central vein cannulation ( cvc ) using a large - bore catheter (  7.0 fr ) is widely used in renal patients for hemodynamic monitoring , rapid large - volume replacement , parenteral nutrition or antibiotic administration , and hemodialysis ( hd ) . in particular , the creation of temporary vascular access by cvc for hd under ultrasound ( us ) guidance , preferably using the internal jugular vein ( ijv ) , is increasingly accepted as a straightforward procedure by nephrologists and the so - called " the new nephrologist " trained in nephrology - related procedures . the aim is to minimize procedure - related delays in initiating immediate hd therapy , improve the convenience of those patients , and enhance the doctor - patient relationship ( 1 ) . however , although this procedure has helped numerous renal patients with uremia , it occasionally has serious complications , and can even lead to fatal outcomes . therefore , through described our case , nephrologists and nephrology - trainees should not only be thoroughly trained in the temporal hd catheter ( thc ) placement , but should also be well - informed about how to prevent and manage the procedure - related complications such as arterial injury and arterial misplacement . a 65-yr - old woman with an underlying chronic kidney disease was presented to the emergency room ( er ) with uremia because of sepsis accompanied by oliguria and severe metabolic acidosis on august 29 , 2008 . to begin emergency hd , we attempted to insert a 7.5 french ( fr ) catheter into the right ijv under ultrasound guidance . the initial puncture with an 18-gauge needle into the right ijv using real - time us guidance by the short - axis method was successful with no pulsatile arterial back flow . thereafter , the rest of the procedure with removal of the ultrasound transducer was performed without any resistance to advancing the guide wire and hd catheter by the seldinger technique . no immediate complications such as rapidly expanding hematoma , pain , dyspnea , shock , or signs of neurologic deficits were noticed during insertion of the thc . however , a routine post - cannulation chest x - ray suggested that the catheter tip had been misplaced into the right subclavian artery ( sca ) ( fig . 1 ) , and subsequent computed tomographic ( ct ) angiography with contrast enhancement revealed that the catheter had indeed passed through the right ijv and been misplaced into the right sca ( fig . we assumed that the puncture needle had initially been inserted into the right ijv , but had been unintentionally advanced into the right sca after the absence of arterial back flow had been established and before inserting the guide wire . the hd catheter into the right sca was left in place without an immediate catheter removal and direct external compression , because of the uncontrollable arterial bleeding that might result from application of the pull / pressure technique . following consultation with a vascular surgeon , the surgical exploration in the operating room revealed that the hd catheter had transected the right ijv and the right sca . an angiogram under real - time fluoroscopy revealed no further bleeding or fistula between right ijv and right sca ( fig . 3 ) . also , subsequent evaluation of neurological status following open surgical repair and angiography for any intra - arterial catheter - related thrombi or emboli , revealed no neurologic deficit . the patient underwent an uneventful hospital course with antibiotic therapy and intermittent hemodialysis through the thc into the right femoral vein , as required . among the various mechanical complications of cvc , unintended arterial cannulation has been reported to occur in up to 8% of the cases ( 2 ) , and has been particularly noted in patients at high risks due to obesity , short neck , emergency puncture and hemodynamic instability with severe hypotension or low hemoglobin saturation or coagulation defects , as well as in the absence of ultrasound guidance ( 3 ) . iatrogenic arterial injury to patients following percutaneous cvc with a large - bore catheter (  7.0 fr ) has resulted in various devastating complications such as arteriovenous fistula , arterial dissection , pseudoaneurysm , airway obstruction with massive cervical bleeding and hematoma , shock from hemothorax , stroke from arterial thrombosis or cerebral emboli , and even fatality ( 4 ) . compared to traditional blind central venous catheter placement using superficial anatomical landmarks , catheter placement under us guidance achieved an initial high success rates including fewer needle attempts , rapid vein localization and fewer complications ( 3 , 5 , 6 ) . in fact , the use of us - guided cvc lowered the risk of complications by up to 73% ( 7 ) . however , inadvertent arterial trauma or cannulation under us - guided cvc , as in our case , still occurs ( 7 ) . there is evidence that novice operators of ultrasonograms may lose track of the puncturing needle tip when using the short - axis method only , rather than both short- and long - axis trials , and this can lead to the accidental arterial cannulation ( 8) . as in our case , accidental advancing of the puncture needle into an artery prior to insertion of the guide wire , with no further tracing under us guidance after confirmation of absence of pulsatile blood return or puncture of the right ijv , has been reported ( 9 ) . thus , the cvc of a large - bore catheter under us guidance is not always guaranteed as a safe procedure free from the risk of inadvertent arterial cannulation . once inadvertent arterial cannulation of a large - bore catheter is suspected , immediate management of arterial injury following its confirmation by imaging studies is required to avoid complications from prolonged arterial cannulation such as thrombus at the site of arterial injury . compared to surgical specialties ( 3 , 4 ) , workers in the nephrology field have seldom proposed definite guidelines on how to manage this accidental