which is estimated to be present in up to 8.5% of patients [7]. Patients who are either obese or who have short neck represent an additional challenge to such an extent that cannulation, then, becomes safer by using ultrasound guidance [8].
Vascular problems after IJV cannulation via the Seldinger technique [9] represent around 8% of the complications [10]. The bulk is related to carotid artery puncture [10, 11], which may lead to neck haematoma and subsequent upper airways obstruction [12, 13]. Venous complications are rare. Those reported so far, are either arterio-venous fistulae formation [2–4] or superior sagittal sinus thrombosis [5].
In this case report, the recurrent attempts at inserting the central line damaged to the wall of the right internal jugular vein. The end result was a weakened venous wall and most probably, the formation of a clinically non-significant venous pseudo-aneurysm. There was no or minimal localized thrombus as the patient was fully anti-coagulated. Following the severe bout of coughing, there was a significant increase in the venous pressure causing ballooning of the venous pseudo-aneurysm. The connective tissue sheath of the surrounding structures limited the size of the lesion. The size was further limited by the blood which collected within the aneurysmal sac creating a tamponade effect on the leak from the feeding vein. The tamponade was effective because the low pressure that prevails in the IJV could not maintain the blood flow from the IJV to the pseudo-aneurysm. The venous wall was, then, strengthened when the haematoma in the sac became organized clot. Thus, the feeding channel was closed and the lump shrunk in size.
This clinical complication was managed conservatively with favorable outcome. If the lump did not resolve, enlarged, or if the patient developed symptoms of space occupying lesions such as dyspnoea and dysphagia, then a surgical approach to close the feeding channel, aneurysmectomy and IJV repair would have been necessary. However, there is always the risk that either clot may embolise from the pseudo-aneurysm or there may even be a propagated thrombus formation which would lead to IJV obstruction and impairment of the venous drainage from the head and neck region. Surgical drainage of chronic haematoma following IJV cannulation has been previously described by Brown & Wallace [14]. Non-surgical treatment was adequate in this case and successful closure of the venous pseudoaneurysm was achieved.
This complication was unexpected, as the central venous catheter was in-situ for only a short period of time. Unfortunately the multiple attempts at IJV catheterization prior to the valve replacement surgery along with its re-insertion for the re-exploration procedure weakened the venous wall and predisposed this anti-coagulated patient to this complication. It seems fair to conclude that in high-risk patients (as in this case with planned post-operative anticoagulation), multiple attempts at puncturing the same central vein should be avoided and alternative routes should be used if one attempt fails. Moreover, the use of ultrasound to locate the vein prior to catheterization will reduce the need for multiple blind attempts [8, 10].