Introduction

Placement of central venous catheter (CVC) is essential during major surgery for monitoring of cardiovascular system, for infusion of fluids and for administration of drugs [₁].

Whereas placement of CVCs provides advantages to the clinicians such as reducing the incidence of major cardiovascular complications and improving outcome [1], various complications associated with the use of them must be taken into consideration [₂,₃,₄,₅,₆].

In our case report, we aimed to present the mechanical occlusion of a peripherally inserted CVC intraoperatively. To our knowledge, this is the first case report of a ligation of a long-length CVC into the left innominate vein in a patient undergoing anterior mediastinal mass surgery.

Case History

A 57 yr old female (body weight 58 kg) with an ASA physical status II was scheduled for thoracic surgery because of her anterior mediastinal mass.

Her medical history revealed that she had a cataract surgery under regional anesthesia. She had no symptoms of superior vena cava (SVC) syndrome or of myasthenia gravis during the preoperative assessment. A chest radiograph and a computer tomograph scan examination of the patient's thorax showed anterior mediastinal mass located mainly around the left hilus of the lung. She didn't receive chemotherapy or radiotherapy prior to surgery.

Laboratory tests including hemoglobin level, hematocrit, blood glucose, blood urea nitrogen, electrolytes, partial thromboplastin time and prothrombin time were within normal levels. Also, preoperative ECG results of the patient were normal.

We didn't premedicate the patient. In the operating room, we provided peripheral venous access with a large bore cannula (14 G) and established routine monitoring including non-invasive blood pressure, electrocardiogram and pulse oximetry.

We preoxygenated the patient and then induced anesthesia with fentanyl 3 µg.kg-1 and etomidate 0.2 mg.kg-1. We administered atracurium 0.5 mg.kg-1 to facilitate tracheal intubation after observing appropriate ventilation with positive pressure. Rigid bronchoscope was available in the operating room. Then, we inserted an arterial cannula percutaneously in the left radial artery and a CVC (Cavafix 375, catheter length 70 cm, 23 ml/min, 1,1 X 1,7 mm/16 G, B. Braun Melsungen AG, Germany) via left basilic vein. We advanced the CVC 45 cm from the insertion site while holding the patient's head at the ipsilateral side and applying the digital pressure to the patient's ipsilateral supraclavicular fossa. We confirmed the proper placement of the catheter after we had obtained the characteristic waveform in the central venous pressure (CVP) tracing.

We maintained anesthesia with 1-3% sevoflurane (inspired concentration) and 50% N20 in oxygen and supplemented with fentanyl 2 µg.kg-1. We maintained neuromuscular blockade with a continuous infusion of atracurium 0.5 mg.kg-1.hr-1 (perfusor, B. Braun, Melsungen AG, Germany) from the central venous line.

Additional monitoring included invasive systemic arterial pressure, end-tidal CO2, gas analysis and intermittent arterial blood gas analysis during the maintenance of anaesthesia. We monitored CVP intermittently because the catheter had one lumen.

After median sternotomy, our surgeons exposed an anterior mediastinal mass spreading to the left bronchial hilus and innominate vein. They resected the tumour totally with partial resection of the left innominate vein. Then, the innominate vein was sutured longitudinally by running sutures. A few minutes later, approximately 55 min after the induction of anesthesia, we heard high-pressure alarm from the perfusor.

In order to identify the cause of the high-pressure alarm, we checked the insertion site and the external portion of the catheter, the perfusor line and the stopcock which was attached to the catheter. We observed no kinking or clamping, but, we couldn't aspirate the blood through the catheter. Also, we couldn't flush the catheter and failed in the attempt to withdraw it.

We notified our surgeons that the occlusion of the catheter might have been due to extraluminal causes because the removed tumor was very close to the intrathoracic vascular structures. Then, they detected that the suture material which was recently applied to the left innominate vein unfortunately ligated the catheter (Figure 1).

Figure 1

After they removed the suture, the catheter patency was restored. We withdrew it to a 20 cm insertion length. The surgery lasted for two hours. The patient was hemodynamically stable intraoperatively. We extubated the patient at the end of the surgery and transported her to the cardiothoracic intensive care unit. The patient's post-operative recovery was uneventful. Mature cystic teratoma was diagnosed by pathological investigation of the resected tumour (dimensions were 10 x 9 x 6 cm).

Discussion

There are different sites for placement of CVC in patients undergoing major surgery. In most of the cases, the right jugular vein is preferred [1, ₇]. Besides, CVC placement in patients with mediastinal masses requires special attention. Central access should be obtained via a femoral route in these patients having symptoms of SVC syndrome [₈]. Moreover, if the surgical team decides the clamping of SVC is necessary intraoperatively, a second intravenous line should be secured from one of the lower extremity veins [₉].

Because the patient had no SVC syndrome and our surgeons thought that it was not necessary to clamp the SVC for resection of the tumor, we used a left basilic vein approach for central venous access line and we took necessary precautions in order to provide an intravenous access line from her left vena saphena magna intraoperatively.

Central venous catheterization via a peripheral approach in the antecubital fossa remains a valuable technique. It is an easier and safer site for central venous cannulation because peripheral CVCs are far from the major complications like pneumothorax or arterial puncture during insertion [₁₀].

Contrarily, the major disadvantage of the peripherally inserted CVCs is the low success rate of correct tip placement in most cases [2, ¹¹]. Additionally, the incidence of malpositioning of the left-sided CVCs were higher than the right-sided ones according to some reports [3,4,5].

In our case, we confirmed the proper placement of the tip of left basilic vein catheter, but the anatomical location of teratoma being very close to the left innominate vein played an important role in ligation of the catheter. Early diagnosis of the catheter occlusion and subsequently the successful treatment prevented reoperation. Ng KS et al [2] reported a ligation of a long-length catheter which was malpositioned into the right inferior thyroid vein in the course of major neck surgery. They reexplorated the neck wound in order to remove the ligated catheter.

It may be an alternative to prefer right-sided CVCs, especially the short ones in patients undergoing this kind of surgery whenever femoral route is not definitely indicated for central venous cannulation.

After searching the possible external reasons for high-pressure alarm of perfusor, we thought mechanical occlusion of the internal portion of the catheter primarily due to specifity of the surgery instead of other causes such as thrombosis or blood clot. Because they are frequently the cause of the occlusion of long-term central venous access devices [6].

In conclusion, this case report may be helpful in choosing the central venous access site and giving importance to the monitoring of catheter patency during anterior mediastinal mass surgery in order to protect the patient from further catheter-related complications when femoral route isn't absolutely indicated.

Correspondence to

Dr. Hasan HEPAGUSLAR Address: 1463 Sok., No:22 / 2, Alsancak-Izmir, TURKEY, 35220. Phone No: 00 90 232 4225659 Fax No: 00 90 232 4634971 e-mail : hasan@deu.edu.tr.