arterial cannulation ( 10 , 11 ) . scattered case reports have documented accidental arterial catheterization of cvc , but they barely mentioned methods of managing these complications and how to predict the likely success of the chosen option , i.e. , pull / pressure with immediate catheter removal and manual external compression , open surgical exploration with catheter removal , or arterial repair under direct vision , and endovascular interventions . the pull / pressure technique has been well recognized for resulting in serious complications such as massive hemorrhage leading to respiratory distress , pseudoaneurysm , arteriovenous fistula , and strokes ( 12 - 14 ) . also , cases of bleeding after pull / pressure technique require urgent open surgical intervention . the probability of serious complications is usually dependent on catheter diameter , time since catheter insertion and puncture site ( 3 ) . a retrospective analysis of 30 cases of arterial misplacement with large - bore cannula (  7.0 fr ) showed that , unlike the pull / pressure technique , managements by immediate surgical exploration and artery repair under direct vision caused no complication at all and was considered the most effective and safe treatment ( 46% vs 0% , p = 0.004 ) ( 4 ) . furthermore , a retrospective analysis of 57 cases based on published series and case reports of carotid artery or sca catheterizations with large - bore cannula revealed that the pull / pressure technique was associated with significantly more complications than surgical or endovascular repair ( relative risk , 17.86 ; p < 0.001 ) ( 4 ) . in the same study , a single patient in the surgical repair group ( 1/14 ) developed a post - surgery embolic stroke due to delayed surgical intervention after cannulation of the carotid artery for more than 72 hr ( 15 ) . thus , prompt open surgical repair has been noticed to be safe , but its usual requirement for general anesthesia and even sternotomy cause some morbidity in patients with serious underlying diseases including uremia ( 3 ) . recently , less invasive endovascular interventions , such as use of a covered stent or percutaneous arterial closure device or balloon tamponade , have been reported ( 16 - 18 ) . these options are ideal for managing arterial injuries that are difficult to expose or inaccessible surgically , such as in the proximal carotid or subclavian artery below or behind the clavicle ( 4 ) . although one recent retrospective analysis for the endovascular interventions of 13 patients of inadvertent sca catheterization was promising with clinical success rate of 100% and without need for surgical reconstruction , complications requiring additional stent - graft placement were still noticed in 4 patients ( 30.8% ) ( 19 ) . therefore , any suspected arterial catheterization during cvc should be confirmed by radiologic methods , and the catheter should be left in place without use of the pull / pressure technique while arranging for open surgical repair or the endovascular intervention with skilled experience , particularly if the location appears surgically inaccessible ( 3 , 4 ) . since the avoidance of accidental arterial cannulation is clearly preferable to its managements in cvc with a large bore catheter , the following elements are needed : 1 ) a properly organized instruction program for cvc under us guidance ; 2 ) supervision of novice physicians by an experienced or interventional expert in cvc ; and 3 ) us - guided cannulation with real - time fluoroscopy in patients at high risk . an observational cohort study comparing traditionally - trained residents for cvc versus simulation - trained residents showed that the simulation - based mastery program reduced complications related to cvc in actual patient care ( 20 ) . in summary , to prevent and manage unintended arterial cannulation during large - bore hd catheter placement , 1 ) cannulation should be performed by well trained and competent physicians under us guidance as a standard of care , and with real - time fluoroscopy , for high - risk patients ; 2 ) an operator should check for excessive or pulsatile backflow through the initial puncturing needle and the cannulated catheter , as well as any expanding local hematoma , dyspnea or pain ; 3 ) chest x - ray should be performed to check the position of the catheter tip after cannulation ; 4 ) in the event of accidental arterial misplacement , ct angiography or conventional angiography should be immediately arranged to establish which artery is injured and to analyze the regional vascular anatomy ; 5 ) open surgical repair or endovascular intervention , if surgery is unsuitable or experienced ones for it are available , should be promptly arranged ; and 6 ) after surgical repair or endovascular intervention , prompt clinical evaluation should be performed to detect procedures - related neurologic deficits such as strokes .
ultrasound - guided cannulation of a large - bore catheter into the internal jugular vein was performed to provide temporary hemodialysis vascular access for uremia in a 65-yr - old woman with acute renal failure and sepsis superimposed on chronic renal failure . despite the absence of any clinical evidence such as bleeding or hematoma during the procedure , a chest x - ray and computed tomographic angiogram of the neck showed that the catheter had inadvertently been inserted into the subclavian artery . without immediately removing the catheter and applying manual external compression , 
 the arterial misplacement of the hemodialysis catheter was successfully managed by open surgical repair . 
 the present case suggests that attention needs to be paid to preventing iatrogenic arterial cannulation during central vein catheterization with a large - bore catheter and to the management of its potentially devastating complications , since central vein catheterization is frequently performed by nephrologists as a common clinical procedure to provide temporary hemodialysis vascular access .